Gallstone disease and its complications


Stones of many types can form in the human gallbladder for various reasons, as it slowly increases in size, it can remain completely undetected and symptom-free or present with complications related to gallstone disease (cholelithiasis). This article gives an insight into gallstones, the illness associated with it, when and how to seek medical attention.

Introduction

We would have heard about stones in the kidneys and how painful it can be, similarly, stones can form in the gallbladder leading to pain, infection and other major complications. It is common in women, mothers after their deliveries, people who are obese or have high blood cholesterol and people who lose weight rapidly, it is often mistaken for acidity like pain (gastritis) hence a delay in seeking medical help. The treatment of gallstones causing symptoms is almost always surgical removal of the gallbladder with the stones.

Gallstones, How and Why?

In layman terms, the liver in human body synthesizes and secretes the bile juice (golden yellow) that is important in the digestion of fatty foodstuffs. The bile from the liver flows into two tubes/ducts that unite to form a single duct called as the common hepatic duct. Cystic duct form the gallbladder joins the common hepatic duct to form the common bile duct that ends in the second part of the duodenum (which continues below as rest of small intestine and above as stomach). The function of the gallbladder is to thicken the bile (golden yellow/dark green). The thick bile from the gallbladder is expelled out at times of need.

The thick bile has sediments (bile salts and bile pigments); these along with cholesterol form the basis of the gallstones. The stones can be of variable size (few mm to few cm), different shapes and consistency (soft, hard). Once the stones form, they keep moving in the gallbladder as based on the size, the smaller ones can go across the cystic duct, into the common bile duct and pass into the duodenum. In some young adults and children, there can be an increased breakdown of red blood cells leading to an increased load of the bile pigment bilirubin leading to stone formation.

Gallstones and its effects

Asymptomatic

Few individuals are lucky enough to have no troubles due to gallstones for many years even after diagnosis. It is difficult to say which patient will develop symptoms and which patients will not.

Symptomatic Gallstones

  1. Biliary Colic: : Pain after a heavy meal or a fatty meal at home or at a party, pain that starts in the lower border of the rib cage on the right side going up to the back. Pain which is so intense, that it does not settle with oral tablets. Sometimes pain due to gallstones can mimic a heart attack and vice-versa. This is often associated with nausea and vomiting

  2. Inflammation and Infection: Here the gallbladder with the stones within it becomes the seat of infection that can be sudden in onset or keep recurring over a period of few months or years. Here apart from abdominal pain, the patient can also have fever and abdominal bloating

  3. Empyema or Gangrenous conditions: in patients who have lowered immunity or people who are diabetics and people who cannot fight an infection can develop this extreme infective conditions that make the patient very sick requiring intensive care. Such patients would have an increased heart rate, low BP or even quite sick

  4. Jaundice: Sometimes the smallish stones from the gallbladder can slip into the bile duct causing blockage to the flow of bile leading to Jaundice. Stones in bile ducts (choledocholithiasis) if left untreated, it can be life-threatening with infection of the bile and the bile ducts. Here patients have concentrated yellow colored urine and pale stools

  5. Pancreatiti: The stones which slip down into bile duct can get impacted in the duodenum where they can cause blockage of the pancreatic duct also. This triggers pancreatitis, a self-limiting mild illness or a major critical illness where patients would be in ICU for a few days - few weeks


  6. .Intestinal obstructio : On rare occasions, a large stone from the gallbladder can erode into the small intestine and cause a blockage at the narrow areas resulting in intestinal obstruction that would need hospitalization and a surgical procedure. Here patients have a distended abdomen, nausea, vomiting and constipation

Diagnosis

Usually, gallstones are seen on routine ultrasound scans of the abdomen. CT scan also would show stones but not always. Blood tests are done when the doctor suspects an infection, jaundice or pancreatitis. When a stone is suspected to be in the bile ducts, then the doctors perform a test called as MRCP, it's an MRI scan referred to as Magnetic resonance cholangiopancreatography. When going for such scans, it is advisable to check and disclose any metal implants (small or big) that would have been inserted into the body.

Treatment

  • Medical treatment : There are tablets available to thin the bile and sometimes this can reduce the size of the stone. However, the issue is, these medicines need to be taken every day for a prolonged period of time (around 12-18 months) with the stone resolution being variable including the chances of it forming back once the medications are stopped

  • There are many forms of alternative remedies available that claim to dissolve the stones completely. I cannot comment on these are I'm not an expert in those fields.

  • Surgical treatment: The standard treatment around the world is the removal of the gallstones and gallbladder. Many people wonder why gallbladder also needs to be removed along with the stones. The stones are forming primarily because the gallbladder is not functioning (working) properly. The gallbladder is not important for life because it does not make the bile, it only stores and thickens it. Hence it is standard practice to remove both gallbladder and gallstones. In contrast, kidney stones have focused treatment to remove the stones and or relieve the obstruction to the passage of urine because, as we know, kidneys are vital for life

Traditional open surgery (Open Cholecystectomy) would involve a cut or incision below the right lower rib cage in the upper abdomen. The recovery for this open operation takes a long time with prolonged pain for a few days that increases hospital stay and need for medications.

Key-hole gallbladder surgery (Laparoscopic Cholecystectomy) is almost a day care procedure or with an overnight stay. Three to four small incisions (5mm-10mm) are made to facilitate removal of the gallbladder and the stones. Recovery is faster, hospital stay and the need for medications is lesser and hence early return to normal activities and work.

Advances in gallbladder surgery

There are skilled surgeons who can remove the gallbladder with just one hole at the umbilicus; this is called Single Incision Laparoscopic Surgery. However, it is important to remember that all patients would not be suitable for this and there is a chance that during the surgery, the surgeon may have to change over to the standard 3-4 hole surgical method.

Presently, Robotic surgical techniques are also available to remove the gallbladder and the gallstones, this would be an expensive procedure, all cannot afford and or all would not need this specialised robotic surgery.

Unusual situations

Patients with Jaundice or pancreatitis related to the gallstones would need symptomatic treatment along with an endoscopic procedure to remove the stone in the bile duct, Endoscopic retrograde cholangio pancreaticography (ERCP). This is similar to having an endoscopy done for stomach ulcer or acidity. The ERCP and duct clearance is followed by removal of the gallbladder during the same hospital admission or subsequently depending on the patient's condition and the severity of the illness.

Life after gallbladder removal

Some individuals take time to settle down after gallbladder removal with respect to their digestive system. Some can have hurried bowel emptying or intestinal hurry after food. Usually, this settles with time, some may need medications to slow the bowel or to reduce the bile salts.

Further medical care

After gallbladder removal, the patient needs to see his or her surgeon or physician on a regular basis initially to check that the wounds have healed well, there is no infection or jaundice and at a later date to check whether they are developing a hernia.

Some patients do not undergo surgery when they first come to hear that they have gallstones, in such patients medical treatment is given to tide over the current infection etc. It is important that they visit the physician or the surgeon once more because the same symptoms or illness can recur.

Tips to avoid chances of gallbladder stones

These are not foolproof but general healthy living measures are worth mentioning
  • Avoid becoming overweight or obese
  • Regular exercises
  • Regulate diet to reduce fatty foodstuffs, food that increases blood cholesterol
  • Good control of high cholesterol levels and diabetic status
  • People who lose weight rapidly or take high dose estrogen treatment for other conditions should be aware of gallstones and discuss with their doctors.

Conclusions

In humans, the gallbladder is a storehouse of bile which can result in stone formation within the gallbladder. These stones cause a range of illness ranging from the upper abdominal pain to life-threatening infections of the gallbladder and the bloodstream. In the absence of effective medical therapy coupled with the fact that gallbladder is not important for life, the standard of care is the removal of the gallbladder and the stones by means of a surgical procedure that can be done traditionally and by laparoscopic techniques. If you need further details or known someone with gallstones, please seek medical advice from your family physician, surgeon or gastroenterologist.


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