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Gallstones

What are Gallstones?

Gallstones are basically crystals formed from bile. Remember the time honoured school experiment of growing a beautiful copper sulphate crystal from a jar of concentrated copper sulphate solution. Gallstones are much the same and they may be made of cholesterol, bile pigments or a mixture depending on which constituent of the bile is saturated. These stones can vary from minute (1-2mm) to the ridiculously large sizes (Easter egg).

What Causes Gallstones

Many factors can predispose to gallstones? First of all gallstones are more commonly found in women between 40 and 60 years of age but can also be found in the twenties or younger. They may also develop in people who suffer from liver cirrhosis, blood disorders, such as sickle cell anaemia, obesity, diabetes, rapid weight loss, drugs like cholesterol lowering medications, high oestrogen levels including pregnancy, contraceptive pill and HRT.

​What is Bile?​

Have you ever tried doing washing up without washing up liquid? The result is greasy plate and horrible fat globules floating in the water. Put in a few drops of washing up liquid and the fat disappears. Bile is nature's washing up liquid. It emulsifies the fat in your food to allow the digestive enzymes to digest it.

 

Bile is made in the liver, collected by the bile ducts and is stored in the gallbladder. The gallbladder contracts and squirts the bile into the gut when we eat anything containing fat. Bile has three main components, they are bile salts, cholesterol and water.

​Symptoms of Gallstones​​​​​​​​​​​​​​​​​​​​​

Symptoms of gallstones can be silent or it may come as a surprise attack often called `biliary colic. A typical attack:

  •     A steady pain in the upper right abdomen that increases rapidly.

  •     The pain may go into the back and up to the right shoulder.

  •     It may last from 30 minutes to several hours.

  •     Causes nausea or vomiting.

Gallstone attacks often follow fatty meals, and they may occur during the night. Other gallstone symptoms include:

 

  •     Abdominal bloating.

  •     Recurring intolerance of fatty foods.

  •     Colic.

  •     Belching.

  •     Gas.

  •     Indigestion.

People who also have the above and any of following symptoms should see a doctor right away if you experience:

 

  •    Chills.

  •     Low-grade fever.

  •     yellowish colour of the skin or whites of the eyes.

  •     Clay-coloured stool.

 
Diagnosis

When gallstones are suspected, your doctor is likely to organise an ultrasound examination. This is the same test as baby scans. Ultrasound is the most sensitive and specific test for gallstones.

Other tests may also be used include:

  • Computed tomography (CT) scan may show the gallstones or complications.
     

  • Magnetic resonance cholangiogram may diagnose blocked bile ducts.

  • Cholescintigraphy (HIDA scan) is used to diagnose abnormal contraction of the gallbladder or obstruction. The patient is injected with a radioactive material that is taken up in the gallbladder, which is then stimulated to contract.

  • Endoscopic retrograde cholangiopancreatography (ERCP). The patient swallows an endoscope; a long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts.

  • Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

  • Gallstone symptoms can be similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

Treatment - Surgical

Surgery to remove the gallbladder is the gold standard for treating symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.) Each year more than 500,000 Americans have gallbladder surgery. The surgery is called cholecystectomy.

Nowadays this is done by keyhole surgery called laparoscopic (keyhole) cholecystectomy. For this operation, the surgeon makes several tiny cuts in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. Recently this can be done all through a single cut also known as SILS through your belly button. The resulting scar is virtually invisible in the belly button when its healed. The gallbladder is separated from the liver, common bile duct and other structures. The gallbladder is then disconnected from the common bile duct and removed through one of the small incisions. In my series open surgery is required in less than 1 percent of gallbladder operations.

Because very little abdominal muscles are cut during laparoscopic surgery, patients have less pain and faster recovery. Recovery usually involves only one night in the hospital or return home the same day (daycase), followed by several days of slightly restricted activity at home.

Most complications from gallbladder surgery are minor. The most serious complication is injury to the common bile duct and this can occur in approximately 1 in 1000 procedures. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can be treated nonsurgically.

Major injury is more serious and usually requires additional surgery.

If gallstones are found in the main bile duct, your doctor may decide to treat this by endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove them before or during the gallbladder surgery. Alternatively this may be treated at the same time as your gallbladder surgery (bile duct exploration). In bile duct exploration, the bile duct is opened or entered via the tube connecting the gallbladder and main bile duct (cystic duct) to remove the stones.

Do we need our Gallbladder?​

Fortunately, the gallbladder is an organ that people can live without. Losing it won't even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder.

However, because the bile is not stored in the gallbladder, it flows directly into the bowel and may cause a slight diarrhoea that usually recovers after a few months.
​​

Treatment - NonSurgical

Nonsurgical approaches are used only in special situations such as when a patient has a serious medical conditions preventing safe surgery and anaesthesia. Some gallstones (cholesterol stones) can be dissolved by taking medicine but they usually recur after nonsurgical treatment.

Oral dissolution therapy​​​​​​​​​​ - Drugs made from bile acid are used to dissolve the stones. The drugs, ursodiol (Actigall) and chenodiol (Chenix), work best for small cholesterol stones. Months or years of treatment may be necessary before all the stones dissolve. Both drugs cause mild diarrhea, and chenodiol may temporarily raise the blood cholesterol and the liver enzyme transaminase.

Contact dissolution therapy​​​​​​​​​​ - This experimental procedure involves injecting a drug directly into the gallbladder to dissolve stones. The drugmethyl tertbutyl ethercan dissolve some stones in 1 to 3 days, but it must be used very carefully because it is a flammable anesthetic that can be toxic. The procedure is being tested in patients with symptomatic, noncalcified cholesterol stones.