Gallstones

The gallbladder is a small sac which lies beneath the liver and acts as a reservoir to store bile. Bile is made by the liver and contains bile pigments, bile salts, lipids and cholesterol which are released into the duodenum (first part of the small bowel) to help digest fats. Gallstones can form in the gallbladder due to an imbalance in the constituents of bile and can be made up of bile pigments, cholesterol and sometimes mixed stones. The large majority of patients with gallstones have little or no symptoms. If symptoms do present from gallstones they are usually as a result of complications of gallstones and are described below.

Gallstones are associated with 20% of women and 12% of men and may be because the female hormones cause more cholesterol to be excreted in the bile.  However, the majority of patients with gallstones do not require any treatment with only 20% of patients undergoing surgery.

Any individual can develop gallstones but factors, which increase the risks, include:  

• Patients with diabetes
• Undergoing obesity surgery
• Use of the oral contraceptive pill
• Pregnancy
• Overweight and obese individuals
• Certain blood disorders (Haemolytic Anaemia)
• Inflammatory bowel disease (Crohn’s disease).
• Age - chance of developing gallstones increases with age
• Ethnicity – American Indians have the highest incidence of gallstones in the world

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Diagnosis 

Gallstones are most commonly diagnosed with an ultrasound scan of the abdomen.  Gallstones may not cause any symptoms and are only discovered by chance while testing for other conditions. They can however, cause five main conditions:

Biliary Colic - ‘Sharp intense abdominal pain’

This is pain experienced predominantly in the right upper abdomen. The pain usually comes and goes and can also go through or around to the back and in between the shoulder blades.  The pain can last a few hours or up to a day, and is often associated with feeling sick (nausea). The attacks of pain can sometimes be associated with the consumption of ‘fatty’ or rich foods.

Sometimes gallstones may present with symptoms of chronic indigestion, which may include abdominal bloating, flatulence and nausea especially after a fatty meal. However, these symptoms may also be associated with gastro-oesophageal reflux. 

Acute cholecystitis - ‘Fever, sickness and abdominal pain’

Acute cholecystitis is much more severe pain than biliary colic, often lasts more than 24 hours and is caused by acute inflammation and sometimes infection in the gallbladder itself.  Along with the pain, patients often have a fever, sweating, and usually need hospital admission for intravenous antibiotics and painkillers.  Guidelines from NICE¹ recommend that patients with acute cholecystitis should have their gallbladder removed with keyhole surgery within 7 days.

Jaundice – ‘Yellow discolouration of the skin’

This is a yellow skin discolouration, which occurs when a stone from the gallbladder enters the main bile duct and is unable to pass through into the duodenum (see diagram).

Jaundice can present with a fever and generally feeling unwell and is described as cholangitis. This is an emergency and patients are often very unwell in hospital. A specialised camera test called an ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is required to remove the stone but sometimes patients can safely undergo removal of the stone by keyhole surgery at the same time as the gallbladder is removed, laparoscopic cholecystectomy with bile duct exploration (see bile duct stones).

Acute pancreatitis – ‘Intense abdominal pain with vomiting’

Small gallstones or ‘sludge’ can pass into the bile duct and block the main pancreas duct resulting in acute pancreatitis. This is a condition that usually presents with severe abdominal pain, nausea and vomiting. Pancreatitis tends to be treated in hospital with painkillers and fluids to allow the symptoms to settle following which, at an appropriate time, the gallbladder is removed by keyhole surgery.

Your surgeon will be able to identify if you might have gallstones based on your symptoms. If gallstones are suspected then further tests as outlined below will be required (also see Diagnostics)

Ultrasound: The most sensitive test performed when gallstones are suspected is the ultrasound examination. An ultrasound machine uses sound waves to create images of the gallbladder and other organs in the abdomen. The sound waves from the machine bounce off gallstones if present and the images are captured on a video monitor.

Magnetic resonance cholangiogram (MR scan): is used to diagnose suspected bile duct stones. It is non-invasive and is used when the suspicion of bile duct stone is high.

Endoscopic Ultrasound (EUS): can be used to diagnose stones from the bile duct as well as biliary sludge. It involves passing a flexible camera tube down the oesophagus (food pipe) and into the small intestine (duodenum). The flexible camera has an ultrasound probe at its tip, which can accurately diagnose stones both in the gallbladder and the bile ducts. It is sometimes combined with an ERCP, which is designed to remove bile duct stones.

Computed Tomography (CT scan): sometimes is used mainly in the evaluation of complications of gallstones such as pancreatitis.

‘Fatty’ or ‘rich foods’ (high in cholesterol) can bring on the symptoms of gallstones as described above

Do not over eat

Try and eat fresh food and fruit

Do’s Don’ts

Salad Eggs
Fresh fruit Chocolate
Fish Spicy foods
Tomatoes Cheese and other dairy products
Fresh vegetables Cakes and biscuits

Treatment of symptomatic gallstones is usually with keyhole surgery to remove the gallbladder.  Many patients often ask whether there is medication to “dissolve” the stones and prevent the need for an operation.  The danger with this approach is that a small stone could travel down the bile duct and cause jaundice or even worse, pancreatitis.

Laparoscopic Cholecystectomy is the recommended approach to remove the gallbladder. Surgery is performed under a general anaesthetic using four small incisions. All surgery is performed inside the abdomen with the entire gallbladder containing the stones is removed. Laparoscopic cholecystectomy is the treatment of choice for all patients presenting with any of the complications of gallstones described above from biliary colic to acute cholecystitis and pancreatitis.

The advantages of laparoscopic approach include:

• Less postoperative pain
• Reduced hospital stay
• Quicker physical recovery
• Less wound scarring

Occasionally as happens in 3-5% of patients, it may not be possible to complete the procedure using the keyhole approach. The operation will therefore be converted to an open procedure. Your surgeon will discuss this with you prior to surgery.

Gallbladder Surgery Diagram

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Links:

1. https://www.nice.org.uk/guidance/cg188