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GALLSTONES

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10% of the population have gallstones, most never develop symptoms.  In those who develop symptoms from gallstones, removing the gall bladder usually resolves the problem. 

The gallbladder stores bile that is made in the liver.  When we eat it contracts and empties the bile into the bile ducts. It then flows into the intestine, where it helps with the digestion of fat.  In between meals, it fills up again until the next meal when it empties again.   Because the bile sits in the gallbladder most of the time, this is where gallstones tend to form.

 WHY DO WE GET SYMPTOMS?

We get symptoms when the gallstones that form in the gall bladder get impacted or stuck in the bottlenecks or narrow parts of the system.    The first bottleneck is the neck of the gall bladder. This is where most gallstones become impacted. If the stones are small, they can sometimes pass into the bile duct proper.  Once in the bile ducts proper, the next bottleneck system is where the bile ducts and pancreas join and empty into the small intestine. 

 SYMPTOMS

Typical Symptoms

When gallstones get stuck in the neck of the gall bladder, typical symptoms are pain in the right side under the ribs or in the mid-upper abdomen or lower chest.  This pain will often radiate to the back or to the right shoulder.  Pain often occurs after eating a meal high in fat, and will usually build over the course of an hour, then it will remain steady for more than one hour.  Once the gall bladder relaxes or quits contracting, the pain will slowly subside.   There is often associated nausea, vomiting and sweating with this.  This is also referred to as Biliary Colic.

If the stone becomes impacted in the neck of the gall bladder and does not fall back, the pain will continue for longer 4-6 hours.  This situation becomes more serious as inflammation and infection occur.  The individual will become ill and often develop a fever.   This is referred to as Acute Cholecystitis (acute inflammation of the gall bladder).  When this occurs, the individual should go to the hospital.

Atypical Symptoms

Some individuals with gallstones can have bloating, indigestion, heartburn, nausea and vomiting and intolerance to dietary fat without the typical pain symptoms.  In these individuals, it is often difficult to know whether the pain is due to gallstones or to something else such as ulcers or a “nervous stomach.”   If the pain occurs on exertion and resolves with rest, heart causes need to be ruled out. 

DIAGNOSIS

Usually gallstones are diagnosed by ultrasound, sometimes by CT scan.  Although often CT scans are better at seeing things internally, this is one of the few times that ultrasound is better, unless the individual is significantly obese.

TREATMENT

For Individuals with No Symptoms

For individuals who have gallstones with no symptoms, the typical approach is just to follow them and waiting for symptoms.  Only about 1%  of individuals with gallstones  per year will develop symptoms due to their gallstones.  Once those individuals develop symptoms, they are at higher risk to develop complications.

For Individuals with Symptoms

In an individual who develops typical symptoms, either biliary colic or symptoms of acute inflammation (acute cholecystitis), surgically removing the gallbladder (cholescystectomy) is the typical treatment.  In individuals with biliary colic, once they have developed symptoms, 70% will develop increasing symptoms or complications such as acute cholecystitis within 2 years.   In individuals with acute inflammation (acute cholecystitis), they are usually admitted to hospital, put on an IV and given antibiotics.  Most will have surgery during that hospitalization or, if things settle down during hospitalization, undergo surgery thereafter as an outpatient.  

For Individuals with Atypical Symptoms

In individuals with atypical symptoms with gallstones, it is more difficult to know what to do.  In some individuals if the gallbladder is removed, the symptoms  resolve; in others, the symptoms continue.  The best situation is to have the gallbladder removed with resolution of symptoms. The approach in this situation has to be individualized, after discussion between the patient and their surgeon.

Typical Symptoms with No Gallstones

In individuals with typical symptoms of biliary colic but no gallstones on ultrasound, it is more difficult to know what to do.  In some individuals, when the ultrasound is repeated, gallstones are then found.  Then the solution is simple, removing the gallbladder.  In others, in spite of repeat ultrasounds  and typical symptoms, no gallstones are detected.  In some of these individuals, the gallstones are quite small, like grains of sand, and difficult to detect with ultrasound.  In other individuals, there is no disease in the gallbladder or gallstones. 

 In individuals with typical biliary colic and no stones, approximately half of them will have their pain resolve with removal of the gallbladder.  The approach in this situation has to be individualized, after discussion between the patient and their surgeon.

 TREATMENT SUMMARY

In individuals with typical gallstone pain, the decision is usually straightforward, removing the gallbladder will usually cause resolution of symptoms.  In individuals with atypical symptoms and gallstones, or who have typical symptoms but no gallstones, the approach has to be individualized after discussion between the patient and their surgeon.

RISK FACTORS FOR GALLSTONES

Gallstones are more common in:

  •  Women
  • As we age, especially over the age of 40
  • Individuals with a family history
  • Pregnancy
  • Obesity
  • Diabetics
  • Women using oral contraceptives
  • Sickle Cell disease
  • Cirrhosis  

WHAT IS A CHOLECYSTECTOMY?

A cholecystectomy is a surgical procedure whereby the gallbladder is removed.  In the past, this was done through a large incision in the abdomen, in the last 15-20 years this surgery has been performed laparoscopically (“keyhole surgery”).  Laparascopic surgery is done using small instruments and a video camera which is inserted into 3 small puncture holes made in the abdomen.  This is referred to as a laparascopic cholecystectomy.  This is often done as day surgery.   In some patients, either because of their anatomy or scarring from previous surgeries, this cannot be done laparascopically, and has to be done in the traditional fashion with a larger abdominal incision.

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Most individuals who have had their gallbladder removed feel better and can return to their usual routines.   In about half of the individuals who have had their gallbladders removed, they can go on to develop loose stools, gas, and bloating.   In most of these individuals, however, these symptoms are tolerable and mild, and these side-effects outweigh the risk of having their gallbladder left in.

OTHER COMPLICATIONS

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Choledocholithiasis:  This refers to a situation when gallstones are smaller and are able to pass through the neck of the gall bladder (the first bottleneck of the system) into the bile ducts proper.   When this occurs, the gallstones will usually cause symptoms when they get stuck in the second bottleneck of the system, where the bile duct and the pancreatic duct join to empty into the intestine.   When the gallstone(s) impact in this area, the individual often becomes jaundiced (skin turns yellow) because the entire bile duct system is blocked.  Symptoms are usually typical of biliary colic, with pain, nausea and vomiting.  Sometimes an infection can occur and the individual develops fever and chills and can become quite ill.

Individuals who have infection of the bile duct usually require antibiotics and the stones need to be removed.  This is usually done with a procedure known as an Endoscopic Retrograde Cholangeopancreatography (ERCP). With an ERCP, gallstones can usually be removed from the bile ducts proper.

Pancreatitis:  Sometimes when the stone gets stuck at the second  bottleneck (where the bile duct and the pancreatic duct join to empty into the intestine), blocking the pancreas causes inflammation of the pancreas (Pancreatitis).  This will often cause very similar pain to biliary colic, but lasts longer. The pain can be quite severe and the individual will usually need to be hospitalized for treatment.