The Function of the Gall Bladder:Because fat cannot be dissolved in water, a special system has evolved for its digestion and its absorption through the intestinal wall. Bile is an essential factor in this, since it contains substances that allow fats to be emulsified. It also stimulates the secretion of an enzyme concerned with the breakdown of fats. ‘Bile is secreted by the liver and stored in the gallbladder until needed. When fat is eaten, this stimulates the gallbladder to contract and bile flows down the cystic duct, into the common bile duct and through the ampulla of Vater into the intestine. As well as acting as a storage vessel, the gallbladder concentrates the bile within it by removing water through its wall. Although the gallbladder has a specific function, when the gallbladder is removed the bile flows down the common bile duct and directly into the intestines and the digestion of food is unchanged.
What are Gallstones and How Do They Form? Gall stones are pieces of hard solid matter in the gallbladder. The form when the components of bile (especially cholesterol and bilirubin) precipitate out of solution and form crystals, much as sugar may collect in the bottom of the jar. In general, either cholesterol or bilirubin precipitates out of solution to form stones, but not both. In the United States, almost 80 percent of patients with gallstones have cholesterol stones. Gallstones may be as small as a grain of sand or as large as a golf ball, and the gallbladder may contain anywhere from one stone to hundreds. Sometimes the gallbladder contains only crystals and stones too small to see with the naked eye. This condition is call bile sludge. No one knows why some people develop gallstones and other don’t. But doctors do know some things which seem to increase the risk of developing stones. Anything that increases the amount of cholesterol in bile increases the risk of cholesterol stones, and those things that increase the bilirubin in bile increases the risk of pigment (bilirubin) stones. Other factors are probably also important in gallstone development, such as poor contractions of the gallbladder muscle with incomplete emptying of the gallbladder, and the presence of substances in bile which may speed up or delay precipitation of crystals. Many people with gallstones have a combination of factors. Exactly how diet affects gallstone formation is not clear, but diets which are high in cholesterol and fat and low in fiber may increase the risk of developing gallstones.
Pigment (bilirubin) gallstones are found most often in:
What are the Symptoms of Gallstones?
The most typical symptom of gallstone disease is severe steady pain in the upper abdominal or right side. The pain may last for as little as 15 minutes or as long as several hours. The pain may also be felt between the shoulder blades or in the right shoulder or back area. Sometimes the pain can be in the chest and be misdiagnosed as cardiac pain. The pain may also cause vomiting or sweating.
Attacks of gallstone pain may be separated by weeks, months, or even years.
It is thought that gallstone pain results from blockage of the gallbladder duct (cystic duct) by a stone. When the blockage is prolonged (greater than several hours), the gallbladder may become inflamed. This condition, called acute cholecystitis, may lead to fever, prolonged pain and eventually infection of the gallbladder. Hospitalization is usually necessary for treatment with antibiotics and surgery.
More serious complications may occur when a gallstone passes out of the gallbladder and into the main bile duct. If the stone lodges in the main bile duct, it can lead to a serious bile duct infection ( acute cholangitis). If it passes down the duct, it can cause an inflammation in the pancreas ( acute pancreatitis), which has a common drainage channel with the bile duct. Either of these situations can be extremely dangerous. Stones in the bile duct usually cause pain, fever and jaundice (yellow discoloration of the eyes and skin).
Many people with gallstones have no symptoms. Often the gallstones are found when a test is performed to evaluate some other problem. So-called “silent gallstones” are likely to remain silent, and no treatment is recommended.
What Tests are used to Diagnose Gallstones?
The most important parts of any diagnostic process are the patient’s description of the symptoms and the doctor’s physical examination. When gall stones are suspected, routing liver blood tests are helpful since bile flow may be blocked and bile may back up into the liver. There are several excellent radiographic (X-ray) tests used to help in the diagnosis of gallbladder disease.
Ultrasound: An ultrasound transducer is placed directly on top of the skin over the gallbladder area. The sound waves travel through the skin and into the gallbladder area. Stones can be seen as they reflect back the sound waves.
HIDA Scan: A radioactive chemical is injected intravenously into the patient. the radioactive chemical is removed from the blood by the liver and excreted into the bile. This chemical should go into the gallbladder and common bile duct and into the intestines. If a stone obstructs the gallbladder’s cystic duct and the dye can not go into the gallbladder this is considered abnormal and a sigh of a gallbladder infection.
Oral cholecystogram (OCG): Pills containing a dye are taken by the patient the night before the test. The patient comes to the hospital and an X-ray is taken. Normally the dye will be taken up by the gallbladder and it will be seen on the X-ray. If the dye is not seen this is a sigh of obstruction to the gallbladder and infection in the gallbladder.
ERCP (endoscopic retrograde cholangio-pancreatography): A procedure to see if there is a stone or obstruction in the common bile duct. The patient is given sedation and then swallows a long, flexible, viewing instrument about the diameter of a fountain pen. The scope is then directed through the stomach and into the duodenum where the common bile duct enters. A catheter is placed into the common bile duct and dye is injected. If a stone is found a small cut in the muscle is made and the stone removed. This will solve the problem with a common bile duct stone but surgery is still needed to remove the gallbladder and gallstones so this does not happen again.
What is the Treatment?
Surgery: Surgery to remove the gall bladder is the most common way to treat symptomatic gallstones. (Asymptomatic gallstones usually do not need treatment.) The surgery is called cholecystectomy. The most common operation is called laparoscopic cholecystectomy. For this operation, the surgeon makes four tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close up view of the organs and tissue. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions.
North American location for tochars (left) Europeans (right)
Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. Recovery usually involves only one night in the hospital, followed by several days of restricted activity at home. If the surgeon discovers any obstacles to the laparoscopic procedure, the operating team may have to switch to open surgery (about 5-10%). In some cases the obstacles are known before surgery, and an open surgery is planned. It is called “open” surgery because the surgeon has to make a 5-8 inch incision in the abdomen to remove the gallbladder, This is a major surgery and may require about a 2-5 day stay in the hospital and several more weeks at home to recover.
The most serious complication in gallbladder surgery is injury to the bile ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes treated nonsurgically. Major injury, however, is more serious and requires additional surgery.
If gallstones are in the bile ducts, the physician (usually a gastroenterologist) may use endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove them before or after surgery. In ERCP, the patient swallows an endoscope—a long, flexible, light 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. Then the affected bile duct is located and an instrument on the endoscope is used to cut into the opening in the duct. The stone is pulled out in a tiny basket and removed with the endoscope.
Occasionally, a person who has had a cholecystectomy is diagnosed with a gallstone in the bile ducts weeks or months after the surgery. The ERCP procedure can usually successfully remove the stone without need for more surgery.
Nonsurgical Treatment: Nonsurgical approaches are used only in special situations- such as when a patient has a serious medical condition preventing surgery- and only for cholesterol stones. Stones usually recur after nonsurgical treatment.
Oral Dissolution Therapy: Drugs made from bile acid are used to dissolve the stones. The drugs, ursodiol (Actugal) and chenodiol (Chenix) work best for small cholesterol stones. Months or years of treatment may be necessary before all stones dissolve.
Contact Dissolution Therapy: This experimental procedure involves injecting a drug directly into the gallbladder to dissolve stones. The procedure is being tested in patients with symptomatic, noncalcified cholesterol stones.
What Should I Expect After Gallbladder Surgery?
Gallbladder removal is a major abdominal operation and a certain amount of postoperative pain occurs. Nausea and vomiting are not uncommon. Once liquids or a diet is tolerated, patients leave the hospital the same day or the day following the laparoscopic gallbladder surgery. Activity is dependent on how the patient feels. Walking is encouraged. Patients can remove the dressings and shower the day after the operation. Patients will probably be able to return to normal activities within a week’s time, including driving, walking up stairs, light lifting and working. In general, recovery should be progressive, once the patient is at home. Most patients return to work within a week following the surgery. It does take between 4-6 weeks before the patient regains full strength and is completely recovered from the surgery.
What Complications Can Occur?
While there are risks associated with and kind of operation, the vast majority of laparoscopic gallbladder patients experiences few or no complications and quickly return to normal activities. Infection, bleeding, pneumonia, blood clots, or heart problems can occur with any surgery. Unintended injury to adjacent structures such as the common bile duct or bowl may occur and may require another surgical procedure to repair it. Bile leakage into the abdomen from the liver can occur. Stones may occur in the common bile duct requiring the ERCP procedure to remove them.