Gall bladder

Gall stones
Cholecystectomy


Gall stones

Gallstones (biliary calculi) are small stones made from cholesterol, bile pigment and calcium salts, usually as a mixture that forms in the gall bladder. The gall bladder is a small sac that holds bile, a digestive juice produced by the liver that is used in the breakdown of dietary fats. The gall bladder extracts water from its store of bile until the liquid becomes highly concentrated. The presence of fatty foods triggers the gall bladder to squeeze its bile concentrate into the small intestine. Gallstones are a common disorder of the digestive system, and affect around 15 per cent of people aged 50 years and over. Some things which may lead to the formation of gallstones include the crystallisation of excess cholesterol in bile and the failure of the gall bladder to fully empty. In most cases, gallstones don't cause any problems. However, prompt treatment may be necessary if stones block ducts and cause complications, such as infections or inflammation of the pancreas (pancreatitis).

Symptoms

In approximately 70 per cent of cases, gallstones cause no symptoms (asymptomatic). The symptoms of gallstones may include:

Pain in the abdomen and back. Pain is generally infrequent but severe.

Increase in abdominal pain after eating a fatty meal.

Jaundice.

Fever and pain, if the gall bladder or bile duct becomes infected.


Different types

There are three main types of gallstones, including:

Mixed stones - the most common type. They are comprised of cholesterol and salts. Mixed stones tend to develop in batches.

Cholesterol stones - comprised mainly of cholesterol, a fat-like substance that is crucial to many metabolic processes. Cholesterol stones can grow to significant sizes, large enough to block bile ducts.

Pigment stones - bile is greenish-brown in colour, due to particular pigments. Gallstones made from bile pigment are typically small but numerous.


Complications of gallstones

If gallstones present no symptoms, there is rarely any need for treatment. Complications that may require prompt medical treatment include:

Biliary colic - a gallstone can migrate from the body of the gall bladder into its neck (cystic duct), leading to obstruction. Symptoms include severe pain and fever.

Inflammation of the gall bladder (cholecystitis) - the gall bladder duct becomes blocked by a gallstone, leading to infection and inflammation of the gall bladder. Symptoms include severe abdominal pain, nausea and vomiting.

Jaundice - if a bile duct leading to the bowel is blocked by a stone, trapped bile enters the bloodstream instead of the digestive system. The bile pigments cause a yellowing of the skin and eyes. The urine may also turn orange or brown.

Pancreatitis - inflammation of the pancreas, caused by a blocked bile duct low down near the pancreas. Pancreatic enzymes irritate and burn the pancreas and leech out into the abdominal cavity.

Cholangitis - inflammation of the bile ducts, which occurs when a bile duct becomes blocked by a stone and the bile gets secondarily infected. This causes pain, fever, jaundice and rigors (shaking).


Diagnosis methods

Gallstones are diagnosed using a number of tests, including:

General tests - such as physical examination and x-rays.

Ultrasound - sound waves form a picture that detects the presence of gall stones.

Endoscope test - called endoscopic retrograde cholangiopancreatography (ERCP). A thin tube is passed through the oesophagus and injects dye into the bowel to improve the quality of x-ray pictures.

HIDA scan - a special type of nuclear scan that assesses how well the gall bladder functions.

Treatment options

Gallstones that present no symptoms generally don't require any medical intervention. Treatment depends on the size and location of the gallstones, but may include:

Dietary modifications - such as limiting or eliminating fatty foods and dairy products.

Surgery - to remove the entire gall bladder, or stones from bile ducts. Around eight in 10 symptomatic gallstone cases will require surgery. Procedures include 'keyhole' (laparoscopic) surgery and abdominal surgery (laparotomy), where the gall bladder is removed through an incision in the abdomen.

Lithotripsy - a special machine generates sound waves to shatter stones. This treatment is used for those people with small and soft stones, which accounts for around two out of 10 cases of symptomatic gallstones.

Medications - there are drugs available that can dissolve gallstones, but this treatment is only rarely given, due to side effects and a variable success rate.

Cholecystectomy
Most gallstones do not cause any symptoms, and generally do not require any treatment. However, if the stones are in the gallbladder, and are causing recurrent abdominal pain, known as biliary colic, it may be necessary to surgically remove the gallbladder using a procedure called cholecystectomy. There are 2 different ways this operation can be done-through open surgery, or through 'keyhole' surgery (laparoscopy). Gallstones that are in the bile duct are usually removed by endoscopy or by surgery.

Open cholecystectomy

Open cholecystectomy is a relatively safe procedure where the gallbladder is removed through an incision in the abdomen below the ribs on the right-hand side of the body.

The gallbladder is not an essential organ, and can be removed with few adverse effects. Some people (less than 5 per cent) might find that they have an increase in stool frequency after the operation. This can usually be easily corrected using anti-diarrhoeal medications. There is a small risk of other surgical complications which include damage to the bile duct or bleeding of the bile duct. Only one in 20 people having their gallbladder removed requires open surgery. The rest undergo laparoscopic cholecystectomy.

Laparoscopic cholecystectomy

These days most gallbladders are removed using a procedure known as laparoscopic cholecystectomy or 'keyhole' surgery. This technique involves inflating the abdominal cavity with carbon dioxide, then inserting very fine instruments and a specialised tiny video camera through a few small cuts in the abdomen wall. The gallbladder is then cut free under video surveillance and taken out of the body through one of the incisions.
Laparoscopic cholecystectomy is safer, and has fewer complications, than open surgery. It also involves less post-operative pain, less scarring and allows a speedier recovery time. In open cholecystectomy the abdominal muscles are cut, but with laparoscopic cholecystectomy this is not necessary, so recovery is simpler. Hospitalisation is generally 1-2 days, rather than the 5-8 days associated with open cholecystectomy. On occasion, surgeons may have to abandon the laparoscopic method and switch to open surgery if they have difficulties during the procedure.

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