Gallstones

What and where is the gall bladder?

The gall bladder is a small pear-shaped organ on the underside of the liver that is used to store bile. Bile is made in the liver and is stored in the gall bladder until it is needed to help the digestion of fat.
 

What are gallstones?

Gallstones are solid stones formed in the gall bladder from cholesterol, bile salts and calcium. They can vary in size from a few millimetres to a few centimetres.
 

What causes gallstones?

Gallstones are formed when bile contains too much cholesterol. The excess cholesterol forms crystals from which gallstones are made.

Who is at risk of developing gallstones?

Gallstones are seen in all age groups but they are rare in the young. The possibility of developing gallstones increases with age.

The following groups are considered to be at increased risk:

  @ people who have relatives with gallstones.

  @ obese people.

  @ people with a high blood cholesterol level.

  @ women who take drugs containing oestrogen, eg contraceptive pills.

  @ people with diseases such as chronic intestinal inflammation (Crohn's disease and

      ulcerative colitis).

What are the symptoms of gallstones?

It is thought that approximately two thirds of patients will have no trouble at all from their gallstones and only one third of patients will at some time experience symptoms. These symptoms can be extremely variable but usually present in one of three ways.

Chronic cholecystitis (biliary colic)
 

This is a chronic inflammation of the gall bladder and causes:

@ sporadic pains in the middle of the upper abdomen, or just below the ribs on the right side.

@ pain which becomes worse over an hour and then stays the same.

@ the pain may spread to the right shoulder or between the shoulder blades.

@ the pain can be accompanied by nausea and vomiting and sometimes excessive wind.

@ the attack can last from a few minutes to two to three hours before getting better.

@the frequency and severity of attacks is very variable.

@ attacks can be triggered by eating fatty foods such as chocolate, cheese or pastry.

@ it can be difficult to distinguish the pain from other diseases, such as: gastric ulcer, back

    problems, heart pains, pneumonia and kidney stones.

Acute cholecystitis (acute inflammation or infection of the gall bladder)

This condition results in:

@ persistent pain and a temperature lasting more than 12 hours.

@ pain and tenderness under the ribs on the right side.

@ the pain is made worse by movement or coughing.

Jaundice (yellow discolouration of the skin and whites of eyes)

This is caused when there is an obstruction to the flow of bile from the liver. Jaundice is not always caused by gallstones. The symptoms are:

@ increasingly yellow eyes and skin.

@ the skin can become itchy.

@ pale bowel motions and dark urine.

@ the condition is often preceded by symptoms similar to those of cholecystitis.

@ fever and shaking chills are serious symptoms and must be treated by a doctor - they are

   suggestive of infection travelling through the bile duct system.

@ patients with acute cholecystitis may not always have gallstones but usually do.

@ the condition must be treated by a doctor and usually requires admission to hospital.

@ the treatment consists of a course of antibiotics but if this is not effective emergency surgery

    may be required to remove the gall bladder.

How are gallstones diagnosed?

Blood samples are often taken to test if the liver is working normally. The most accurate method of detecting stones is by using an ultrasound scanner. This technique is quick and painless.

If the result of ultrasound scanning is inconclusive, other possible tests include a CT-scan and an MRI scan.

CT stands for computerised tomography and is a method of taking X-ray 'slices' of the body.

MRI stands for magnetic resonance imaging and pictures of the internal organs can be obtained without X-rays. MRI is very useful for looking at the bile ducts.

An oral cholecystogram. This is an X-ray examination with films taken over two days which will show if the gall bladder is still capable of contraction. This gives a good indication of the function of the gall bladder. If a gall bladder is diseased it may not function or contract properly and this will be seen using the oral cholecystogram.

ERCP (endoscopic retrograde cholangio-pancreatography) - this is used if it is suspected that the patient has gallstones in the bile ducts.

A small tube or endoscope is introduced down the gullet and into the duodenum under sedation. The bile duct is identified where it enters the duodenum and a very thin tube is placed into the duct. A dye is then injected into the duct and an X-ray taken to look for gallstones. Any gallstones detected may be removed at the same time which means that an operation may not always be necessary.


 

How are gallstones treated?

 

Gallstones which do not cause symptoms do not need any treatment. If a low-fat diet is not successful in controlling the symptoms some other form of treatment is required - this usually, but not always, means surgery.

Alternatives to surgery include

Dissolution therapy - sometimes a specific type of gallstone can be dissolved using medicines. If the patient is unfit or unwilling to have an operation, dissolution therapy with ursodeoxycholic acid (Urdox tablets) is occasionally possible although it takes a long time to dissolve a gallstone and it often comes back after the treatment is stopped.

To be suitable for dissolution therapy the gallstones have to be small to medium in size and 'radiolucent', ie they do not show up on plain X-rays. Gallstones that do show up on plain X-rays do not dissolve. The gall bladder also needs to still show the ability to contract.

Lithotripsy - single gallstones in the gall bladder or bile ducts can sometimes be 'shattered' by a technique called lithotripsy, which uses a 'beam' of sound energy. This method is commonly used for treating kidney stones but is only rarely useful for gallstones. The fragments of shattered stone will still need to be removed by ERCP or dissolution therapy.

Surgery for gallstones

When an operation is required for gallstones in the gall bladder it is usual to remove the gall bladder and gallstones together - this is called cholecystectomy.

If the gall bladder is left behind it is quite likely that further gall stones will form in it. There are two ways of removing the gall bladder and nowadays more than 90 per cent are removed by laparoscopic or keyhole surgery.

This involves making four small cuts less than 1cm long in the abdomen and the use of a tiny camera inserted though one of these cuts to see the gall bladder.

Other instruments are placed in the abdomen through the other cuts. If the operation is successful most patients are able to go home the day after surgery and return to normal everyday activities within two weeks.

In some cases laparoscopic surgery is considered too dangerous or too difficult and it is then necessary to do a traditional or 'open' cholecystectomy. This involves making a cut in the abdomen between 9 and 18cm long. The patient will usually need to stay in hospital for at least five days and will not be able to return to work for six to eight weeks.
 

Will the patient notice any difference after surgery?

After the gall bladder has been removed most people will be aware that their pain has completely disappeared and they no longer need to avoid fatty food.

Complications following gallbladder surgery are very rare and there are usually no long-term effects from having a gall bladder removed.