A gallstone, is a lump of hard material usually range in size from a grain of sand to 3-4cm. They are formed inside the gallbladder formed as a result of precipitation of cholesterol and bile salts from the bile.
Types of gallstones and causes
- Cholesterol stones
- Pigment stones
- Mixed stones – the most common type. They are comprised of cholesterol and salts.
Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason.
Pigment stones are small, dark stones made of bilirubin. The exact cause is not known. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anaemia in which too much bilirubin is formed.
Other causes are related to excess excretion of cholesterol by liver through bile. They include the following
- Gender. Women between 20 and 60 years of age are twice as likely to develop gallstones as men.
- Obesity. Obesity is a major risk factor for gallstones, especially in women.
- Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or birth control pills
- Cholesterol-lowering drugs.
- Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides.
- Rapid weight loss. As the bodymetabolizesfat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.
Symptoms may vary and often follow fatty meals, and they may occur during the night. They may include:
- steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
- pain in the back between the shoulder blades
- pain under the right shoulder
- nausea or vomiting
- Indigestion & belching
- abdominal bloating
- recurring intolerance of fatty foods
Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called “silent stones.” Gallstone symptoms can be similar to those of heart attack, stomach ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. Accurate diagnosis is important.
Ultrasound is the most sensitive and specific test for gallstones.
Other diagnostic tests may include
- Blood tests – may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.
- Computed tomography (CT) scan may show the gallstones or complications.
- Endoscopic retrograde cholangiopancreatography (ERCP). – Under sedation a telescope is passed via the stomach into the duodenum. The bile duct is accessed and a special x-ray dye used to look for stones that have passed into the bile duct. These can then be extracted.
- HIDA scan – a special scan that assesses the function of the gallbladder. A gallbladder damaged by stones and inflammatory tends to lose the ability to contact and empty properly.
Course of illness
With prompt diagnosis and treatment, the outcome is usually very good. However bile-duct blockage and infection caused by stones in the biliary tract can be a life-threatening illness.
Complications of gallstones
- Biliary Colic – pain caused when the gallbladder is obstructed by a stone. It is usually lasts several hours and relieves when the stone moves. It may be exacerbated by fatty foods which make the gallbladder contact.
- Chronic Cholecystitis – repeated inflammation causes thickening and scarring of the gallbladder
- Acute Cholecystitis – if the stone blocking the gallbladder does not move then a severe attack occurs. This can be very painful and cause you to feel very unwell. If untreated, infection can develop leading to an Empyema or abscess of the gallbladder.
- Jaundice – can occur if the bile duct becomes blocked by a passing stone. The bile backs up in the liver and eventually caused the skin and eyes to become yellow. The urine becomes dark and stools pale.
- Cholangitis – Cholangitis is an infection of the bile duct, which carries bile from the liver to the gallbladder and then to the intestines. This can be a life threatening illness and requires urgent treatment
- Pancreatitis – Passage of stones through the bile duct can cause inflammation of the pancreas. This causes severe pain that radiates through to the back. A severe attack of pancreatitis can cause may complications and may be life threatening
- Cancer – Prolonged inflammation of the gallbladder from stones can lead to the development of gallbladder cancer. It is often untreatable once diagnosed.
Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. The most common operation is called laparoscopic cholecystectomy. For this operation, the surgeon makes several 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 tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures.
If gallstones have passed into the bile ducts there are several methods to remove them. Sometimes a skilled laparoscopic (key-hole) surgeon can remove them at the same time as taking out the gallbladder. Alternatively a different procedure using a telescope passed through the stomach can be used to locate and remove them before or after the gallbladder surgery. This is known as endoscopic retrograde cholangiopancreatography (ERCP). We offer all these procedures and are able to select the best approach for your specific condition.
Indications for Gall Bladder removal
- Once a patient develops symptoms the risk of further attacks of pain and complications is high and surgery is recommended
- As diabetics with gallstones have a higher risk of complications and infection they should usually have their gallbladder removed
- Pancreatitis is commonly caused by gallstones. When no obvious cause is found cholecystectomy is often recommended as a significant proportion of these patients have microscopic stones that may cause further attacks.
- Gallbladder polyps or tumours
- Gallstones are very common. If gallstones are found incidentally in patients without any symptoms they can usually be observed as the risk of developing problems is only about 2-3%.
What are the Benefits?
Open surgery to remove the gallbladder requires a large incision, 5-7 days in hospital and many weeks to fully recover. The main benefit of laparoscopic cholecystectomy is that it is minimally invasive surgery. Minimally invasive surgery means “Lesser Pain” and “Faster Recovery”. The majority of patients are discharged the day after surgery. Most patients resume normal activities within 1-2 weeks following their procedure.
Is laparoscopy always advised?
There are very few instances when laparoscopic surgery is not preferable to conventional open surgery for cholecystectomy.
- Obesity – there are fewer post-operative complications with laparoscopic surgery as a larger incision can be avoided
- Previous surgery – adhesions can often be dealt with successfully with laparoscopy
- Common bile duct stones can be removed by laparoscopy, or by ERCP.
- Severe cholecystitis is best dealt with acutely – one operation and recovery period – and can be done safely with laparoscopic technique.
- Pregnancy – the gallbladder can easily be removed during the first half but in the later stages of there may not be enough space to operate. You must tell us if you are pregnant as x-rays must be avoided.
Risks & Complications
Laparoscopic Cholecystectomy is one of the most commonly performed operations. Complications are uncommon and may include:
- Bleeding & infection may occur with any surgery
- Blood clots in the legs and/or lungs (DVT/PE) – this is minimised by early mobilisation and blood thinning injections after the surgery
- Conversion to an open procedure may be required if the gallbladder cannot be safely removed by keyhole surgery. This is uncommon in the hands of a skilled surgeon but the risk increases with a severe attack of cholecystitis, recurrent attacks or if surgery is delayed
- Retained stone – if a stone has passed from the gallbladder into the bile duct this would be left behind if only the gallbladder is removed. An x-ray is performed routinely during your surgery with a special “dye” injected into the bile ducts to look for stones. Sometimes a skilled laparoscopic surgeon can remove these using keyhole surgery. If that is unsuccessful then an ERCP will be required as a subsequent procedure.
- Bile leak – leakage of bile from the duct or the liver where the gallbladder has been removed occurs in about 1 in 200 cases. A further procedure for drainage or an ERCP may be required to stop the leak.
Bile duct injury – damage to the bile duct tubes that join the gallbladder to the liver and bowel occurs in less than 1 in 300 cases. It is usually only a risk when severe inflammation causes the gallbladder to stick to the bile ducts making them difficult to separate. Management usually requires further surgery by a specialist Upper GI surgeon.