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  • Dr Lee Chin Li

Gallstone Disease, published Dec 2021

Updated: Apr 22

The Gallbladder:

Gall bladder
Image courtesy of Lee Surgery

The gallbladder is a pear-shaped sac-like organ situated below the liver on the right side of the upper abdomen. It is connected to a complex tube system that links the liver to the intestine. Its function is to store bile produced in the liver. The bile juice is then concentrated and secreted into the bile duct and from there into the intestine. This occurs after ingestion of fatty food and bile juice aids in digestion of fatty or oily food.


Gallstones:

Gallstones are crystalline deposits in gallbladder. There are 3 different types of gallstones, namely pigmented, cholesterol and mixed stones. The most common stones being cholesterol stones. Although there is no clear cause on why gallstone forms. Healthcare professionals think that it is due to imbalance in multiple components and factors in bile juice. Some risk factors have been identified and they are obesity, rapid weight loss, lack of physical activities, dietary (high fat and cholesterol diet), diabetics, genetic traits, and diseases such as blood disorders, Crohn’s disease, and liver cirrhosis. Some ethnicity such as native American Indian and Hispanics have also been shown to have higher incidence of gallstone. A change in diet reducing fatty food intake may not prevent formation of gallstone completely but may reduce the symptomatic attack of gallstone pain.

Presentation:


Gallstone is common and may affect up to 20% of the population. 90% of patients with gallstone will not have symptom and in these patients, most will not require treatment. In patients with symptomatic gallstone, the commonest symptom will be feeling of indigestion or bloatedness with discomfort over right upper or middle abdomen (biliary colic). The discomfort may move to right upper back, below the right shoulder blade and this is maybe triggered after eating oily meals. The risk of developing symptom in patients with no symptom ranges from 2-4 % yearly.


There are also more severe presentations of gallstones. Complications of gallstone depends on the location of the stone. In patients with stone impacted at the neck of gallbladder, patient may develop a gallbladder infection (acute cholecystitis). Symptoms include more severe and persistent pain over the upper right abdomen with fever. These patients will require antibiotics and a surgery to remove the gallbladder.

Gallstone
Image courtesy of Lee Surgery

If stones or sand passes out into the bile duct, patient may have obstructive jaundice, bile duct infection (cholangitis) or gallstone pancreatitis. Bile duct infection and inflammation of the pancreas can be severe, and it has been reported to be life threatening in up to 20% of cases. Patients may have severe right upper or central abdominal pain with fever, vomiting and jaundice. Patients need to seek treatment early. Appropriate tests may be ordered, and treatment includes hydration, antibiotics, and an endoscopy to remove stones before performing a surgery to remove the gallbladder.


In patients with symptoms, a visit to an experienced Hepatobiliary and pancreatic surgeon with proper history taking and examination, supported with investigations is essential to ensure an accurate diagnosis of the condition. Blood tests such as full blood count and a liver function test can aid the surgeon in diagnosing complications of gallstones. Ultrasound of gallbladder is the commonest imaging test ordered to identify gallstones and gallbladder infection. Occasionally, a Computed Tomography of the abdomen (CT Abdomen) or Magnetic Resonance Imaging (MRI) may be ordered by the surgeon to confirm diagnosis of bile duct infection or gallstone pancreatitis.

Patients with no symptom need not undergo any treatment except when the patient has blood disorders such as sickle cell disease or patient is undergoing bariatric surgery. In cases when patient has other underlying gallbladder disorders such as gallbladder polyps and porcelain gallbladder, surgery may be offered even if there is no symptom. This is because in these conditions, risk of gallbladder cancer will be higher. In porcelain gallbladder, the risk of developing gallbladder cancer is in the range of 30-50%.

Gallbladder surgery

Patients with biliary colic or acute cholecystitis should undergo a surgery to remove gallbladder is necessary. Identifying and seeking treatment early when patient has symptomatic gallstone is important to prevent more severe and life-threatening complications.

The surgery of choice will be a keyhole (laparoscopic) removal of gallbladder and gallstones. The surgery requires 3-4 small incisions of about 0.5-1.5cm. As these scars are small, most will not be well seen after it has healed. The success rate of performing keyhole surgery is approximately 98%. In view of proximity to bowel and adjacent bile duct, the risk of injury to the organs are 1% and 0.3% respectively. Overall, laparoscopic cholecystectomy is safe with low overall risks in experienced hands. This surgery can be performed as day procedure or patient only need stay for a day in hospital for observation, making it one of the commoner surgeries in general surgery.


Other modes of treatment:

  1. Medication (Ursodeoxycholic acid)

Surgeons may sometimes prescribe ursodeoxycholic acid in attempt to dissolve gallstones. It will take a some time to be effective and in >50% gallstones may recur. Only about 25% of patients will have improvement in symptoms.


  1. Lithotripsy

Lithotripsy treatment of gallstone uses ultrasonic shock waves aiming to break up the stones. This type of treatment is uncommon and may only be beneficial for a small number of patients. Both Medication and lithotripsy is not the first choice of treatment in patients who are fit to undergo surgery due to high recurrence risk and low long term improvement of symptoms.


Life without gallbladder:

Cholecystectomy is a common procedure and a person can survive without a gallbladder. Bile juice produced by liver will flow into the small intestine from the liver via the bile ducts, rather than being stored in the gallbladder. A small percentage of patients who have had their gallbladder removed will experience more frequent and softer stools. This is because their bile flows into the small intestine more often. This is usually temporary as the body adjust to changes in the body.

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