The gallbladder is a pear-shaped organ located beneath the liver at the right upper quadrant of the abdomen. It stores and concentrates bile which is secreted from the liver throughout the day. It contracts and empties the concentrated bile only when we eat. It contains a lot of excretory materials like cholesterol and bilirubin (Hemoglobin degradation by-product). When the bile is oversaturated with products like cholesterol or bilirubin, they get hardened and form gallstones. Other than this, if the contraction of the gallbladder is not proper, it can also lead to stasis and stone formation.
Size of the stone: The stone size varies from sand-like material (sludge) to lemon size. Gallstone may be single or multiple. The size and number of stones normally don’t matter to decide the treatment. It’s only the symptom results from the stone matters.
Types of gallstones:
It's difficult to pinpoint exactly what causes gallstone in a particular patient. It may be due to
Gallstones may or may not be symptomatic. It may cause a variety of symptoms depending on the location of the block it causes in the biliary tract.
Biliary colic: If a gallstone blocks the neck/cystic duct temporarily, it causes pain alone. It usually short-lasting and felt in the epigastric/right upper quadrant of the abdomen. In medical terminology, it is called biliary colic.
Acute calculous cholecystitis (inflammation of the gallbladder): If a gallstone blocks the neck/cyst duct permanently, this will lead to stasis bile inside gallbladder and infection. This condition is called acute calculous cholecystitis. Sometimes if the infection is severe, the gallbladder will be filled with pus (Empyema gallbladder) or gangrene/perforation of the gallbladder. When this occurs, the patient will develop severe pain in the upper abdomen. This pain can radiate to the right shoulder/back. There may be associated fever/vomiting. Unlike biliary colic, this will be a continuous pain that often needs injectable analgesics (pain killers) or hospital admission.
Choledocholithiasis (Common bile duct stones): If gallstones enter into the common bile duct, it will be called choledocholithiasis. This may block the bile flow and cause jaundice, pain, and fever. Liver function tests will show abnormally elevated bilirubin and enzymes level. Obstruction of bile flow along with superadded infection can lead to a life-threatening infection called cholangitis. In this condition, the bacteria, as well as toxins from the biliary tree, enter into blood circulation. If the block has not been relieved promptly, the patient may go into septic shock and multiorgan failure.
Acute pancreatitis: In some patients, the gallstones slip into the common bile duct and block the common channel of bile and pancreatic duct (Ampulla). Again, this is one of the dreaded complications of gallstones. Acute pancreatitis may be mild or severe types. Patients usually have upper abdominal pain often radiating to back and vomiting. In this condition, scans may not show any pancreatic abnormality in the initial few days. But the pancreatic enzymes like amylase/lipase will be elevated. Only in severe type of pancreatitis, patients go into multi-organ failure and often developed necrosis of pancreas (dead pancreatic tissue) with collections
Gallbladder cancer: Although it is not proven beyond doubt, there is a suspicion that gallstones may be associated with gallbladder cancer. More or less, the likelihood of gallbladder cancer is very less
Gallstone ileus: Rarely large gallstones perforate the intestine directly (bilio-enteric fistula) and block the intestine. Patients present with acute abdominal distension, pain and vomiting.
Asymptomatic Gallstones: Gallstones not associated with symptoms have been observed over a long time successfully. Only a small group of people developed problems, mostly pain to start with. The concept of observing (without surgery) asymptomatic gall stones is becoming common nowadays. But there are some medical exceptions to do surgery even if the stones are asymptomatic like hemolytic disorders.
Risk factors for gallstone development:
The tests and procedures used to diagnose gallstones and its complications are as follows.
The liver function test will be normal in asymptomatic/ uncomplicated gallstones. Elevated bilirubin/Alkaline phosphatase along with other enzyme abnormalities indicates complicated gallstone. Total leukocyte counts may be elevated in the presence of infection. Amylase/lipase enzymes are elevated in acute pancreatitis.
Ultrasonography: Routine first investigation of gallstone disease is ultrasonography. It will pick up gallstones in most of the cases. However, if we suspect stones in the common bile duct, we need to do further imaging like MRCP (Magnetic resonance cholangiopancreatography)
This is a form of Magnetic resonance imaging (MRI) which gives a map of the biliary and pancreatic ducts. It will show stones /block in the common bile duct.
This is an invasive test usually done by endoscopists under anesthesia. Through endoscopy, the bile duct is cannulated and radiopaque dye is injected and X-ray (using C arm) taken. After the arrival of MRCP, this is no more used for solely diagnostic purposes.
An alternative/ complementary test for MRCP. This will be done by endoscopist usually under anesthesia. This will pick up smaller stones. It can also help to rule out any other pathology causing biliary obstruction.
Gallstones if symptomatic require Surgical removal of the gallbladder (Cholecystectomy). Only removing the stones and leaving behind the gallbladder is not at all an option as the stones reform in all the patients. No proven medical treatment which provides cure as of now. Even if it dissolves stones temporarily, they will reform once the patient stops taking drugs. Your doctor will determine whether treatment for gallstones is indicated based on your symptoms and the results of tests like liver function tests. Olden days gallbladder removal is done by cutting open the abdomen (Open cholecystectomy). In difficult situations during surgery, a small portion of the gallbladder is left towards the liver side or common bile duct side to prevent injury. This is called a subtotal cholecystectomy. Drainage tubes may be selectively required and removed after a few days.
Patients will undergo a package of tests to access their fitness for surgery. Laparoscopic gallbladder removal surgery requires general anesthesia. Patients need a short period of fasting before surgery. If patients have comorbidities like diabetes, hypertension, hypothyroidism, asthma, cardiac ailments, they should be optimized before surgery. If the patient is taking antiplatelet drugs (aspirin, clopidogrel) or anticoagulants (warfarin), they should be stopped before surgery in consultation with the primary treating physician. Single-dose of preoperative antibiotics given at the time of induction of anesthesia.
Laparoscopic (Keyhole) Cholecystectomy is the gold standard nowadays. Through 4 small holes (two 10mm, two 5mm) the gallbladder can be removed. By this, we can avoid a big scar after surgery. The same day patient can go home and resume normal activity. However, they may require to take pain killers (analgesics) for a few days. Contrary to the common belief, no dietary restrictions (including fatty foods) are required. Avoiding prolonged fasting and taking small frequent meals are usually advised.
In Acute cholecystitis, if the patient comes early to hospital, Laparoscopic cholecystectomy can be done at the same admission. However, if the patient's general condition does not allow surgery or if he/she comes to the hospital after a week of disease onset, a tube will be put into the gallbladder under ultrasonography guidance to drain the infective fluid out as a temporizing measure. Laparoscopic cholecystectomy will be done later after 6 weeks.
In common bile duct stones, it is mandatory to clear the stones before cholecystectomy. This is usually done by the endoscopic method (ERCP stone removal) followed by laparoscopic cholecystectomy. These two procedures are done in the same anesthesia. This will reduce the cost and hospital stay. The patient can go home the same day. In selected patients, removal of bile duct stones along with the removal of the gallbladder is done fully laparoscopically.
In acute pancreatitis, if it is a mild attack, cholecystectomy can be done in the same admission before discharging the patient. However, in severe cases, it will be delayed up to 6 weeks. This is to observe how the pancreatic pathology evolves. Some patients develop symptomatic fluid collections around the pancreas and can be addressed along with gallbladder surgery if needed.
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