Gallstones

Gallstones

The gallbladder is a pear-shaped organ with a volume of 50 ml, attached to the underside of the liver. It stores and concentrates bile. The bile produced by the liver collects in this sac through ducts and is released into the intestine after meals, especially for the digestion of fatty foods. Gallstones, which occur in one in every 10 adults, are seen more often in women, especially after the age of 30. After the age of 60, gallstones form in 10–15 percent of men and 30–40 percent of women.

Gallstones form by the precipitation of solids in the bile. Most stones contain cholesterol. There may be a single stone in the gallbladder, but there are also cases in which the number reaches the thousands. Gallstones are common in fair-haired women, in overweight people, in those who lose weight very quickly, in those fed intravenously for a long time, and in those who have had part of the stomach removed surgically. There is evidence that the disease has a hereditary side. There are publications suggesting that caffeinated drinks and alcohol reduce gallstones. Gallstones can block the duct of the gallbladder so that its contents cannot empty, thus leading to inflammation that we call cholecystitis. Stones can block the main bile duct, causing bile to pass into the blood, that is, jaundice, or block the pancreatic duct, causing inflammation of the pancreas gland (pancreatitis). Sixty percent of patients with gallstones have no complaints at all. Twenty percent of hospital visits due to gallbladder disease are for inflammation of the gallbladder, that is, ‘acute cholecystitis’, which results from a suddenly developing stone blocking the duct. In 10 percent of these patients, severe complications such as jaundice, cholangitis (inflammation of the extrahepatic bile ducts) and pancreatitis are seen.

Giving ursodeoxycholic acid and similar drugs by mouth gives favorable results in the treatment of some gallstones. However, its success rate remains very low, and in half of the patients stones form again within the first 4 years. Today, the gold standard for patients with complaints due to gallstones is laparoscopic cholecystectomy. An operation performed with this method is less painful, and the patient can return to work within 2–3 days. By removing the entire gallbladder, the possibility of recurrence of the disease, new stone formation, cancer and development of complications is eliminated. Not having a gallbladder does not cause any serious problem in people.
 

Where is the gallbladder and what is its function?
The gallbladder is a pear-shaped sac located beneath the ribs, on the underside of the liver, attached to the upper right part of the abdominal region. Its function is to store and concentrate the bile produced by the liver, to be used when it is needed for digestion.
 

In which foods is bile especially necessary for digestion?
Bile is especially necessary for the digestion of fats and fatty foods.
 

How does bile reach the intestinal system?
Through a system of ducts or tubes. The gallbladder duct extends from the gallbladder to the common bile duct. The common duct is the result of the joining of two liver ducts that begin in the liver. Bile passes from the liver and the gallbladder through the common bile duct and enters the intestine at the “ampulla of Vater” of the duodenum.
 

If the liver produces and secretes bile, what is the specific function of the gallbladder?
The task of the gallbladder is to store and concentrate bile and, after a meal, to release into the intestine the extra bile that will be needed.
 

Which foods affect people whose gallbladder does not work well the most?
All pan-fried and fatty dishes, fried potatoes, heavy sauces, meat broths, chicken and turkey skin, eggs cooked in fat, turnips, cabbages, cauliflower, radishes, some raw fruits, etc.
 

Are gallbladder and bile duct diseases very common?
It is generally accepted that gallbladder disorders and poor functioning of the sphincter at the end of the common bile duct are the main causes of indigestion.
 

Is gallbladder surgery needed very often?
In people past middle age, removal of a diseased gallbladder is the most common abdominal operation. It is also one of the most frequently performed operations in all age groups.
 

What causes gallbladder disease?
a. Bacterial infection. Like appendicitis, tonsillitis or an infection in any other organ, this can cause acute or chronic inflammation of the gallbladder.
b. A functional disorder that prevents the gallbladder from releasing bile into the body.
c. A chemical imbalance that causes bile to form stones. These stones can block the passage of bile through the ducts into the intestines.
 

Do gallstones always develop from a chemical disturbance in the gallbladder?
No. Gallstones can result from a chemical disturbance, but they can also develop from an infection in the gallbladder.
 

How common are gallstones?
It is estimated that roughly one in four women and one in eight men will develop gallstones before the age of sixty.
 

Are there particular types of people who are more prone to gallbladder disease?
Yes. Overweight, heavily built people who eat a lot of fatty food are thought to be more prone to gallbladder disease. However, the disease can develop in any age group and in any type of person.
 

At what age does gallbladder disease first begin to develop?
Between thirty and forty. However, the disease is sometimes seen in younger people as well.
 

Does having children increase the tendency to form gallstones?
Yes. Pregnancy causes disturbances in fat and cholesterol metabolism. As a result, stones often begin to form within a few months after the pregnancy ends.
 

Does gallbladder disease often occur during pregnancy?
Not often. (When the disease is found in pregnant women, it is usually in women who have one or two children.)
 

Do gallbladder diseases tend to run in families or to be hereditary?
However, there may be an inherited tendency related to body build, the type of chemical metabolism, and the eating habits of the parents.
 

What happens when the gallbladder becomes acutely inflamed?
The blood flow to the gallbladder may be blocked, the gallbladder may fill with pus, or, because of insufficient blood flow, gangrenous changes may develop in the gallbladder wall.
 

What causes acute inflammation of the gallbladder?
Blockage of the bile duct by a stone.
 

What happens when there is chronic inflammation of the gallbladder?
Whether they arise from an earlier inflammation and infection or from a disturbance in the chemical mechanism, stones that develop in the gallbladder are associated with thickening of the gallbladder wall and its chronic inflammation. This leads to inadequate filling and emptying of the gallbladder and, in some cases, to its not functioning at all.
 

What happens when there is a functional disorder of the gallbladder or bile ducts?
This condition is characterized by the gallbladder being unable to empty and release bile when it is needed. In addition, a spasm may occur at the outlet of the common bile duct, and this too can prevent the free flow of bile into the intestinal tract. In this case the patient experiences indigestion, heartburn, and an inability to digest fatty foods, fats and some raw vegetables and fruits.
 

Do functional disorders of the gallbladder usually occur together with the development of gallstones?
Not always.
 

Are there measures to prevent gallbladder diseases or the symptoms of a poorly functioning gallbladder?
Following a light diet and eating foods that are low in fat and pan-cooked will reduce the load on the gallbladder and also reduce the rate of symptoms that may arise from poor function.
 

How can you tell that you have gallbladder disease?
a. Acute gallbladder disease ("acute cholecystitis") comes with rising fever, nausea, vomiting, and pain felt in the upper right part of the abdomen, below the ribs. An X-ray of the gallbladder may show that the organ is not functioning or may reveal stones in the gallbladder. A blood count may also show that there is acute inflammation.
b. Chronic gallbladder disease ("chronic cholecystitis"), when accompanied by stones, can cause severe colicky pain in the upper right part of the abdomen. This is usually due to a large stone lodged in the gallbladder or the bile duct. The pain often spreads to the right shoulder or the back.
Nausea and vomiting will occur, along with abdominal pain. If the stone falls back into the gallbladder or passes through the blocked duct, this pain will disappear within half an hour. In chronic gallbladder disease, X-rays usually show a non-functioning gallbladder and, in some cases, stones within it.
c. Functional disorders of the gallbladder show themselves as chronic indigestion and an inability to digest fats, fatty foods and some raw vegetables and fruits. Heartburn is another symptom. In such cases X-rays will show that the gallbladder is not filling and emptying adequately.
 

Is there a test that can definitively identify gallbladder disease?
Yes. It is an X-ray test called a "cholecystogram." Before the test, the patient swallows a special dye in the form of pills. A few hours after the pills are taken, an X-ray of the gallbladder is made; if the gallbladder is normal, the dye will fill the organ and thus show its outline. The X-ray will also show the emptying of the gallbladder after a fatty meal. In some cases, instead of pills taken by mouth, the dye is given to the patient by injection into a vein before the X-rays are taken.
 

What does it mean if the gallbladder does not show up on a gallbladder X-ray?
This is almost always evidence that the gallbladder is not functioning. Often, if the dye given to the patient is not visible on the X-ray, the patient is given the dye once more at a much larger dose and the X-ray is taken again. If the gallbladder still does not appear on the X-ray after this double dose, it is regarded as definite evidence that the gallbladder is diseased and, in some rare cases, indicates the presence of advanced liver disease.
 

Are gallstones always visible on X-rays?
No. In some cases, even when there are many stones in the gallbladder, they do not show up on X-rays.
 

Do X-rays show stones in the bile ducts?
Yes. Stones in the bile ducts can be seen with a relatively new diagnostic method performed through a vein, called "cholangiography." In this method, dye is injected into a vein in the patient's arm and the X-ray is taken immediately afterwards.
 

Is this method dangerous?
No, apart from rare cases such as an allergy to the dye.
 

How does the doctor decide whether medical or surgical treatment is needed for gallbladder disease?
Gallbladder diseases that are not accompanied by stone formation are preferably treated medically. For all other gallbladder diseases, surgery is preferred.
 

Are the treatment methods used for functional disorders of the gallbladder successful?
Yes, provided that the patient follows a sensible diet and does not neglect to take the necessary medication.
 

Does every patient with gallstones need surgery?
Surgery is not necessary in all cases. There are many people who have stones in their gallbladders that cause no symptoms at all. However, if gallstones are causing any symptoms, surgery is always necessary.
 

When is gallbladder surgery absolutely necessary?
a. When the organ is acutely inflamed.
b. When, because of the stones, the patient suffers repeated and severe attacks of colicky pain.
c. When stones are known to be present in the gallbladder and the patient suffers from chronic indigestion, nausea, gas and some abdominal pain.
d. When jaundice (yellowing of the skin) has developed because a stone has blocked the bile duct.
 

What is the medical treatment for gallbladder disease?
a. Avoiding foods that cause indigestion, for example fats, fatty foods, sauces, stuffings and some raw vegetables and fruits.
b. Continuing a well-prepared, light diet in small portions.
c. Taking the necessary medications to reduce stomach acidity and relieve spasms in the gallbladder.
 

When it is known that there are no stones in the gallbladder but there is a functional disease of the gallbladder, will surgery always relieve the symptoms?
Some patients will benefit from having the gallbladder removed, while others will not benefit from the operation.
 

What can happen if gallbladder surgery is not performed when it is definitely necessary?
a. Acute inflammation of the gallbladder can turn into gangrene and cause the organ to rupture. Such a condition can cause peritonitis and death.
b. Because of an obstructing gallbladder stone, recurrent attacks of colic can develop, and if the stone passes into the common bile duct, it can cause jaundice.
c. If jaundice is caused by a stone blocking the duct and surgery is not performed, the patient can die from the toxic effects of prolonged bile obstruction and from damage to the liver.
 

Is jaundice always caused by gallstones?
No. There are various causes of jaundice. The most common of them is hepatitis, an inflammation of the liver.
 

How can you tell whether jaundice is caused by a stone blocking the ducts or by something else?
There are various tests to determine whether jaundice is caused by a duct obstruction or by inflammation. The correct diagnosis can usually be reached by taking a complete medical history of the patient, examining the patient thoroughly, taking X-rays and performing various chemical blood tests.
 

Can stones increase the tendency to develop cancer in the gallbladder?
Yes. Gallbladder cancer develops in about 2% of people who have stones in the gallbladder. For this reason, surgery is always strongly recommended for people with gallstones, whether or not the stones cause symptoms.
 

Is gallbladder removal surgery (cholecystectomy) a dangerous operation?
No, it is no more dangerous than an appendectomy.
 

Can gallstones be dissolved with medication?
Recently, some gallstones have been successfully dissolved with concentrated bile salts given over several months. However, this treatment method is still at the experimental stage.
 

When performing gallbladder surgery, does the surgeon remove only the stones in the gallbladder or the entire gallbladder?
In the great majority of cases the gallbladder is removed. However, in some cases the organ is so acutely inflamed and the patient so unwell that the surgeon will prefer to remove only the stones from the gallbladder and place a drainage tube in it. This procedure takes less time and carries less risk.

Are the bile ducts also removed during gallbladder surgery?
No. A free passage from the liver to the intestines is required; for this reason the bile ducts are left in place.
 

How does the surgeon remove stones in the bile ducts?
The surgeon makes a small incision in the duct and removes the stone or stones with an instrument made specially for this purpose. After this procedure the duct is cleared with a rubber tube (T-tube) by drainage. This tube, which is left in the bile duct, will be removed after a few days or a few weeks, depending on the tests and the images that appear on the X-rays taken afterwards.
 

How long does gallbladder removal surgery take?
Between forty-five minutes and one and a half hours, depending on the severity of the inflammation.
 

What type of anesthesia is used in gallbladder surgery?
Either general anesthesia by inhalation or, in some cases, spinal anesthesia.
 

Is it common to remove the appendix as well during gallbladder surgery?
This used to be done often. But since a great decrease in appendicitis cases has been observed, most surgeons no longer use this practice.
 

What preoperative precautions need to be taken before gallbladder surgery?
If the operation is being performed for a simple inflammation without jaundice, no preoperative precautions are needed. However, in patients with acute inflammation or jaundice, a number of special preoperative precautions are required.
 

What are the special preoperative precautions in such cases?
a. A tube will be passed through the nose to ensure that the stomach is completely empty during the operation.
b. Before surgery, fluids, glucose and certain vitamins are given intravenously. If there is jaundice, vitamin K in particular will be given to prevent bleeding after the operation.
c. Antibiotics will be given to patients with an acutely inflamed gallbladder or inflammation of the bile ducts.
 

Are blood transfusions given in gallbladder surgery?
Generally not. However, in very serious cases and when there are complications, blood transfusions are considered necessary.
 

Is a private nurse needed after gallbladder surgery?
If the patient's financial situation allows, hiring a private nurse for two or three days will be of great help to the patient in terms of comfort.
 

How long does the patient need to stay in hospital for these operations?
Roughly between nine days and two weeks.
 

Where are the incisions made for gallbladder surgery?
One incision runs lengthwise in the upper right part of the abdomen, and another runs obliquely on the right side, just below the rib cage. The incisions are 12.5 to 17.5 centimetres long.
 

Are drainage tubes usually placed in the wound area in these operations?
Yes. One or two tubes are placed after the operation. They are left in place for six to ten days.
 

Does gallbladder surgery cause a lot of pain?
No. You may feel mild pain for a few days when breathing deeply or coughing after the operation, but the surgical wound itself does not cause much pain.
 

How soon after the operation can the patient get out of bed?
In uncomplicated operations, one or two days after the operation.
 

What special precautions are taken after the operation?
a. In a routine operation for a chronically inflamed gallbladder, the necessary postoperative precautions are only a few: the patient can eat the day after the operation, but should not be given fats, fatty foods, raw vegetables or fresh fruit. If there is a fear of infection, antibiotics may be given. So that the patient does not suffer discomfort from straining and bloating, in some cases a tube is passed through the nose into the stomach for one day after the operation.
b. A patient operated on for acute gallbladder inflammation or jaundice will probably receive intravenous injections, drainage through a tube passed from the nose into the stomach, vitamin K medication against jaundice, and large doses of antibiotics for a few days. In some cases, blood transfusions may also be needed.
 

How long does a normal gallbladder surgical wound take to heal?
Roughly between twelve and fourteen days.
 

Will a patient be able to lead a normal life after the gallbladder is removed?
Yes.
 

After the gallbladder is removed, which organ takes over its function?
Bile continues to flow directly from the liver into the intestines. The bile ducts begin to take over many of the functions of the gallbladder.
 

Is it normal for indigestion to continue for a few more weeks after the gallbladder is removed?
Yes.
 

Is there any danger for a woman who has had her gallbladder removed in becoming pregnant after the operation?
If she wishes to become pregnant, there is no harm at all.
 

Is it necessary to follow a special diet after the gallbladder is removed?
Yes. The patient should continue the diet they followed before the operation; in other words, they should avoid fatty foods.
 

How long after a stone is removed from the common bile duct does the jaundice go away?
Within a few weeks.
 

Can the symptoms of gallbladder disease continue or recur after the operation?
Yes. In about 10% of patients who have had gallbladder surgery, symptoms persist after the operation. These symptoms are thought to arise from spasms at the lower end of the common bile duct (biliary dyskinesia).
 

Can new stones form in patients after the stones have been removed?
If the gallbladder has been removed, there is no possibility of stones forming again in the gallbladder. However, in a very small proportion of patients, new stones may form in the common bile duct. Stones can also develop again in the stump of the bile duct that is left behind after the gallbladder is cut away.
 

What treatment method is used if stones have formed again in the common bile duct?
A specially made instrument is passed through the mouth and stomach into the duodenum. The opening of the bile duct where it enters the duodenum is then widened, which makes it possible for the stones to be released. If this procedure fails, another operation is needed.
 

Can any doctor perform the passing of a tube into the duodenum?
No; it is a very complex procedure and can only be performed by endoscopy specialists.
 

Are there ways to prevent stones from forming again?
Generally there are not. However, patients should be protected against infections and should follow a light, low-fat diet.
 

Does removal of the gallbladder have any effect on life expectancy?
It has no effect at all.
 

What are the recovery rates after gallbladder surgery?
The mortality rate in gallbladder operations is less than 1%. Deaths generally occur in very complicated cases or in people who have neglected to seek treatment for a long time.
 

When should one see the doctor for check-ups after gallbladder surgery?
After the operation, you should go for check-ups twice, at six-month intervals.
 

Extrahepatic bile duct stones

They usually occur when stones from the gallbladder fall into the bile ducts, or, more rarely, when stones form in the bile ducts themselves. Today they are removed by an intervention called ERCP, performed by passing an endoscope through the mouth, and this is followed by keyhole gallbladder surgery.
 

Bile duct strictures

They are usually encountered as strictures that develop after gallbladder surgery, or in conditions such as a lymph node or mass pressing on the duct from outside. In this case the bile ducts need to be reconnected to the small intestine.
 

Tumors of the gallbladder and bile ducts

Extrahepatic bile duct cancer is a rare disease in which cancer cells develop in the bile ducts outside the liver.
The bile ducts are the channels that connect the liver and the gallbladder to the small intestine. This network begins with tiny ducts that collect bile, a fluid made in the liver that helps absorb fats during digestion. These small ducts join together to form the right and left hepatic ducts, which leave the liver. Outside the liver, the two ducts join to form the common hepatic duct. The part of the common hepatic duct outside the liver is called the extrahepatic bile duct. The extrahepatic bile duct joins the duct of the gallbladder (which stores bile) to form the common bile duct. During the digestion of food, bile is emptied from the gallbladder into the small intestine through the common bile duct.

Colitis and certain liver diseases may affect the risk of developing extrahepatic bile duct cancer.

Possible signs of extrahepatic bile duct cancer are jaundice and pain.
These and similar symptoms can occur in extrahepatic bile duct cancer as well as in other diseases. You should see a doctor if the following problems occur:

Jaundice (yellowing of the skin or the whites of the eyes)

Abdominal pain

Fever

Itching of the skin