What are gallstones?

The gallbladder is a small organ that lies beneath the liver. The function of the gallbladder is to concentrate and store bile. Bile is required to digest and absorb fatty food. As a meal containing fat is consumed, the gallbladder contracts and empties into the bowel where is mixed and helps to digest food.

 

Gallstones are solid, stone like structures that form inside the gallbladder. There are two main types of stones; cholesterol or pigment. Cholesterol stones are a lot more common than pigment stones. 

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Who gets gallstones?

what are the risk factors ?

  • Women more commonly develop gallstones
  • Becomes more common with age, especially after 40
  • They can run in the family
  • Pregnant women
  • Obesity
  • Rapid weight loss including surgical interventions for weight loss
  • Diabetes
  • Sickle cell disease- there patients are more likely to develop pigment stones

What are the symptoms of gallstones?

Most people do not get any symptoms from gallstones and are found incidentally on scans performed for other reasons. These do not need to be treated unless they become symptomatic. When symptomatic the signs to look out for include:

  • Abdominal pain on the right upper abdomen just below the ribs. This pain can also be in the centre of the upper abdomen or in the right chest and is often confused with a heart attack. The pain caused by gallstones is known as biliary colic
  • May get right shoulder or back pain
  • Nausea and or vomiting

What are the complications associated with gallstones?

  • Acute cholecystitis which is infection and inflammation of the gallbladder. This occurs when a stone blocks the gallbladder. The pain with cholecystitis is usually constant and is often associated with a fever. The treatment of cholecystitis is antibiotic, fluids and painkillers. If this is not treated the gallbladder can burst and the patient can become very unwell. 
  • Choledocholithiasis is when the stones leave the gallbladder and enter the ducts of the liver or the pancreas. This can result in: 
  • Jaundice which is a yellow discolouration of the skin and eyes
  • Cholangitis which is when a stone blocks the main duct of the liver resulting in severe infection. The patient experiences severe pain, jaundice and fever. This stones occasionally can pass through by itself but often the patient requires a procedure for this to be removed; endoscopic retrograde cholangiopancreatography also known as an ERCP.
  • Pancreatitis which is when of the stones blocks the duct of the pancreas leading to inflammation of the pancreas

How are gallstones diagnosed?

The commonest way to identify stones is with an ultrasound scan of the abdomen. Often they are also picked up on other imaging such as a CT or an MRI scan but this is less common. 

What are the consequences of not undergoing treatment?

As mentioned above patients may develop complications if they do not undergo treatment. These include

  • Pain in the right upper abdomen also known as biliary colic
  • Infection of the gallbladder, known as cholecystitis
  • Stones that have move out of the gallbladder into the ducts of the liver and the pancreas leading to cholangitis and pancreatitis.

What are the treatment options?

  • Wait and watch. This is the likely course of action when the stones are asymptomatic. 
  • Non-surgical treatment includes a medication known as ursodeoxycholic acid which can help to dissolve gallstones. It can usually take a few months for symptoms to settle but a few years for the stones to dissolve completely. 
  • Shock wave therapy although usually used for kidney stones and rarely used for gallstones is a known treatment. It uses shock waves to break down gallstones into a finer consistency so it can be mixed in bile. 
  • Extraction of stones through the skin, although rarely performed can be done. This involves inserting a tube though the skin into the gallbladder, removing the bile and gradually increasing the size of the tube to remove the stones. 
  • The disadvantage of undergoing non-surgical management is that they are rarely used and also hold the risk of recurrence of stones. 
  • Surgical intervention is an operation that removes the gallbladder known as a cholecystectomy. This is one of the most commonest operations in the surgical world.

How is procedure performed?

Cholecystectomy or removal of the gallbladder can either be performed as a key hole procedure or with a larger incision. A key hole operation also known as a laparoscopic cholecystectomy involved making four small cuts on the abdomen and inserting a camera to visualize the gallbladder and removing the gallbladder through the small cuts.

What are the risks surgery?

  • Infection
  • Pain
  • Intra or post procedure bleeding
  • Damage to other organs within the abdomen including the bowel, liver, stomach etc
  • Bowel perforation
  • Damage to the ducts of the liver known as the bile duct
  • Damage to the bile duct can lead to a bile leak, need for open conversion and drain insertion
  • Conversion to open surgery
  • Need for endoscopy post-surgery if there is concern of a leak or further stones
  • Complications related to a prolonged operation/anaesthetic including clots in the legs, lungs, brain or heart. 
  • In the long-term patients must be warned about the risk of loose stools and bloating.

    These symptoms are usually mild and do not need any intervention

 How long will I be in hospital and what is the recovery period and follow up?

After surgery the course of recovery is as follows:

  • Tend to go home the same evening or the next day if the operation was uncomplicated
  • Can eat and drink as tolerated immediately after the operation
  • 1- 2 weeks before going back to work
  • Absorbable stitches are usually used for the skin
  • No heavy lifting or strenuous activity for 6 weeks
  • Patients will be followed up 4-6 weeks after surgery

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