Gallstones

Where is my gallbladder and what does it do?

The gallbladder is a small pear shaped sac with a capacity of around 50 mls. It is situated just below the liver. Its main job is to collect bile which is released into the gut after eating to aid digestion, particularly of fatty foods.

How common are gallstones and how do they form?

Gallstones are very common, their incidence increases with age and they are far more common in females. They are seen in around 10% of women in their forties and 30% over the age of 60, the incidence of gallstones in men being roughly half that for women. Bile contains a variety of substances such as cholesterol, phospholipids, bile salts (the by-products of red blood cell breakdown) and water. These substances remain in solution but when one of them becomes too concentrated it begins to precipitate and form a stone. These stones may continue to grow in size as more of the bile constituents “stick” to them or a great many may form in a similar way. A number of factors may contribute to the formation of stones including obesity, small intestinal disease (such as Crohn’s disease), oestrogen (such as the oral contraceptive pill), diabetes, previous surgery and liver disease, although the majority of patients with gallstones do not have any serious underlying disease to account for their formation.

What symptoms do gallstones cause?

Gallstones may give rise to a variety of symptoms, the following is a summary of the most common;

Silent gallstones
The vast majority of gallstones cause no symptoms at all and are often detected incidentally by a scan performed for other reasons. These stones are unlikely to cause the patient any problems and are usually don’t require any treatment.

Chronic cholecystitis (Biliary colic)
Gallstones may cause recurrent, intermittent bouts of pain in the upper abdomen often related to eating fatty foods. This may also give rise to a mild fever and vomiting. Pain is often cramping in nature and usually settles without seeking medical treatment, only to return at a later stage. It is caused by the gallbladder contracting forcing a stones to temporarily block the gallbladder, the pain stops when the stone falls back allowing bile to pass freely again.

Acute cholecystitis (inflammation of the gallbladder)
This occurs when a gallstone blocks the outlet of the gallbladder leading to inflammation that doesn’t resolve spontaneously. Patients often have severe, sharp pain below the ribs on the right side and may be associated with a high temperature. This often requires admission to hospital. These symptoms usually settle with time, antibiotics and bowel rest but often require an operation to prevent the pain from returning.

Jaundice
Stones may pass from the gallbladder and lodge in the common bile duct (which carries bile from the liver and gallbladder to the intestine) and become lodged without passing into the gut. In this case the bile can not pass from the liver into the gut, the by-products of red blood cell breakdown can not be excreted from the body and the patient develops jaundice with classical pale stools and dark, tea coloured urine.

Pancreatitis
Pancreatitis is the most dangerous complication of gallstones and can be life threatening. A stone may lodge in the bile duct which also blocks the pancreatic duct. This causes inflammation of the pancreas gland as digestive juices become activated within the gland causing the tissue to digest itself. Pancreatitis leads to sudden onset, severe upper abdominal pain requiring admission to hospital.

How can my gallstones be diagnosed?

Gallstones are usually seen clearly by a simple ultrasound test. In some cases an MRI scan may be used to visualise the stones particularly if they are present in the bile ducts.

Treatment for gallstones

The majority of gallstones do not require any medical treatment with only 2% of those found to have silent gallstones developing symptoms each year. Patients with chronic cholecystitis can often manage by following a low fat diet but many patients prefer to undergo an operation to remove the stones. Gallstones can be dissolved with drugs however this is a very slow process and they usually reform. Currently the best treatment for gallstones is to remove the gallbladder by keyhole surgery (laparoscopic cholecystectomy). People have no difficulties living a normal life and eating a normal diet without their gallbladder and around 40,000 cholecystectomy operations are performed in the UK each year. The majority of patients are able to go home the same day as the surgery. Only around 5% of patients have to undergo a more “traditional”, open operation, which is usually performed in particularly complex cases. This results in a much larger scar and a slower recovery but may be necessary when the gallbladder is particularly inflamed or there are stones present in the bile ducts which require removal. Although laparoscopic cholecystectomy is generally very safe, 0.3% of people sustain injuries to their bile ducts requiring complex surgery to correct. If a patient has been jaundiced or has abnormal liver tests it is important to ensure there are no stones in the bile ducts, this is generally done before the operation by means of an endoscopy known as an ERCP. This is performed under sedation and may require an overnight stay. Stones may also be removed from the bile ducts at the time of surgery either laparoscopically or by an open operation.

What happens after surgery?

Patients can usually go home the same day and return to normal activities as soon as they feel ready.