Gallbladder stones

1. What is a gallbladder?
Gallbladder is a pear shaped organ present close to the liver.Its function is to store and concentrate bile juice which is produced in the liver. It does not produce bile as many people think.
2. What is bile?
Bile is a liquid produced by the liver which helps the body to digest fat. On eating a meal, the gallbladderpushes this bile into the common bile duct which carries it to the intestine.
3. What are gallstones?
  •    The exact cause for their formation is not known , however, risk factors include:

  •    Gender: Women between 20 and 60 years of age are twice as likely to develop gallstones as men

  •    Age: Practically all age groups but more common in the 30-40 years

  •    Obesity

  •    Excess estrogen (women on oral contraceptive pills etc.)

  •    Cholesterol-lowering drugs

  •    Diabetes

  •    Rapid weight loss

  •    Prolonged fasting

  •    Hereditary blood disorders

  •    Unknown geological factorssuch as gallstones are much more common in northern and eastern part of india.
4. Who is at risk for gallstones?
  •    Women are more prone than men

  •    people in their 30's and 40's

  •    Overweight men and women

  •    people who fast frequently or lose a lot of weight quickly

  •    Pregnant women, women on hormone therapy and women who uses birth control pills for a prolonged period.

5. What are the symptoms.?
Symptoms of gallstones are severe abdominal pain often called a gallstone 'attack' (colic) because they occur suddenly. Gallstone attacks often follow fatty meals, and they may occur during the night.A tipical attack can cause the following.
  •    Severe pain in the right upper abdomen that increases rapidly and lasts fromfew minutes to several hours

  •    Pain in the back between the shoulder blades

  •    Pain under the right shoulder

  •    Nausea or vomiting

Other symptoms of gallstones include:

  •    Abdominal bloating (gasformation)

  •    Recurring intolerance to fatty foods

  •    Belching

  •    Indigestion

People who also have the following symptoms should see a doctor right away:

  •    Sweating

  •    Chills (shivering)

  •    Low-grade fever

  •    Yellowish colour of the skin or whites of the eyes

  •    Clay-coloured stools

  •    Many people with gallstones have no symptoms. These patientsare said to be asymptomatic and these stones are called 'silent stones'.

6. What complications can these stones cause?
  •    Recurrent severe abdominal pain or vomiting

  •    Pus formation in the gallbladder (Empyema)

  •    Cholangitis (life threatening in fection of biliary system)

  •    Gangrene and perforation of the gallbladderisAcute pancreatitis (swelling of pancreas) which can have a catastrophic sequel of multi-organ failure and other serious complications

  •    Jaundice due to blockage of the common bile duct due to stones

  •    Associated with cancer of gallbladder in the long term.

7. What is the treatment?
Medical: Treatment of symptoms of pain with injectable ororal painkillers. No medical therapy is available for gallstones as such which can cure the disease. Though, injectable or oral antibiotics and supportive medications are available for treating the infection.

Surgery: Surgery to remove the gallbladder (cholecystectomy) is the only way to treat gallstones. This can be done by conventional (open) method or a well established endoscopic (laparoscopic) method which is now the 'Gold standard'. The surgery is called Laparoscopic Cholecystectomy (Lap. Chole). For this operation, the surgeonmakes few tiny incisions in the abdomen and insesrtssurgical instruments and a miniature telescope with a mounted video camerainto the abdomen. The camera sends a magnified image from inside the body to a video monitor,giving the surgeona close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts and vessels. The gallbladder is then removed through one of the small incisions, Recovery usually occurswithin a day in the hospital, followedby few days of rest at home.

Because the abdominal muscles are not cut during laparoscopic surgery, patientshave less pain and fewer wound complications.

If the surgeon finds any difficulty in the laparoscopic procedure, the operating team may decide to switch over to open surgery. It is called 'open' surgery because the surgeon has to make a 5 to 8 inch incision in the abdomen to remove the gallbladder. Open surgery is now requiered in less than 0.1 percent gallbladder operations at our institute.
8. What if a stone slips into the Common Bile Duct (CBD)?
Slippage of the stone(s) in CBD may cause pain or jaundice or both. This situation requires an encoscopy (ERCP)for removing the stone(s). This should preferably be done before surgery. However it may also be done after the operation.
9. How do we confirm if a stone is in the CBD?
Sometimes stone in the CBD may not show on ultrasound, however patient may have symptoms which are indicative of the same. In this event, the patient requires magnetic resonance cholangiopancreatography (MRCP-an MRI scan) which show the presence of stones in the common bile duct.
10. What is ERCP?
The surgeon may use endoscopy for removing CBD stones before gallbladder surgery. Once the endoscope is in the small intestine, the surgeon locates the affected bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope. This two-step procedure is called ERCP and EPT.
11. Non Surgical treatment
Non surgical approaches are used only in special situations such as when a patient's condition is not fit for anaesthesia and surgery. This does not cure the patients as it only provides symptomatic relief.
12. Don't people need their gallbladders?
Fortunately, the galbladder is an organ that people can live without. Losing it won't even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder.

Points to remember:

  •    Gallstones form when substances in the bile juice get precipitated

  •    Gallstones are common among women and people who are overweight

  •    Gallstone attacks often occur after eating fatty meals

  •    Accurate diagnosis is important because symptoms can point towards other problems, including heart attack. Diagnosis can be made in majority of te patients by simple untrasound conducted in a fasting state.

  •    Gallstones can cause serious problems if they become trapped in the bile ducts such as jaundice and pancreatitis

  •    Laparoscopic surgery to remove the gallbladder is now the 'Gold Standard' for treating gallstones

  •    This surgery can be done in practically all the patients including patient with a previous abdominal operation / cardiac history / asthma / diabetes etc.

13. Can the surgery be performed as a day care procedure?
Yes, day care surgery may be performedin young an selected patients. The patient is supposed to be fasting and would be calle dto the operating theatre in the morning. The operation will be performed and the patient would be observed for 4-6 hours post operatively in our day care facility. The patient would normally be discharged the same afternoon.However, if the need arises, he/she could be admitted overnight as well.
14. What happens after admission for surgery?
The patient is normally admitted to the hospital a day prior to surgery or o the day of surgery. After admission, the patient is examined and investigations reviewed by one of the team members also, a member of the Anaesthesia Team would conduct the pre-anaesthetic check-up. Pre-operative investigations are performed, if needed. The patient would need to be fasting overnight or for 8 hours for the surgery but can take his regulat dose of medicines with sips of water. (please follow the instructions given by the attending staff.)

Next morning, the patient is shifted to the operating theatre about an hour or so prior to the surgery. Aftersurgery, the patient is shifted to the recovry ward under the cae and supervision of our Anaesthesia Team. The patient is observed in the recovery ward normally for 2-4 hours after surgery and they shifted back to the room. Hence, the patient may come back to the room after about 5-8 hours after he/she has left the room.

Oral diet is started with sips of water when the patient returns to the room. he/she gradually progresses to drinking all liquids on the same day of surgery. The patient is encouraged to sit up, visi the toilet and move around the same day. In fact, movements are encouragedbecause this causes a dramatic reduction is pain and increases the sense of well-being.

The patient is given a normal breakfast next morning and will generally be discharged from hospital after a visit by one of the team members. On discharge, a discharge summary with the advised medication is handed over to the patient along with the date for next appointment.

Post operative instructions and information

  •    After the operation you will be kept in the recovery room. This period may vary form few minutes to few hours. The anaesthestist decides aboutyour shifting to room. The decision depends on many technical factors.

  •    Your will be sleepy immediately after the operation due to sedation give during anaesthesia and during the recovery period.

  •    You may have some discomfort when coming out of the effect of sedation. It gradually reduces to a tolerable level within a few minutes without any pain killer. However, ifnecessary you may ask for pain killer injections/tablets.You shouldtry to avoid these drugs because they produce drowsiness and you may sleep for a longer period which isnot desirable.

  •    Yu may feel nauseated in the immediate post-operative period, and you may even vomit which should not cause any worry. This generally gets over after few hours.

  •    You are generally allowed to have sips os water immediately after the operation and liquids on day of operation. In case of vomiting the liquid intake may be stopped and restarted after 30 minutes. The liquids may include water/ cold drinks/ milk/juices or some clear soups.

  •    You are allowed to have normal home cooked meals of your choice from the next morning at breakfast.

  •    You should have small frequent meals for few days after operation following which you can resume your normal diet gradually. This is vital because you may feel bloated and distended if the quantity fo food is in large quantities at a time.

  •    You should try to move the limbs can sit up immediately after operation. You should also go to the toilet on your own. There are no restrictions whatsoever for the physical movement. In fact majority of the patients will feel much better after they have started the movement. The pain also dramatically reduces once you start sitting up, moving and walking.

  •    There is no restriction on your physical activity. You are allowed to walk as soon as you recover from your sleep. There is no restriction on climbing of stairs, lifting weight etc. you may even drive two wheelers or car as soon as you feel fit. This infact is one of the major advantages of the laparoscopic procedure.

  •    You will be discharged on the same day or next day of operation unless there is some associated medical/social problems. You are advised to visitagain for follow up after 2-5 days when the dressings are removed . You should avoid wetting the dressings unless they are waterproof. After the removal of dressing, you can have normal bath with soap and water.

  •    In very few cases there may be some bloodly/whitish discharge from the wound in the post operative period. This should not bother your because it is generally harmless. You can wipe the discharge and apply band-aid so as to avoid staining the clothes. If it is more you ask any question tha tmay come to your mind.