Ohhh, that was good: southern fried chicken, mashed potatoes with gravy, biscuits dripping with butter and a slice of apple pie a la mode for dessert. Then, ow! That pain! What was that? Why does it keep happening? That pain may be a gallbladder attack. If you have recently been told you have gallstones, you certainly are not alone. Over 25 million Americans now have gallstones and about 1 million new cases are added each year.

What Is The Gallbladder?

Right Upper Abdomen

The gallbladder is a small pear-shaped hollow sac nestled beneath the liver in the right upper abdomen. It stores about a quarter cup of a yellowish-green material called bile. Made in the liver, bile tastes bitter, and this is why the word bile has come to denote bitterness. A duct is a hollow tube that carries fluid from one place to another, like a water pipe in your home. The gallbladder is really just a side branch of the common bile duct, the main duct that drains liver bile into the small intestine. The side branch that connects the gallbladder to this main duct is called the cystic duct. These ducts carry the bile to the intestine. The pancreas usually shares a common drain with the liver via its pancreatic duct.

When bile enters the small intestine, it breaks up large globs of fat into smaller globs, a first step in digestion. A healthy gallbladder keeps bile flow moving like a mountain stream. However, when the gallbladder becomes diseased, the flow slows and the river turns into a swamp. The stagnant bile gradually crystallizes and the crystals clump together to form stones - like snowflakes making a snowball. (This is totally separate disease from kidney stones that form in the urinary system. Having one kind of stone does not increase your risk of the developing the other.)

What Are The Symptoms Of Gallstones?

About half of those with gallstone have no symptoms and need no treatment. Most of them don't even know that the stones are there. Painless stones probably float freely in the gallbladder. But, others are plagued with unpleasant attacks of abdominal pain. The pain occurs when a stone is small enough to escape from the gallbladder and then become lodged in the bile ducts below. The type and severity of symptoms depend upon where the stones lodge.

Called "biliary colic," gallbladder pain is felt as a sharp, severe, stabbing pain, often located in the right upper abdomen. Attacks may last 15 minutes to several hours and may be separated by weeks, months, or even years. The pain often occurs after meals, particularly a high fat meal. Pain may also be felt between the shoulder blades or right shoulder and sometimes in the chest, where it is often confused with a heart attack. There may be associated symptoms of nausea, vomiting, and low grade fever. Untreated, symptomatic gallstones may damage the pancreas and liver, leading to gallstone pancreatitis and obstructive liver jaundice. Patients with symptoms must see their doctor.

Who Is At Risk For Gallstones?

We all are, but some more so than others. While all ages and both sexes are susceptible, women are particularly vulnerable accounting for more than 75% of all patients. Pregnancy, birth control pills, obesity, and a high fat diet are all contributing factors. Obesity increases the risk 6-fold, but individuals on crash diets who lose weight too quickly are also at high risk. Gallstones affect all races, but are more prevalent in some populations. Overall about 10% of Americans have gallstones as compared to Sweden where 44% of the population is affected. In this country, the Native American Indians have the highest incidence of gallbladder disease. Amazingly, over 80% of the Pima Indians of southern Arizona develop gallstones by age 35.

How Does My Doctor Know?

Gallstones may occasionally be found on x-rays done for other reasons as about 10% are calcified and show up on routine plain x-rays. More than likely, your doctor ordered additional tests based on your symptoms. Possible gallbladder tests include liver and pancreas blood tests that measure "enzymes" in the blood. High levels signify damage to these organs. Most patients undergo a simple ultrasound exam of the abdomen which uses harmless high-frequency sound waves to create a picture of the gallbladder and ducts. The liver and pancreas can often be seen as well. Special cases may require a more sophisticated x-ray called ERCP. This is a procedure using a lighted "scope" that projects a video image. It can help locate stones or other blockages in the bile ducts.

How About Treatment?

In those patients with gallstones who have no symptoms or very mild and infrequent attacks, watchful waiting may be justified. However, for those individuals with persistent or severe symptoms, surgery to remove the gallbladder and gallstones is recommended. Taking out the stones and leaving the gallbladder behind merely invites new stone formation. For effective treatment, both must be removed. There are usually no consequences to having your gallbladder removed. It probably wasn't working anyway, and your intestine takes over its job. About 2% of patients will develop loose stools after gallbladder removal which can be treated with medication.

Bandaid Surgery

Until 1991, gallbladder surgery was a major undertaking and was often deferred until the last possible moment. Termed open cholecystectomy, this procedure typically required a painful 6 inch abdominal incision, 5 days of hospitalization, and about 4 to 6 weeks of recovery time. In less than a decade, a new technique called laparoscopic cholecystectomy has revolutionized gallbladder surgery. First performed in France in 1987, this simple bandaid technique is now possible in over 95% of patients. Instead of a large skin incision, a "lap chole" is performed by making several 1/4 to 1/2 inch incisions in the abdominal wall and inserting a tiny video camera to guide the operation. With special instruments, the gallbladder is separated from its attachments and removed through a small incision in the bellybutton. The patient may eat and drink within a few hours after surgery and go home the same day with only a few small bandaids on their abdomen. There is very little pain or disfigurement. Most are able to resume full activity within a week's time. Serious complications are rare. Usually that ends the problem. It is possible, but very rare, for gallstones to return once the gallbladder has been removed.

Can't Gallstones Be Dissolved? Not really. Two nonsurgical treatments were in favor a few years ago. One was lithotripsy, a technique that used shock waves to shatter gallstones in hopes that they would pass harmlessly into the intestine. The other was Actigall, a medication that could actually dissolve some gallstones. Unfortunately, neither was very successful, and in both cases, the stones could return since the gallbladder was not actually removed. Actigall is still used on occasion in sick or elderly patients who cannot undergo any surgery. But, it requires taking doses of expensive pills several times every day for a year or two and has a nasty side effect of diarrhea. It's not very popular. Once laparoscopic surgery became the standard, these modalities faded into the history books.

In Summary

Gallstones and they are very common is our society - by age 60, about 25% of women and 10% of men have them. Fortunately, many have no symptoms, and need no treatment. Those that do will eventually require surgery to limit the attacks and prevent permanent damage to their liver and pancreas. There is no reliable way to prevent them. At least it's nice to know that gallbladder disease is one problem for which treatment has become simpler, cheaper, and more successful. Recent advances in laparoscopic surgery have made treatment relatively quick and painless. If you have symptoms suggesting gallstones, it is best to deal directly with the problem before complications occur. Consult with your physician.

Text & Images Courtesy of Three Rivers Endoscopy Center
© Dr. Robert Fusco, Three Rivers Endoscopy Center, All Rights Reserved

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