Gallbladder - gallstones and surgery

The gallbladder is a small sac that stores bile, a digestive juice made by the liver that helps break down dietary fats. The gallbladder draws water out of its store of bile so the liquid becomes highly concentrated. When fatty food enters the digestive system, the gallbladder squeezes this bile concentrate into the small intestine.

Gallstones (also called biliary calculi) are small stones made from cholesterol, bile pigment and calcium salts, usually in a mixture, that form in the gallbladder. They are a common disorder and affect around 15 per cent of people aged 50 years and over. Gallstones can form when excess cholesterol in bile crystallises, or when the gallbladder does not empty completely.

In most cases, gallstones cause no problems#

In around 70 per cent of cases, gallstones cause no symptoms and need no treatment. You may need prompt treatment, though, if a stone blocks a duct and causes complications such as infection or inflammation of the pancreas.

When gallstones (or other gallbladder disease) cause problems, a surgeon may remove the gallbladder. This operation is called a cholecystectomy. The gallbladder is not a vital organ, so the body copes well without it.

Symptoms of gallstones#

When gallstones do cause symptoms, these may include:

• pain in the abdomen and back, which is often infrequent but severe
• pain that increases after eating a fatty meal
• jaundice
• fever, if the gallbladder or bile duct becomes infected

Types of gallstones#

There are three main types of gallstones:

• Cholesterol stones – the most common type, made up mainly of cholesterol, a fat-like substance involved in many metabolic processes. They can grow large enough to block a bile duct.
• Pigment stones – made from bile pigment. Bile is greenish-brown because of these pigments. Pigment stones are usually small but numerous.
• Mixed stones – made up of cholesterol and salts, these tend to develop in batches.

Causes and risk factors#

There is no single cause of gallstones. In some people, the liver produces too much cholesterol, leading to cholesterol crystals in bile that grow into stones. In others, stones form because of changes in other components of bile, or because the gallbladder does not empty normally.

Gallstones are more common in women than in men, in people who are overweight, and in people with a family history of gallstones.

Diagnosis#

Doctors diagnose gallstones using a number of tests, which may include:

• physical examination and x-rays
• ultrasound – soundwaves form a picture that shows the presence of gallstones
• endoscopic retrograde cholangiopancreatography (ERCP) – a thin tube is passed through the esophagus and injects dye to improve the quality of x-ray pictures
• a HIDA (hepatobiliary iminodiacetic acid) scan – a nuclear scan that assesses how well the gallbladder functions
• magnetic resonance cholangiopancreatography (MRCP) – an MRI scan that images the liver, biliary and pancreatic system, giving a picture similar to an ERCP

Possible complications#

Gallstones that cause no symptoms rarely need treatment. Complications that may need prompt medical care include:

• Biliary colic – a stone moves from the body of the gallbladder into its neck (the cystic duct), causing obstruction. Symptoms include severe pain and fever.
• Cholecystitis – a stone blocks the gallbladder duct, leading to infection and inflammation of the gallbladder, with severe abdominal pain, nausea and vomiting.
• Jaundice – a stone blocks the bile duct leading to the bowel, so trapped bile enters the bloodstream. The bile pigments turn the skin and eyes yellow, and urine may become orange or brown.
• Pancreatitis – inflammation of the pancreas caused by a blocked bile duct low down near the pancreas. Pancreatic enzymes irritate the pancreas and can leak into the abdominal cavity.
• Cholangitis – inflammation of the bile ducts when a duct becomes blocked and the bile becomes infected, causing pain, fever, jaundice and rigors (shaking).
• Cancer of the gallbladder – this occurs rarely.

Treatment#

Stones that cause no symptoms generally need no treatment. In certain cases – for example, during abdominal surgery for another condition – a doctor may remove the gallbladder if you are at high risk of complications. Treatment depends on the size and location of the stones, and may include:

• Dietary changes – such as limiting or avoiding fatty foods and dairy products.
• Lithotripsy – a special machine generates soundwaves to shatter the stones. This is available in certain centres only and is usually reserved for stones stuck inside the bile duct rather than in the gallbladder.
• Medications – some medicines can dissolve gallstones, but this is rarely used because of side effects and a variable success rate.
• Surgery – around 80 per cent of people with gallstone symptoms will need surgery. A surgeon may remove the entire gallbladder (cholecystectomy) or just the stones from the bile ducts.

Surgery to remove the gallbladder#

There are two main techniques:

• Laparoscopic (‘keyhole’) cholecystectomy – the surgeon makes several small incisions through the skin to allow access for slender instruments, and removes the gallbladder through one of the incisions.
• Open surgery (laparotomy) – the surgeon reaches the gallbladder through a single, wider abdominal incision. You may need open surgery if you have scarring from previous operations or a bleeding disorder.

Before the operation#

Discuss the following with your doctor or surgeon:

• your medical history, since some pre-existing conditions may influence decisions on surgery and anaesthetic
• any medications you take regularly, including over-the-counter preparations
• any bad reactions or side effects you have had from medications

Laparoscopic cholecystectomy#

The general procedure includes the following steps:

• The surgeon makes several small incisions in the abdomen so that slender instruments can reach the abdominal cavity.
• A tube blowing a gentle stream of carbon dioxide gas is inserted, separating the abdominal wall from the underlying organs.
• A tiny camera on the laparoscope lets the surgeon view the gallbladder on a monitor.
• Special x-rays (cholangiograms) during the operation can check for stones wedged in the bile ducts.
• The ducts and artery serving the gallbladder are clipped shut. These clips are permanent.
• The gallbladder is freed using laser or electrocautery and pulled out through one of the incisions, along with its load of stones.
• The instruments and gas are removed, and the incisions are sutured (closed up) and covered with dressings.

Open gallbladder surgery#

The procedure is the same as for laparoscopic surgery, except the surgeon reaches the gallbladder through a large, single incision in the abdominal wall. Sometimes an operation that begins as a laparoscopic cholecystectomy becomes open surgery if the surgeon meets unexpected difficulties, such as not being able to see the gallbladder properly.

Immediately after surgery#

After the operation you can expect to:

• feel mild pain in your shoulder from the carbon dioxide gas
• receive pain-relieving medications
• be encouraged to cough regularly to clear your lungs after the general anaesthetic
• be encouraged to walk around as soon as you feel able
• stay overnight in hospital if you had a laparoscopic cholecystectomy, or up to 8 days if you had open surgery

Possible complications of surgery#

All surgery carries some degree of risk. Possible complications of cholecystectomy include:

• internal bleeding or injury to blood vessels
• infection
• injury to nearby digestive organs
• injury to the bile duct
• leakage of bile into the abdominal cavity

Self-care after surgery#

Be guided by your doctor, but general suggestions include:

• rest as much as you can for around 3 to 5 days
• avoid heavy lifting and physical exertion
• expect your digestive system to take a few days to settle; common short-term problems include bloating, abdominal pain and changes to bowel habits

Most people recover within one week of laparoscopic surgery. See your doctor between 7 and 10 days after surgery to make sure all is well. Some rare complications may need to be followed up with another operation.

Key points#

• Gallstones are a common disorder and affect around 15 per cent of people aged 50 years and over.
• In most cases, gallstones cause no problems.
• In around 70 per cent of cases, gallstones cause no symptoms.
• When symptoms do occur, they may include abdominal pain, pain after fatty meals, jaundice and fever if the gallbladder or bile duct becomes infected.
• Surgery to remove the gallbladder can be done by laparoscopic (‘keyhole’) cholecystectomy or open surgery.

Where to get help#