GALLSTONES

Gallstones are very common. About 1 in 5 people will develop gallstones during  their life.
(Actual lifetime risk is about 14-20% in the West) Fortunately, the vast majority( two thirds - 90%) do not cause any symptoms. Someone with gallstones have 7.6%(about a 1 in 10 chance) of developing  symptoms needing hospitalization in the next 5 years.

Types of gallstones

Gallstones come in all shape, number & sizes - some  gallbladders are packed full of them and some have only one gallstone in it. Some gallstones are the shape of millet seeds and some are as large as a chicken egg! Some are hard and some are soft and crumbly! Some are faceted and can even look like  multi-sided dice!

Generally, there are cholesterol  which tend to be yellow, pigmented stones which tend to be brown or black.

Causes of gallstones

Many things can contribute to the development of gallstones. Factors that increases the risk factors for the development of gallstones include:

1. Ethnicity - American Indians have a much higher risk

2. Obesity - It is increasingly common for younger people to suffer from symptoms of gallstones - this is in part due to the obesity epidemic.

3. Pregnancy(this is why women tend to get gallstones more than men)

4. Diet - high energy, high fat and low fibre

5. Resection of the terminal ileum, jejunal-ileal bypass surgery for obesity treatment, gastric surgery, treatment with TPN(total parenteral nutrition)

6. Infection of the biliary tree especially by parasites - this is an important cause of pigmented gallstones in the East(eg China, Hong Kong)

7. Diabetes mellitus, hyperlipidaemia

8. Crohn's disease

9. Haemolytic anaemia such as thalassaemia, hereditary spherocytosis and sickle-cell anaemia

10. Family history - one's risk of developing gallstones would be doubled if one has a first-degree relative with gallstones

Symptoms of gallstones

Gallstones can cause a variety of symptoms including:
1. Abdominal pain - especially in on the right side below the rib cage, occasionally the pain travels to the back. This pain is know as biliary colic. Typically one is not able to find a comfortable position to rest. The pain generally settles within a few hours. 
2. Nausea and vomiting
3. Vague abdominal symptoms including bloating and abdominal discomfort.

A variety of other abdominal pathology can also cause abdominal pain - you should always consult with your doctor if you have any of the above symptoms.

Complications of gallstones

1. Acute cholecystitis - a gallstone can become permanently stuck in the neck of the gallbladder or the cystic duct(duct connecting the gallbladder to the main bile duct).  This would lead to an inflammation of the gallbladder and sometimes an infection. Early on(within 72 hours), this can be treated with an emergency laparoscopic cholecystectomy although the risks are higher(more risks of damage to bile duct and conversion to an open operation). Otherwise this is treated with intravenous antibiotics and an elective operation after 6 weeks(to allow time for the adhesions to soften)

2. Jaundice - a gallstone can become stuck in the bile duct causing blockage of the bile. One's skin and white of the eyes would become yellow

3. Acute pancreatitis(inflammation of the pancreas) - this can be serious. The bile duct and the pancreatic duct are joined just before they drain into the duodenum(1st part of the small intestine). When a stone gets stuck at where they join or a bit after, the bile would backflow into the pancreas. This can bile can potentially damage the pancreatic cells and cause an inflammatory cascade leading to pancreatitis. 

4. Mucocele - Sometimes when the gallbladder outlet is blocked for a long time, there will only be mucus within the gallbladder as no bile can enter the gallbladder.

5. Fistula - This is very rare. The gallstone can erode through the gallbladder wall into the small bowel. Sometimes if the gallstone is large, it would cause a bowel obstruction(This is called a gallstone ileus. Ileus is in fact a misnomer as the bowels are in fact blocked and are still working)

6. Mirrizi's syndrome - this is where there is so much inflammation and swellling from the stone impacted in the neck of the gallbladder that the bile duct becomes compressed by the swelling. This is another cause of jaundice in someone with complicated gallstones. Again this is very rare. The danger in Mirrzi's syndrome is that the bile duct is stuck to the gallbladder and may be damaged during the surgery to remove the gallbladder. 

7. Gangrene and perforation of the gallbladder - rarely, the blood supply to the gallbladder may become blocked by the inflammation from acute cholecystitis. This would lead to the gallbladder becoming black(gangrenous) and there would be a risk of the gallbladder perforating.

Indications of Surgery to Remove the Gallbladder

The indications include:
1. Any symptoms from the gallstones -eg biliary colic
2. Any complications from gallstones 
3. Suspicion of cancer or high risk of cancer of the gallbladder eg porcelain gallbladder, large polyp within the gallbladder

Variations in Anatomy

Everyone's anatomy is different. Around the gallbladder, the are many different normal variations too. For example, although most people have one cystic artery, some people may have a double cystic artery.

Sometimes the anomaly is with the way the cystic duct enters the gallbladder - it may be hooking behind the bile duct. There may be more than one cystic duct.  Or there may be an accessory duct(Duct of Luschka) that drains into the gallbladder. Or even more rarely, small bile ducts can drain directly into the gallbladder from the liver bed itself!

If these anomalies are not recognized during the operation, complications may occur. One of the way to reduce this is to do an operative cholangiogram(X-ray of the bile duct with contrast) to look at the anatomy of the bile ducts before any structure is clipped and cut!

Benefits of an Operative Cholangiogram

1. It can detect an unsuspected gallstone in the bile duct(The detection rate is about 4%)
2. Fewer bile duct injuries - Studies from the literature shows that when a routime operative cholangiogram is performed the rate of bile duct injury is halved(to about 0.21%) Someone has even worked it out that a surgeon needs to do 455 operative cholangiogram to prevent one bile duct injury!

 

Surgical Stories

1. Did you know that the first person who performed keyhole gallblader surgery(Prof Erich Muhe from Boblingen, Germany in 1985) was initially critised. After he performed over a hundred cases, one of his patients died from a complication unrelated to the surgery. He was charged and convicted with manslaughter as laparoscopic cholecystectomy was considered unconventional surgery. He has only recently being acknowledged for his achievements. Today, more than 25 years on, laparoscopic surgery to remove the gallbladder is a very common operation. There used to be a steep learning curve when surgeons changed from doing gallbladder removals from the open method to the laparoscopic method. Surgeons my generation are trained in laparoscopic surgery to remove the gallbladder from the start.

2. One of the first randomized controlled trials in surgery was for early ERCP and sphincterotomy in severe acute pancreatitis. The senior author was Mr David Fossard - a tall man with white hair who was known to be often grumpy on ward rounds if anything was suboptimal. He makes it a point in ward rounds to ensure that all patient notes have patient stickers on both sides of the page! I used to work with him in Leicester and he was the person who first taught me how to do inguinal hernia repairs under local anaesthesia.  I must say I enjoyed working with him and learning from him. (2 of the other authors of that paper Neoptolemos and London went on to become Professors in Surgery)

3. Danger of waiting on the waiting list for too long. Back in my first year as a consultant, I used to do a lot of cases from other consultants waiting lists as prt of the waiting list initiative. One patient had a severe episode of acute cholecystitis(CRP over 200) and was booked for an elective lap cholec. At surgery 6 weeks later, his gallbladder was found to be completely gangrenous(black!) and it was probably the fibrous tissue in the wall preventing the black foul bile within the gallblader  from perforating out!

4. From how the DHS funds public hospitals in Victoria - the hospitals get more WIES from doing an interval laparoscopic cholecystectomy than an emergency one!

 

For more information about surgery to remove the gallbladder, click here.