HYDERABAD: One of the most common questions encountered by surgeons in their practice is this: “Doctor, I have gallstones; do I need to undergo surgery?” A few others include “Do gallstones disappear with pills?”
“My gallstone was 0.5 cms in size, then it grew to 1 cm and now, it is 0.7 cms. Why is it so doctor?“, “is it mandatory to remove the gallbladder or can removal of the stone alone address the problem?”, “Doctor, I heard from my neighbor that gallbladder removal can cause problems later in life, is that true?” and so on. In this article, I will try to address some of these vexing questions.
What is gallbladder?
The gallbladder is a pear shaped organ located in the right upper abdomen. It acts as a reservoir of bile and aids in digestion by pumping out bile when food enters into the small intestine. Gallstones occur as a result of solidification of bile components. The two main types of gallstones are cholesterol stones (80%, yellow in color) and pigment stones (black: due to infection).
Causes of gallstones
1. Genetics, ethnicity
2. Gender (more common in women)
3. Excessive cholesterol in bile (Diet, dyslipidaemia, drugs incl. oral contraceptives & fibrates, obesity)
4. Decreased contractility of gallbladder
5. Blood disorders (Haemolytic Anaemias)
6. Rapid weight loss (esp. following bariatric surgery)
Behaviour of gallstones
Gallstones may either remain asymptomatic or may cause upper abdominal pain which may manifest as back pain as well; dyspeptic symptoms – including nausea, belching, flatulence. Symptoms include, fever with rigors, jaundice and rarely intestinal obstruction as well.
How are gallstones diagnosed?
Diagnosis of this condition is usually done by ultrasound study of the abdomen in conjunction with physical examination and blood tests.
Sophisticated techniques including EUS (Endoscopic Ultrasound), CT scan, MRCP (Magnetic Resonance Cholangio Pancreatography) may be required to diagnose gallstones when the previous evaluation is inconclusive or having suspicion of complications.
Cholescintigraphy (HIDA Scan) is another useful test to assess contractility of the gallbladder. It should be noted that only an approximate estimate of the size of the gallstone is possible with these investigations. Moreover, the size of the gallstone doesn’t always show a correlation with symptoms. Those who have small gallbladder stones are likely to develop complications like pancreatitis, whereas those with larger stones have a propensity to develop cholecystitis.
Is there any non-surgical treatment?
Yes, there are some, but are not effective. Pills like Ursodeoxycholic acid are useful only in patients with small cholesterol stones and once patients stop taking the pills, the gallstones recur. They are usually considered for patients unfit for surgery. Other options include lithotripsy and contact dissolution therapy, which are not used widely in the management of gallstones.
Do all gallstones need to be treated?
All symptomatic gallstones need to be removed to prevent complications.
Also, those patients with gallstones and associated illnesses like diabetes (who are at risk of developing severe complications), haemolytic anaemias, spinal cord injuries, family history of gall bladder malignancy, calcified gall bladder (also referred to as porcelain gallbladder) or working in locations where immediate access to quality healthcare is not available (Offshore employees, etc) would be better off undergoing surgery to prevent complications.
What are the types of surgeries available?
In this procedure termed laparoscopic cholecystectomy, under general anaesthesia, three or four tiny holes (0.5-1 cm) are made in the abdomen, and then the gallbladder is removed with the help of long instruments.
The procedure usually takes about an hour. The postoperative recovery is usually smooth and the patients are discharged in a couple of days. However, in patients who have complicated gallstone disease or those who have co morbidities like hypertension, cardiac problems, diabetes or asthma, may have to anticipate difficult surgery and a slightly longer hospital stay.
Very rarely, one may have to convert to an open cholecystectomy if the gallbladder is densely stuck to the surrounding organs (Usually as a result of repeated infections and delayed presentation / referral to the Surgeon).
Following Surgery, one has to keep in mind that 5 per cent of patients may experience transient diarrhea, which usually subsides with time. If the gallstone has already slipped into the bile duct by the time the patient presents to the surgeon, the patient may need to undergo an ERCP (Endoscopic Retrograde Cholangiopancreatography) to remove the stone prior to laparoscopic cholecystectomy.
It would be prudent to opt for a consultation with a qualified, expert medical professional when confronted with a medical ailment.