Tag: gallstones

Dear Dr. B: Who needs treatment for gallstones?

Answer: Sooner or later all patients with gallstones need treatment. The treatment is surgery. The question is: should it be sooner or later?

Once upon a time, the surgical procedure of choice was open cholecystectomy. In fact, Langenbuch carried out the first cholecystectomy in 1882. Patients who undergo open cholecystectomy have a long surgical incision in the abdominal wall, have to stay in the hospital three to five days, consume fair amount of pain killers for post-operative pain and the recovery time at home is three to six weeks.

Things have changed in the last 15 to 20 years. Now most patients undergo laparoscopic cholecystectomy when there is an indication for surgical removal of the gallbladder. Laparoscopic cholecystectomy was first performed in France in 1987. In this procedure, there are four tiny incisions in the abdominal wall, the hospital stay is usually overnight, the amount of pain killers required after surgery is minimal and the recovery time at home is usually less than one week.

Prophylactic cholecystectomy is done only in few exceptional cases. Otherwise, gallstone surgery is required only if you have symptoms. The most common symptom is recurrent attacks of biliary colic. The colicky pain is in the upper abdomen usually on the right side. Sometimes the biliary colic can present as chest pain and some people think they are having a heart attack.

The timing of surgery depends on how often you get the attacks of pain. If you are getting recurrent attacks then the surgery is planned to be done within a few days. If you settle down after one or two attacks then the surgery can be done within a few weeks.

Second most common indication for surgery is complications of the disease such as acute cholecystitis and obstructive jaundice. In acute cholecystitis, the gall bladder is acutely inflamed and the patient undergoes urgent surgery, usually within 24 to 48 hours of hospitalization. If the gallbladder is very inflamed and the patient is very sick then the surgeon may elect to drain the gallbladder and plan further surgery to remove the gallbladder after three to six weeks.

In obstructive jaundice the gallstone is usually lodged in the common bile duct which effectively blocks the drainage of bile from the liver and the gallbladder to the small intestine. Patients with obstructive jaundice are not acutely sick but the blockage should be taken care of before patient undergoes surgery for the gallbladder.

Patients who have vague abdominal symptoms and are found to have gallstones (gallstone dyspepsia) need careful assessment to establish gallstones are indeed the cause of the symptoms. In some of these patients, the symptoms may be due to other causes such as irritable bowel syndrome or gastro-oesophageal reflux disease. Removing the gallbladder in these instances will not help.

In gallstone pancreatitis, a stone from the gallbladder passes through a common channel formed by the common bile duct and the pancreatic duct. In the majority of patients this results in a mild attack of pancreatitis and recovery is uneventful. The majority of stones that cause pancreatitis pass spontaneously. These patients should have laparoscopic cholecystectomy done during the same hospital stay.

Early surgery in these patients does not increase post-operative complications or mortality. Early surgery also eliminates the risk of recurrent attacks of pancreatitis while the patient is waiting for elective surgery. Patients with worsening pancreatitis require further investigations as the stone may be jammed in the common and pancreatic duct.

Cholecystectomy is a very common operation and appropriate timing of the surgery is very important for patient care and safety.

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What is the most common elective surgical procedure done in the western countries? Well, Susan knows the answer. Here is her story.

During the Christmas holidays, Susan has to rush to the Emergency Department as she develops severe pain in the right upper area of the abdomen where the liver and gall bladder reside. Pain is associated with vomiting.

After history and a physical examination, the emergency physician makes a provisional diagnoses of biliary colic i.e. pain due to gallstone. Susan gets a painkiller and gravol. She settles down and is discharged home for further investigations.

The first line of investigation is ultrasound of the abdomen. This test will check for problems in the liver, gall bladder, pancreas, aorta and kidneys. It may pick up problems in the stomach. The test is not 100 percent full proof but it is a good, non-invasive, and cost effective first line of investigation. For gallstones, quite often this is the only test required.

The ultrasound confirms Susan has gallstones. She is referred to a general surgeon. For most symptomatic gallstones, the best curative treatment is surgical removal of the gall bladder – cholecystectomy.

Each year, in Medicine Hat Regional Hospital, approximately 250 gall bladders are removed. About 95 percent of them laparoscopically- through four buttonholes. Patients are admitted to the hospital on the same day. Most patients are discharged within 24 hours of surgery with minimal complications. Most patients return to work within 7 days of surgery.

Compare this to the olden days when a patient would be admitted the day before surgery, have a long scar, stay about 5 to 7 days in the hospital and have 6 weeks of recuperation. A major life disruption when you think that this is the most common elective procedure done in western countries. And gall bladders have been removed for the past 116 years!

Observations of human gallstones go back to an Egyptian priestess at Thebes, around 1500 BC. Her mummy, when given to the Royal College of Surgeons Museum in London, was seen to contain a well-preserved gall bladder with 30 stones; unfortunately it was destroyed during the German bombing of World War II, says Dr. Knut Haeger in The Illustrated History of Surgery.

There are two types of gallstones: cholesterol stones (80 percent) and pigment stones (20 percent). Most cholesterol stones are mixed in nature. They are formed when bile becomes supersaturated with cholesterol and there is precipitation of cholesterol micro-crystals. This is a simple explanation of a complicated event in cholesterol gallstone formation.

Incidental finding of gallstones require no treatment if they do not cause any symptoms. Most symptoms are related to blockage of the gall bladder or one of its ducts by a gallstone. Cholecystectomy has minimal complications rate during and after surgery. But every procedure has some risk involved and should be undertaken after careful deliberation with the surgeon.

Susan is on the waiting list to have her gall bladder removed. She does not want to experience the pain of biliary colic again. Let us wish her good luck and speedy recovery!

This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems. They believe in ELMOS!

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