Gallbladder acts as a reservoir to store bile. Normally about 600 to 700 ml of bile is secreted by the liver and this is stored in the gallbladder. During mealtimes, the gallbladder squeezes the bile into the small bowel. This starts fat digestion in the bowel. For some people their bile has a tendency to form stones. Stones usually form in the gallbladder as there are periods of stagnation between meals.
Once stones have formed, it is advisable to remove the gallbladder with the stones. Removing the gallbladder does not affect digestion. Bile is instead stored within the collecting system itself. After removal of gallbladder, there are no subjective or objective changes to the overall digestion process. Often patients forget their operation especially when done laparoscopically.
Gallstones are caused by an imbalance in the constituents of bile, leading to the formation of crystals. The commonest type of gallstone is composed predominantly of cholesterol. The next common type, called ‘pigment stones’ arise on a background of infections or due to excessive breakdown of red blood cells, as in haemolytic disorders. As an emerging economy, India has seen enormous progress. However it is also taking on ‘western’ ills that accompany development. With increase in food sufficiency, we are now seeing an increase in obesity, and obesity related disorders such as gallstones, hypertension, diabetes etc...
I have cholesterol stones. Should I check my blood cholesterol?
Gallstones often occur on a background of obesity and hence the two conditions often co exist. Elevated cholesterol does not necessarily lead to gallstones. However cholesterol needs checking regularly for other preventative benefits, even in those without stones.
Small stones are less dangerous than large stones.
Wrong - they merely cause a different kind of problem. Smaller stones can easily pass through the cystic duct and hence are more likely to cause jaundice and pancreatitis which are potentially life threatening. In fact, it is often the case that elderly patients are often noted to have a solitary large stone which has been growing silently for many years. Often co morbid conditions lead to a decision to avoid surgery in these patients with large stones. Hence it is wrong to base decisions on size of stones.
My kidney stones have been treated with ‘shock wave’ therapy, why can’t the same be done for my gallbladder.
Kidney is a retroperitoneal organ and hence fairly fixed in position. In addition for other technical reasons it is possible to focus the shock waves accurately for kidney stones. However gallbladder moves with respiration and hence attempts at treating with shock waves haven’t been very successful. Kidney stones after being broken down will pass with urine. However a similar event in the biliary system has additional risks. For example, stones on passing through the common bile duct can potentially cause jaundice or pancreatitis. Hence shock wave therapy (lithotripsy) is not a viable treatment option for gallstones.
Are there medications to dissolve gallstone? If so can they be used routinely?
Bile acids have been used to successfully dissolve gallstones. However there are several disadvantages. Prolonged therapy lasting several months is required. Bile acids can cause diarrhoea. It is mostly effective in cholesterol stones. Repeated scans are necessary for follow-up. Stones tend to reform after cessation of therapy. Hence medical therapy is used only in patients who are unfit for surgery.
What happens after gallbladder removal? Are there any long-term problems?
Gallbladder functions as a storage area for bile between meals. After removal of gallbladder, the common bile duct tends to act as a reservoir. Hence after cholecystectomy, the common bile duct will always appear a bit engorged. Radiologists are well aware of this change and make allowances for this in patients who have had their gallbladder removed. Otherwise there are no long-term consequences following gallbladder removal.
I have had a scan for routine health check-up and gallstones have been found. Should I have it operated?
Incidental discovery of gallstones in the absence of symptoms is a dilemma for both patients and surgeons. Surgeons use various factors to decide. Age, multiple stones, presence of diabetes etc are considerations in the decision making process.
I have recently been diagnosed with acute cholecystitis. I have been told to wait 4-6 weeks for my operation.
This used to be the standard advice till recently. Current medical evidence indicates that patients do as well with an earlier operation i.e. during the acute phase itself. It is best performed within a week of onset of symptoms. Beyond this scarring and swelling around the gallbladder, make the surgery difficult. The benefits of early surgery are that pain is relieved early, earlier return to home and work and potential savings due to a single hospital admission. However it needs to be done by surgeons who regularly operate on ‘hot’ gallbladders. I offer ‘same admission cholecystectomy’ for all patients admitted with acute cholecystitis, as we are equipped to deal with complicated gallstone diseases.
Laparoscopic cholecystectomy is done for gallstones and gallbladder polyps. Three to four small cuts (5-10mm) are made over the abdomen.Through these a camera and special instruments are passed. The images appear on screen and the surgery is done from 'outside' using these long instruments. The gallbladder is excised and removed in a bag through one of the cuts. The operation can range from 30 minutes to more than an hour in difficult surgeries. The advantages are lesser pain and earlier recovery, translating to quicker discharge from hospital. Most patients are discharged after an overnight stay.
The timing of the operation depends on the expertise of the surgeon. Patients with marked pain, have acute cholecystitis. Here the gallbladder is very swollen. The adjacent tissues tend to get stuck to the gallbladder. Hence operating on such ‘hot’ gallbladders needs experience. Often surgery is delayed for 4-6 weeks in the hope of quietening the inflammation. However scientific evidence shows that in experienced hands, the results are same whether they are done during the acute stage or later. I offer early surgery for patients with acute cholecystitis. The advantages are that patients can avoid multiple admissions. Also the cause for pain (ie the diseased gallbladder) is dealt with.
Gallbladder polyps are uncommon conditions. However with widespread use of ultrasound, more of these are diagnosed. A polyp is a protrusion of the lining of the gallbladder. It has to be emphasised that the word polyp is merely a descriptive word and not a diagnosis in itself. There are a few conditions that may get reported as polyp. Even a tiny stone if stuck to the wall of the gallbladder can be reported as polyp. Sometimes when the gallbladder is not full and hence in a partially collapsed state, the normal lining might fold and give the impression of a polyp. And then there is of course the ‘true’ polyp where there is a tissue growth hanging from the lining like a wart. These need close attention.
A few general rules are: generally polyps less than 5 mm can be followed with regular ultrasound checks to monitor any increase in size. Any polyp more than 1 cm is suspicious and the surgeon may even decide on ‘open cholecystectomy’ to ensure that it is removed without any disruption of its stucture. Between 5mm and 1cm; it is better to get operated, usually laparoscopically.
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