Gallstones

Gallstone disease is a common medical problem that affects 10 to 15 percent of the population of the United States, or well over 25 million people. About 1 million new cases of gallstone disease are diagnosed every year in this country. Half of these require treatment, with a cost to society of several billion dollars annually. In recent years, important advances have been made in the understanding of gallstone disease and in the development of new treatments.

What is the gallbladder, and what does it do?

The gallbladder is a sac, about the size and shape of a pear, which lies on the undersurface of the liver in the upper right-hand portion of the abdominal cavity. It is connected to the liver and the intestine by a series of small tubes, or ducts. The primary job of the gallbladder is to store bile, which is produced and secreted continuously by the liver, until the bile is needed to aid in digestion. After a meal, the gallbladder contracts and sends the bile into the intestine. When digestion of the meal is over, the gallbladder relaxes and once again begins to store bile.

Bile is a brown liquid which contains bowel salts, cholesterol, bilirubin, and lecithin. About three cups are produced by the liver every day. Some substances in bile, including bile salts and lecithin, act like detergents to break up fat so that it can be easily digested. Others, like bilirubin, are waste products. Bilirubin is a dark brown substance which gives a brown color to both bile and stool.

What are the symptoms of gallstones?

The most typical symptom of gallstone disease is severe pain in the upper abdomen or right side. The pain may last for as little as 15 minutes or as long as several hours. The pain may also be felt between the shoulder blades or in the right shoulder. Sometimes patients also have vomiting or sweating. Attacks of gallstone pain may be separated by weeks, months, or even years.

It is thought that gallstone pain results from blockage of the gallbladder duct (cystic duct) by a stone. When the blockage is prolonged (greater than several hours), the gallbladder may become inflamed. This condition, called cholecystitis, may lead to fever, prolonged pain and eventually infection of the gallbladder. Hospitalization is usually necessary for observation, treatment with antibiotics and pain medications and frequently for surgery.

More serious complications may occur when a gallstone passes out of the gallbladder duct and into the main bile duct. If the stone lodges in the main bile duct, it can lead to a serious bile duct infection. If it passes down the bile duct, it can cause an inflammation of the pancreas, which has a common drainage channel with the bile duct. Either of these situations can be extremely dangerous. Stones in the bile duct usually cause pain, fever, and jaundice (yellow discoloration of the eyes and skin).

Many people with gallstones have no symptoms. Often the gallstones are found when a test is performed to evaluate some other problem. So-called “silent gallstones” are likely to remain silent, and no treatment is recommended.

What treatments are available for Gallstones?

Many new approaches to gallstone treatment have been tried over the past several years, but surgical removal of the gallbladder (cholecystectomy) remains the most widely used therapy. This is partly because the newer non-surgical treatments are useful in only some gallstone patients, but surgery can be used in virtually all patients. Patients generally do well after surgery and have no difficulty with digesting food, even though the gallbladder’s function is to aid digestion. Surgical options include the standard procedure, called open cholecystectomy, and a newer, less invasive procedure called laproscopic cholecystectomy (“belly button surgery”).

In open cholecystectomy, the surgeon removes the gallbladder through a 5- to 8-inch incision. This procedure has been performed for over 100 years and is quite safe, although 4 to 5 days of hospitalization and several weeks of recuperation at home usually are needed.

Laparoscopic cholecystectomy is a recent technique which was introduced in the United States in 1988. The surgeon makes several 1-inch incisions in the abdomen through which a tiny video camera and surgical instruments are passed. The video picture is viewed in the operating room on a TV screen, and the gallbladder can be removed by manipulating the surgical instruments. Because the abdominal muscles are not cut there is less postoperative pain, quicker healing, and better cosmetic results. The patient usually can go home from the hospital within a day and resume normal activities within a few days. Laparoscopic cholecystectomy has become common and is now used for 80 percent of all cholecystectomies in the United States.

Each approach has its advantages, and a doctor can recommend the best method for each patient depending upon the clinical situation. For instance, it may be difficult or dangerous to remove a severely inflamed gallbladder laparoscopically. It may also be more difficult to remove a stone from the bile duct laparoscopically, if one is found at surgery to have passed out of the gallbladder and into the bile duct. However, stones in the bile duct can frequently be left in place and removed at a later date using a non-operative method such as ERCP.

Gallbladder surgery may be complicated by injury to the bile duct, leading either to the leakage of the bile or scarring and blockage of the duct. Mild cases can frequently be treated without surgery, but severe injury generally requires bile duct surgery. Bile duct injury is the most common complication of laparoscopic than the standard approach.