In this article, Mr Satya Bhattacharya, Consultant General and Hepatobiliary Surgeon, explains more about gallstones, the symptoms they can cause, how they are managed, and the surgical techniques used to remove the gallbladder.
- What are gallstones?
- What affects your risk of developing gallstones?
- What symptoms can gallstones cause?
- When gallstones cause no symptoms
- When gallstones cause symptoms
- Types of surgery available
- Risks of gallbladder surgery
Gallstones are very common. Around 10% of all adults have gallstones and the condition becomes more likely over the age of 40. But only a small proportion of people whose gallbladder contains gallstones experience problems. The most common sign that gallstones are becoming troublesome is biliary colic – pain in the upper right of the abdomen. Once any sort of symptoms develop, surgery to remove the gallbladder is the only effective treatment.
In the UK around 4.5 million people have gallstones at any one time and 50,000 of them need to have their gallbladder removed each year.
Gallstones are hard particles that form in the gallbladder. This is a small pouch that sits under the liver and that functions as a storage bag for bile. Bile is made in the liver , stored in the gallbladder and passes into the small intestine through the bile duct. The fluid, which is green and bitter tasting, contains emulsifiers that helps break down fats so they can be more easily digested.
It is common for some of the compounds in bile to become solid and hard. These particles are tiny at first, but they can then attract other particles and grow. Someone with gallstones may have just one large stone, or many smaller ones. The stones themselves contain cholesterol or calcium or bile pigments, or a mixture of two or three different compounds.
Some factors that increase risk include:
- A family history of gallstones
- Being over 40
- Being female
- Having multiple pregnancies
- Having diabetes (type 1 or type 2)
- Losing a lot of weight quickly
Factors that make it less likely that gallstones will develop include:
- Being male
- Drinking alcohol in moderation
- Eating a diet high in plant fibre (vegetarians tend to be less prone to gallstones)
Many people with gallstones will have mild or infrequent attacks of biliary colic. This is the medical term used to describe the sharp pain in the upper right of the abdomen that occurs when the gall bladder tries to push a gallstone into the bile duct. As the gall bladder squeezes hard, this causes pain. If the gallstone is squeezed out into the bile duct and then into the intestine, or falls backwards into the gallbladder, the pain subsides.
This can happen once in a while, or it can happen every so often causing the same type of niggling pain. Attacks of biliary colic can last minutes or a few hours.
More severe symptoms:
- Jaundice: your skin and the whites of your eyes turn yellow. This is because a small stone has become lodged in the bile duct, blocking the flow of bile. The pigments in the bile get into the blood, causing the colour change in your skin and eyes. An operation may be needed to remove the gallstone if it does not pass out of the bile duct.
- Pain in the central upper abdomen: the pancreas and gallbladder both have ducts that empty into the intestine through a common opening. If a gallstone from the gallbladder gets stuck at this point, it can block the exit of digestive enzymes from the pancreas, which can cause the pancreas to become inflamed. Pancreatitis is a medical emergency that often needs hospital treatment and surgery to remove the gallstones.
- Intense pain in the upper right of the abdomen, fever, nausea, vomiting. This lasts more than a few hours and indicates that the gallstones have irritated the wall of the gallbladder, causing it to become inflamed. Cholecystitis, or inflammation of the gallbladder, can lead to infection, so this is a medical emergency. The gallbladder then needs to be removed, ideally as soon as possible.
Infection in the bile duct can also occur and can cause a mixture of all of these severe symptoms. A bile duct infection is called cholangitis and is relatively rare, but can be a serious life-threatening problem.
Many people have gallstones but do not realise this, as they have no symptoms. The presence of stones can be detected during a diagnostic investigation for another medical problem. They show up very well on ultrasound scans, so if you are having one of these, you may find out that your gallbladder contains stones. There is nothing to worry about as long as you have no symptoms. Even though gallbladder removal is a fairly routine operation that is successful in the vast majority of patients, every operation carries some risks. There is no point in having surgery that you do not need.
If you suffer occasional bouts of biliary colic that do not last long, you may find you can cope with them easily and reduce the frequency of the attacks by adopting a low-fat diet. But at this stage you do need to discuss with your doctor if you need tests to exclude other causes of upper abdominal pain.
Once gallstones begin to cause pain, the pain often keeps recurring and it gradually gets worse. Unfortunately, there are no effective drug treatments to dissolve gallstones and using ultrasound to break up the stones does not work very well in the gallbladder (lithotripsy is used successfully for kidney stones).
So, once you experience any symptoms, even mild attacks of biliary colic, surgical removal of the gall bladder is the only effective treatment. The only difference between patients who have mild or severe symptoms is the urgency with which the surgery needs to be arranged. If your symptoms become severe and you develop cholecystitis, pancreatitis or an infected bile duct, you may need emergency surgery to remove the gallbladder and any stones blocking the bile duct.
- Laparoscopic cholecystectomy: this is a minimally invasive technique in which a specialised surgeon removes the gallbladder and the gallstones it contains by making 3-4 small incisions in the abdomen. The instruments and a laparoscope are inserted through these ports, allowing the surgeon to see the inside of the body on a large screen in the operating theatre. The surgical instruments are manipulated from outside the body and the gallbladder is removed. Because only small incisions are used, recovery after a laparoscopic cholecystectomy is much faster than after open surgery and you can be out of hospital in a day, and back to work in 1-2 weeks (depending on the nature of your work).
- Open cholecystectomy: some patients are unable to have laparoscopic surgery – patients with a gallbladder that is very inflamed or scarred, for example. This decision will be taken by your surgical team after assessing all of your risk factors.
- Relieving a bile duct blockage: this is usually done with an endoscopic retrograde cholangiopancreaotography (ERCP). An endoscope is introduced through the mouth, stomach and into the small intestine and the surgeon works directly within the bile duct. But stones in the gall bladder cannot be removed by this method.
- Risks associated with any surgery, having a general anaesthetic and being immobile in hospital (heart problems, deep vein thrombosis, pneumonia, excessive bleeding).
- Damage to the intestine or liver during surgery.
- The bile duct may be injured. This now occurs in fewer than 3 cases in every 1000, but it is a serious complication that can lead to bile leaking into the abdominal cavity. Another operation is required to repair the damage.
- A gallstone can dislodge and fall into the bile duct, unnoticed by the surgeon. This may block the bile duct and cause jaundice and other symptoms. An ERCP will then be necessary.