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Gallstones and Gallbladder Disease
By: Neri Blanco, M.D.

by Neri M. Blanco, M.D.

Definition:

The gallbladder is a pear-shaped sac lying underneath the liver that stores bile. The liver produces the bile, it is stored in the gallbladder in states of bowel rest, and it is released during meals into the small intestines to aid in digestion of foods.

Gallstones are composed of cholesterol, bile salts and bilirubin. When the gallbladder is not functioning properly or when dietary or blood imbalances occur, the components of bile become out of balance leading to crystal formation. The majority of stones are made of a combination of both cholesterol and bilirubin. Gallbladder disease is most often caused by gallbladder dysfunction that leads to stones, rather than the stones themselves, with the exception of stones occluding the bile ducts of the gallbladder and the liver.

Risk Factors:

Age greater than 40

Obesity or rapid weight loss

Gender, more common in females, especially of childbearing age.

Estrogen intake

Ethnicity, more common in Native Americans and Hispanics

Diabetes

Signs and Symptoms:

Asymptomatic where stones found incidentally.

Biliary colic is right upper quadrant abdominal pain just under the ribcage radiating to the back and occasionally associated with nausea and vomiting. Attacks last from minutes to hours and are brought on by fatty meals.

Cholecystitis is an infection or inflammation of the gallbladder often caused by obstruction of the cystic duct leading to biliary colic as well as fevers, chills, and an elevated white blood cell count, or signs of infection reflected in a blood draw.

Choledocholithiasis occurs when stones exit the gallbladder and cystic duct and enter the ducts that connect the liver and gallbladder to the intestines. The stones sometimes pass into the intestines without incident, but they can lead to obstruction of these ducts. This can cause life-threatening infections, liver dysfunction, and pancreatitis. Jaundice or a yellow-tan coloring of the skin and sclera, white chalky stools, and dark bright yellow urine can occur.

Gallstone pancreatitis is an inflammation of the pancreas caused by blockage by gallstones of the ducts that drain the pancreatic juices into the intestines. This can cause abdominal pain that radiates to the back, nausea, vomiting, and bloating.

Diagnosis:

Lab tests can check for infection levels in the blood (white blood cell count) or signs of jaundice/liver inflammation (liver function tests and bilirubin levels. Blood amylase and lipase levels check for pancreatitis.

Plain X-Ray can detect gallstones in the right upper quadrant of the abdomen in only 10-15% of the time because only these are calcified with radio opaque calcium within the stones.

Ultrasound uses sound waves to detect gallstones, gallbladder thickness and inflammation, fluid around the gallbladder, liver abnormalities like a fatty liver or hepatic masses, and bile duct dilation suggesting distal obstruction.

Cat-Scan images the gallbladder and the surrounding organs and is used to detect liver and pancreatic abnormalities or tumors. Gallstones are better detected by ultrasound.

HIDA Scan uses a radioactive tracer that is preferentially taken up by the liver and the gallbladder and is used to detect gallbladder filling. If the tracer bypasses the gallbladder and fills the liver and intestines, then the gallbladder is obstructed consistent with cholecystitis, or infection/inflammation of the gallbladder.

MRCP is a type of MRI that visualizes the gallbladder, bile ducts, and pancreatic drainage ducts to detect obstruction and/or tumors.

ERCP is a test where an endoscopy is performed under conscious sedation. A scope is passed through the mouth and into the stomach and small intestines where the common bile duct is injected with dye. X-rays delineate where the dye fills and does not fill because of obstructing stones or lesions. This test can also be therapeutic and can be used to extract stones and leave stents.

Treatment:

Surgical treatment involves removal of the gallbladder. In 95% of cases, this can be done with minimally invasive surgery using four 1/4 to 1/2 cm small incisions in the belly button and right upper quadrant. A camera and long instruments are used to remove the gallbladder. In about 5% of cases, open surgery is required; one larger incision is made below the right ribcage.

Non-surgical treatment with dissolution agents and lithotripsy have a low success rate and a high recurrence rate. This is only reserved for patients to ill to undergo surgery.

Risks of Surgery:

Bleeding 1-2%

Infection 1-2%

Bile Leak 1-2%

Injury to the Common Duct <1%

Injury to surrounding structures <1%

Incisional Hernias 1%

Recovery/Prognosis:

Surgery can be done as an outpatient or an overnight stay unless there are signs of infection that requires antibiotics and bowel rest for several days. If there is conversion to open surgery, the patient will require hospitalization for three to five days for pain control and to assure that the patient can tolerate a diet. The patient can advance to a regular diet fairly quickly and can resume regular daily activities within two weeks.

Neri Blanco, M.D.