Gall bladder is a pear shaped organ present close to the liver. Its function is to store and concentrate bile juice which is produced in the liver. It does not produce bile as many people think. Bile is a juice produced by the liver which helps the body to digest fat.
Gallstones are stones which form within the gallbladder. They may vary in number and size. For management of these stones, size/shape and number is not relevant.
Symptoms of gallstones are severe abdominal pain often called a gallstone ‘attack’ (colic) because they occur suddenly. Gallstone attacks often follow fatty meals, and they may occur during the night. A typical attack can cause the following :
Other symptoms of gallstones include:
Many patients with gallstones have no symptoms, these patients are said to be asymptomatic and these stones are called ‘Silent Stones’. However, they can anytime become symptomatic and cause complications.
Cholesterolosis and adenomyomatosis conditions of the gall bladder are usually clinically silent. Cholesterolosis is the deposition of cholesterol crystals in the inner lining of the gallbladder wall. Adenomyomatosis refers to an excessive proliferation of the inner lining which then projects into the wall of gallbladder. Adenomyomatosis may be associated with the risk of gallbladder malignancy. Gallbladder polyp includes projections of the gallbladder wall into the lumen. Many of them are soft sand like particles in the lumen. This has been our frequently seen findings after the gall bladder is removed.
Cholecystectomy is advised if polyp is more than 10mm in size for multiple polyps.
Cholecystitis is defined as inflammation of the gall bladder. Most commonly inflammation arises in this system when the flow of bile is stopped of interrupted due to stone (90%) or if infection biliary tract occurs.
The usual symptoms are :
The symptoms may be severe colic or maybe even mild. A diabetic patient may have minimal pain due to neuropathy. One should not wait for the complications to happen. Some of the complications like the Pancreatitis, Gangrene, Empyema, perforation etc may be life threatening and complex to handle. Sometimes they are associated with high morbidity and even mortality.
Biliary pancreatitis is a very serious and life threatening condition and is associated with high morbidity and mortality. It occurs when gallbladder stones migrate into the common bile duct (CBD) and block the pancreatic opening.
Many patients will need a prolonged stay which may include ICU stay and other life supportive measures, many of them may end up with damaged and destroyed pancreas ultimately leading to conditions like Diabetes etc. It is also associated with high morbidity and mortality.
Association of Gallbladder stones with Gallbladder cancer is well established. It is a well documented medical fact that more than 85% gallbladder cancers have gallbladder stones as well.
Genes that may play a role in gallbladder cancer include KRAS, BRAF, CDKN2, HER2 and TP53 tumour suppressor gene. Some of the gene changes that leads to gallbladder cancer might be caused by chronic inflammation.
The female gender, multiple child births and obesity are also some of the factors that are associated with higher risk of developing gall bladder cancer. The evidences point towards the environmental and genetic factors playing an important role in development of gallbladder cancer. The basis for development of cancer in the setting of gallbladder stones likely occurs through chronic irritation and local production of carcinogens. The larger the gallstones (more than 2-3 cm in diameter), the greater the association with gallbladder cancer.
Treatment of symptoms of pain with injectable or oral painkillers. No medical therapy is available for gallstone as such which can cure the disease. Though, injectable or oral antibiotics and supportive medications are available for treating the infection.
Surgery to remove the gallbladder (cholecystectomy) is the only way to cure gallstones. This can be done by conventional (open) method or a well established endoscopic (laparoscopic) method which is now the ‘Gold Standard’. The surgery is called Laparoscopic Cholecystectomy (Lap.Chole.). For this operation, the surgeon makes few tiny cuts in the abdomen and inserts surgical instruments and a miniature telescope with a mounted video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts and vessels. The gallbladder is then removed through one of the small incisions. Recovery usually occurs within a day in the hospital. Because the abdominal muscles are not cut during the laparoscopic surgery, patients have less pain and fewer wound complications. If the surgeon finds any difficulty in the laparoscopic procedure, the operating team may decide to switch over to the open surgery. It is called ‘open’ surgery because the surgeon has to make a 5 to 8 inch incision in the abdomen to remove the gallbladder. Open surgery has faded into the background with the laparoscopic technique providing significant advantages and ease for the patient. Improving technology day by day is making it safer and accurate for even complex cases and situations.
Slippage of the stone(s) in CBD may cause pain or jaundice or both. This situation requires an endoscopy (ERCP) for removing the stone(s). This should preferably be done before surgery. However it may also be done after the operation.
Sometimes a stone in the CBD may not show on ultrasound, however patient may have symptoms which are indicative of the same. In this event, the patient requires magnetic resonance Cholangiopancreatogrphy (MRCP –and MRI Scan) which shows the presence of stones in the common bile duct.
No, the gall bladder is removed with the stones. The disease is in the wall of the gall bladder.
The physician may use endoscope for removing CBD stones before gallbladder surgery. Once the endoscope is in the first part of the small intestine, it locates the affected bile duct. An instrument on the endoscope is used to capture the stone in a tiny basket and removed with the endoscope. Biliary stent may be needed and placed in the common bile duct (CBD). This may be removed endoscopically after few weeks.
Non surgical approaches are used only in special situations such as when a patient’s condition is not fit for anaesthesia and surgery. This does not cure the patients as it only provides symptomatic relief.
Yes, we all need gallbladders to store bile but only when it is functioning normally! Gall Bladder is a storage organ like the store in our house. It also concentrates the bile. When diseased, it starts over concentrating the bile and forming the stones. Another mechanism of the gall bladder is that it distends like a balloon. Diseased gall bladder may be contracted or thick wall may not distend to accommodate bile. Remaining space may get occupied with the produced stones. Fortunately, the gallbladder is an organ that people can live without. Losing it won’t require much change in the diet. Once the gallbladder is removed, bile production remains unaffected as it is produced in the liver and it is only the bile which helps in digestion of food and gallbladder has no role to play in that.
The patient is sifted to the operating theatre about an hour or so prior to the surgery. The surgery is done under General Anaesthesia (GA). The procedure is of approximately 20-30 minutes duration in most cases.
As soon as the surgery is over, patient’s attendants are intimated by the nursing staff about the surgery being completed and the patient is shifted to the recovery ward under the care and supervision of the anaesthesia team. The patient is observed in the recovery ward normally for few hours after surgery and then shifted back to the room.
The patient is discharged within few hours after the surgery on the same day or next day of operation unless there is some associated medical problem. Waterproof dressings are applied on the port sites and the patient may bathe when comfortable.
The patient is advised to visit again after 5 days when the dressings are removed. On discharge, a discharge summary with the advised medication is handed over to the patient along with the date of the first follow up appointment.
The patient is discharged within few hours after the surgery or on the same day or next day of operation unless there is some associated medical problem.
As soon as the patient is out of anaesthesia and is shifted to the room, patient is up and about and can start moving on his/her own and attend to toilet needs. In fact movements are encouraged in most patients because this causes a dramatic reduction in pain and increase the sense of well being. There are no restrictions whatsoever for the physical movement. The patient is allowed to walk as soon as he/she recovers from sleep. There is no restriction on climbing stairs, lifting weight. The patient can resume his/her daily routine activities as he/she feels comfortable as there are no specific restrictions.
In most of the patients, no change of dressing is required till follow-up which is after 5 days of surgery.
To enjoy good health, to bring true happiness to one's family, to bring peace to all, one must first discipline and control one's own mind. If a man can control his mind he can find the way to Enlightenment.
