Gall Bladder Stone

What is gall bladder?GallStones

Gall Bladder is a pear shaped organ situated on the under surface of the liver.  It stores and concentrates the bile juice which is produced by the liver.  Against the common belief, the gall bladder does not produce the bile.

What is bile juice?

Bile juice is produced by the liver, which is primarily important for digestion of fat.  After the person consumes food, gall bladder is compressed and the stored bile is pushed through the bile duct into the duodenum (small intestine) for digestion.

What are Gall stones?

They are the stones formed within the gall bladder.  They are varying in size to number. The ultimate management of these stones does not vary according to number or size of the stones.

How are Gall stones formed?

The exact reason for stone formation in gall bladder is not known.  However there are few factors which increases the chances for stone formation.  They are:

  • Sex: Women are twice as likely to develop stone as compared to men, particularly in 20 to 60 years age group.
  • Age: May occur in any age group but particularly in third and fourth decade of life.
  • Obese individuals are more prone
  • Women taking oral contraceptive pills (oestrogen excess)
  • Cholesterol lowering medications increases the chances
  • Diabetes
  • Long duration of fasting
  • Rapid weight loss
  • Some blood disorders (mostly hereditary)
  • Social factors – more common in north Indian people, sindhi & Punjabi community

Risk Factors for Gall Stones?

  • Women
  • Age group of 30 – 40
  • Obese individuals
  • People who do frequent dieting or fasting
  • Women who are pregnant (multiple), those taking hormones, females taking birth control pills for long durations

How do the patient present?

The usual symptoms are abdominal pain (particularly post prandial) and belching.   The usual order of symptoms of a severe attack are:

  • Severe pain in Right side of upper abdomen – particularly after meals (fatty)
  • Pain may last few minutes to hours
  • Pain radiating between the shoulder blades
  • Pain over right shoulder
  • Nausea and feeling of vomiting.
  • Severe pain over right lower costal margin.
  • In some cases the pain is very severe called Gall Stone Colic.

Associated minor symptoms are:

  • Flatulent dyspepsia (bloating)
  • Intolerance to fatty diet
  • Indigestion and belching
  • If apart from above the complaints include:
  • Fever with chills and rigors
  • Yellowish discolouration of eye and urine
  • Clay coloured stools
  • It indicates complication and urgent medical advice is supposed to be taken.

What are the complications of Gall Stones?gall-stone

  • Pus formation in the Gall Bladder (Empyema)
  • Infection of the biliary tree (Cholangitis)
  • Gangrene and even perforation of the Gall Bladder
  • Slippage of the stone in to the biliary tree causing Obstructive (Surgical) Jaundice
  • May cause Acute Pancreatitis which is a life threatening disease and can end up in multiple organ failure
  • Increased chances of Gall Bladder Cancer in the long standing cases

Management of Gall Bladder Stones?

Medical:

Symptomatic treatment in form of analgesics (oral or injectable). There is no actual medicine which can completely remove the gall stones.  Some available in the market are good for gall bladder sludge.  If the patient develops infection, then symptomatic treatment in form of antibiotics and supportive medicines are given.

Surgical:

Surgical Removal of Gall Bladder (Cholecystectomy) is the only treatment of Gall Stone disease.  It can be done by open procedure or Laparoscopically.  Laparoscopic Cholecystectomy has been established as a Gold Standard Treatment worldwide.  The short name of the surgery is Lap. Chole, one of the most common surgery being performed worldwide.  Few small incisions (key holes) – 3 to 4 are made in the abdomen, surgical instruments are introduced along with a telescope which transmits the image to a monitor.  The surgeon sees in the monitor to perform and dissection and the actual surgery.  Gall bladder is removed from this tiny holes. Since there is no major surgical incision put on the abdomen, the patient has very less pain post operatively and few or no complications.

In very few cases, the surgeon may have to convert into open to complete the surgery.  But depending the experience of the surgeon, the chances of the same are very less.

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 Stone in the Common Bile Duct (CBD)?

It is one of the complications of untreated Gall bladder stone disease.  The stone may slip into the common bile duct.  This results in obstruction to the flow of the bile juice causing back pressure into the liver and jaundice.  Patient will have pain, fever due to secondary infection.

How is it diagnosed?mrcp_scan_gallstone

Basic ultrasound will many times reveal the CBD stone. But it is not always reliable.  Hence in cases where clinically there is a doubt, patient is advised a Magnetic Resonance Cholangiopancreatography (MRCP), which will clearly show any presence of stone in the CBD.

What is the treatment of CBD Stone?

In such cases the patient will have to undergo an endoscopic procedure called (ERCP).  In this procedure, an endoscope is introduced through the oral cavity into the small intestine, the opening of the bile duct is identified, the same is cannulised and dilated or cut, basket is introduced for removal of the stone from the CBD.  The stagnant or the infected bile is drained and an artificial stent is placed into the CBD.  Following this the patient has to undergo the gall bladder removal surgery.  After which the stent has again to be removed endoscopically.

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Are there any non-surgical treatment options for the same?

No.  There is no medical treatment for the same.  Unless the patient is very high risk or unfit for procedure, ERCP is required for removal of the stone.

Can one survive without the Gall Bladder?

The anatomy of the biliary tree is such that, if the gall bladder is removed, the bile which is produced in the liver directly goes through the bile duct into the small intestine.  Hence the patient may not even require to change his dietary habit after the surgery and can live without the gall bladder.

What is the Procedure for the Surgery?

Once the patient is diagnosed and counselled for surgery, patient is submitted to basic pre-operative workup and investigations.  Patient is then evaluated by the anaesthesia team for surgery.  After completion of the formalities, patient is admitted for planned procedure. Patient requires fasting for 6-8 hours prior to surgery.  Patient is shifted to the operation complex, prepared and anaesthetized for surgery.  After the surgery patient can be shifted to the bed.  Following surgery patient is kept nil orally for 5 – 6 hours, followed by liquids and juices.  Later on patient can take semi solid light diet.  Patient is usually mobilized 7-8 hours after surgery.  Next day patient can take normal breakfast and light diet.  After the consultant visits the patient, he can be discharged.  Thus usually the hospital stay is about 36 to 48 hours maximum.

Current trends in Gall Bladder Surgery?

Currently surgery of Gall bladder is done laparoscopically.  It can even be performed in well selected and young patients as a DAY CARE PROCEDURE.  Pre operatively prepared patient is admitted on the early morning of day of surgery, surgery is performed, after 5-6 hours patient is put on liquids and semi-solid diet.  If the patient feels comfortable, he can be discharged same day evening.

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