the liver, gall bladder, bile duct
and bile
gall stones and their
complications
causes of gall stone
formation
symptoms and diagnosis
nonoperative treatment, and
asymptomatic stones
surgical treatment
diet
drugs used in this condition
when to consult your doctor
further reading
the liver, gall bladder, bile duct and bile
The bile is a fluid produced in the liver, and contains waste products of metabolism. Bile also helps in digestion, in particular the absorption of fat. The bile flows from the liver cells to the intestines via a tube called the bile duct. The gall bladder is a sac attached to the side of the bile duct. It stores the bile, and releases it into the intestine when food is eaten, to help in digestion.
gall stones and their complications
Bile contains cholesterol, lecithin, and various complex organic compounds*. The concentration of cholesterol and the other compounds is present in a delicate balance. If this balance is disturbed the compounds can precipitate quite easily. The precipitated solvents form masses called "stones" or gall stones. Gall stones vary in size from small grains, called "biliary sludge" to large, hard masses 3 or more centimeters across. Most stones are made of cholesterol, some are made of the organic bile compounds.
*eg the bile salts, sodium and potassium taurocholate, and the bile pigments, bilirubin and biliverdin.
causes of gall stone formation
Gall stones are more commonly seen in females, and tend to be slightly commoner in fat ladies who have had many children. The intake of estrogens (as in contraceptive pills) has been linked to the development of gall stones. Patients who have had typhoid are more likely to form stones. Certain blood diseases, and some forms of intestinal operations predispose to the formation of gall stones. Any gall bladder disease, including cancer, can in fact result in gall stone formation.
Gallstones are much more common among females than males. Stones irritate the gall bladder, which swells and thickens, and develops an inflammation. The patient feels pain in the upper abdomen, usually on the right and less often in the midline. Indigestion may occur, with fullness after meals, a feeling of gas, abdominal heaviness and other features. Mild and recurrent disease is called chronic cholecystitis. The disease may be more severe, as in acute cholecystitis and in gall bladder empyema. Patients with more severe attacks of cholecystitis have marked pain, and sometimes have fever.
In the past it was very difficult to
diagnose gallstones. However since the availability of
ultrasonography the diagnosis of gallstones and
cholecystitis has become very easy. The gall bladder is
clearly seen as a bag of fluid. Stones show up easily,
and also block ultrasound rays, throwing a sort of shadow
in the ultrasound picture. The accuracy of
ultrasonography is over 98%. The radiologist will make a
diagnosis of gallstones (also termed
"cholelithiasis") along with cholecystitis.
Blood tests to evaluate the liver function are usually
done as well. A very few other investigations are needed
to evaluate fitness for operation.
nonoperative treatment, and asymptomatic stones
There is no effective medical, nonoperative therapy for gall stones. Some drugs have been used, but have too many side effects to be recommended as first-line therapy. For those who absolutely refuse surgery, ayurvedic and homeopathic treatments may be considered.
A large number of healthy persons have gall stones, which are often detected during ultrasonography for some other indication (eg during pregnancy). 33-66% of asymptomatic persons with gallstones will develop symptoms sometime in life. Presently it is controversial if all people, in whom gallstones are detected, should undergo operation. Overall the balance of medical opinion is that if there are asymptomatic gallstones, they should be left alone. However, keeping in mind the many complications of gallstones, all surgeons recommend that even a single episode of pain is an indication for surgery. When dyspepsia is the main symptom, it is perhaps better to advise gall bladder surgery only after peptic ulcer has been thoroughly ruled out.
Gall bladder surgery. Treatment of
gallstones is by removal of the gall bladder, in an
operation called a cholecystectomy.
Surgery should be done not as an emergency, but at the
patient's earliest convenience. In the absence of
complications one may wait for an important family event
to be concluded, but otherwise it is inadvisable to delay
surgery for too long.
The usual method of removal of the gall bladder is by a laparoscope. In a laparoscopic cholecystectomy
4 holes ("ports") are made in the abdomen. The
laparoscope is inserted through a hole near the
umbilicus, and the other holes are for the operating
instruments. The operation takes roughly an hour, and the
patient can ordinarily be sent home in a day. Most
persons are back to work within a week or so.
Complications after surgery are few. Infection at the
site of one of the ports may occur rarely. Some patients
develop a hernia which will need a small operation for
correction. A rare but serious complication is an
operative bile duct injuries.
Cholecystectomy by making a large abdominal incision
("open surgery") is less often performed
nowadays. The gall bladder is removed through a 10-12 cm
incision in the upper abdomen. Although open operation is
slightly safer, the pain and time off work are
significantly more than those seen after laparoscopic
surgery. In the open operation, wound infection and
hernias are also commoner, but bile duct injuries are
rarer. At 5-6 weeks after surgery, there is no difference
between patients who have undergone the different types
of operation, therefore if laparoscopic surgery is
proving difficult, the surgeon should have no hesitation
in converting to the open type. Safety first!
Patients with gall stones may take any type of diet, before or after surgery. Some patients do not tolerate certain types of meal, for example heavy meals or meals containing too much fat. If these cannot be tolerated the patient will naturally have to adjust the diet accordingly.
Painkillers:
diclofenac,dextropropoxyphene, tramadol, pentazocine,
pethidine, and antispasmodics such as dicyclomine
Antibiotics: during the phase
of acute cholecystitis, these may be needed
Ursodeoxycholic
acid and chenodeoxycholic acid: drugs used for
dissolution of gall stones, without surgery. Not
recommended as primary treatment because of their low
efficacy and high incidence of side effects.
Severe pain in the abdomen is always in indication for visiting your doctor. Patients in whom gall stones have been detected should see their doctor to arrange early surgery.
| http://www.niddk.nih.gov/health/digest/pubs/gallstns/gallstns.htm:
very informative http://surgery.about.com/health/surgery/msubfaq.htm: a good site to visit, has many topics including gallstones http://www.surgeries.com/gallblad.shtml: a good gallbladder site http://www.ppphealthcare.co.uk/html/health/cholec.htm: fairly informative on cholecystitis http://www.thrive.net/health/Library/pedillsymp/pedillsymp81.html: worth seeing |
Dr Suneet
Sood, MBBS (AIIMS), MS (AIIMS), MAMS, is a
practising surgeon attached to Dharamshila Cancer
Hospital, Sir Ganga Ram Hospital and to Noida Medicare
Center. Formerly Professor of Surgery, Himalayan
Institute of Medical Sciences, Dehradun, Dr Sood has a
special interest in gastrointestinal surgery. He has had
an active academic career, has published several papers
in national and international journals, and is the Editor
(with Dr Anurag Krishna) of a widely acclaimed book
titled Surgical Diseases in Tropical Countries.
Contact
Nos: 2486788, 9811052966, suneetsood@vsnl.com
Dr Suneet Sood,MS, MAMS,
Editor in chief
Dr
Anurag Krishna, MS, MCh, MAMS
Last revised: May 11, 2000