What are Gallstones?
Acute inflammation of the gall bladder can occur, but in most cases it is associated with gallstones. This is a very frequent problem, more common in women, and more likely with advancing years. At the age of 70 years, about 30 per cent of the population has gallstones. An infection was once believed to have been the initiating cause, bile salts accumulating around a dead bacterial or viral clump however this may or may not be so. In any event there is a gradual increase in size and numbers of these rounded, hard masses, bile salts are added. Any number from a single one, to dozens or hundreds, all tightly packing the gall bladder, is encountered.
In recent years, more young people appear to be affected, so that it is now no longer a disease confined to the “female, fat and 40.”
Cancer of the Gall Bladder is uncommon. It is more likely in women who have suffered from chronic gallstones and gall-bladder disease. Symptoms are similar, and the tumor may not be found until an operation on the gall bladder takes place. The outlook is poor, even with surgery.
Often symptoms set in abruptly, with intense pain in the upper right-hand side of the abdomen associated with vomiting. It travels through to the right shoulder blade or shoulder. It may come and go, or it may be intense and persistent. In an effort to gain relief, the patient often walks about bending, holding a hot-water bag to the affected area. There may be a fever, and there is sometimes jaundice and the urine may be dark (like strong tea).
Symptoms may settle down, or they may be persistent and distressing, necessitating urgent need for surgical intervention. The diagnosis is confirmed by actually visualizing the gallstones. Some types are radio-opaque and readily show up on a plain X-ray of the abdomen. But others are radio-translucent, and will not be revealed in this manner. So, an oral cholecystogram is carried out. This clearly shows the outline of the gall bladder on subsequent X-ray, and if any stones are present they show up as filling defects. Following this, the ability of the gall bladder to contract is checked (by giving a fatty meal), for a diseased organ may not be able to perform this normal function. If this does not produce the desired results, recourse is sometimes made to another test called a cholangiogram, in which the bile ducts are outlined by special dye injected into the bloodstream and subsequently X-rayed.
However, the simpler oral cholecystogram usually gives adequate information for an accurate diagnosis. In most hospitals diagnosis is now made by ultrasound. This is very safe and reliable. Many doctors now believe this is a better diagnostic procedure.
If gallstones are present (usually diagnosed by ultrasound), removal is suggested, for severe bouts of recurring pain are highly likely. Also, there is a modest risk of cancer occurring (probably 1 per cent or less). Often the walls are thickened, and have become chronically infected over a number of years. Smaller stones can readily jam the duct, and this causes the intense, agonizing pain well known to patients.
Removal of the gall bladder and stones via the laparoscope is now the preferred method. Under a general anesthetic, several small incisions called “portals,” measuring about I cm in length, are made in the upper abdominal area. Through these, narrow tubes are introduced. One contains a camera, another lights, and dissecting instruments can be introduced into the others as required. The picture appears in full color on a VDU screen, which stands nearby. There may be more than one screen, to help the surgeons and theatre team with their work.
It is a time-consuming procedure, but very safe in experienced hands. The diseased organ is dissected away from the liver, the stones crushed if necessary, and everything is gradually removed via the tubes. Bleeding points are checked, and finally a small stitch closes the portals. Often the patient is up and about the following day, and frequently returns home in a few days. In the past, the large abdominal incision took many weeks to heal, and this was the most time-consuming and weakening part of the surgery. But now the portals heal quickly, although it takes some time for the internal parts to heal.
Some patients return to sedentary work within a week or so. But more report it may take a few weeks (probably 3-6) before they feel better again, and can return to normal activities. This is understandable, considering the extent of the internal surgery.
Laparoscopy has revolutionized gallbladder surgery, which is now carried out widely in most major hospitals throughout the Western world, and certainly is widespread in Australia and New Zealand. The time under anesthesia will gradually lessen as surgeons become more and more adept at the new skills required.
Operating from a video screen and manipulating equipment that they cannot see by direct vision requires much practice and skill.
Over the past few years many methods have been used for gallstone removal. The lithotripter, successfully used for removing kidney stones, was modified and used by some surgeons to similarly pulverize gall-bladder stones, which were then passed into the bowel via the duct, but this has given way to laparoscopy.
Various orally taken chemicals, chenodeoxycholic acid and related medications, dissolved cholesterol stones (the commonest type). But they quickly formed again when treatment was stopped, and is now seldom used. Drugs, machines, fashions and preferences come and go, and in time it is probable that improved or different technology will again see major changes in surgery for the gall bladder as well as for other forms of internal surgery. It is an ever-changing picture.
At all times patients should keep in touch with the doctor, never neglect potentially serious symptoms, and be guided by the advice offered. Make certain you attend a doctor who is at all times up to date with current technology.