A B C D E F G H I J K L M N O P R S T U V W

GALLSTONES

What are Gallstones ?

Gallstones are stones that form in the gall-bladder. The gall-bladder is on the right side of the upper abdomen, just underneath the liver and the ribs. It stores and concentrates the bile which is produced by the liver. The presence of food in the stomach and duodenum makes the gall-bladder release bile into the intestine via channels called bile ducts to aid digestion. Gallstones may be present and cause no symptoms. However, very severe pain can be caused when the gall-bladder is made to contract and go into spasm. This may be caused by fatty foods. Lesser degrees of bloating, wind and indigestion may also result from gall-bladder disease. If, when the gall-bladder contracts, stones pass from the gall-bladder into the bile ducts, they may obstruct the flow of bile. This may produce yellow jaundice. The jaundice occurs because the yellow pigment in the bile cannot leave the liver and overflows into the blood. This pigment is also responsible for the normally brown colour of the bowel motions. When bile does not reach the intestine because of stones, the bowel motions become pale. The urine also becomes dark, as the bile pigments produced by the liver overflow into the urine. When jaundice has been present for a long period of time, itching of the skin occurs due to the build-up of bile salts in the skin.

How do Gallstones occur ?

Several factors have been identified. First, bile contains a chemical called cholesterol. If the amount of cholesterol in the bile increases, cholesterol stones may form. Secondly, when the gall-bladder does not empty properly, bile becomes stagnant. Infection is then more likely. As a result of infection, small amounts of debris may be formed. Calcium, phosphate, bile pigment and cholesterol are in this debris. Over a period of time the debris builds up to form gallstones.

Why do Gallstones occur ?

Gallstones may occur at any age. They are present in about one in ten of the population over the age of 40. In pregnancy, the hormonal changes result in incomplete emptying of the gall-bladder. Infection is then more likely. With certain diseases or operations of the small bowel, cholesterol stones may form. In some blood disorders where the red cells are destroyed, more bile pigment is produced. This may also result in gallstones.

Treatment Involved for Gallstones

Gallstones are normally treated by operation. Other approaches have been used but are usually less effective. If gallstones do not contain calcium, bile salts may be administered to help them dissolve. However, this involves a prolonged course of treatment (1-2 years). The treatment has side-effects, including skin rashes and diarrhoea. When the treatment is stopped, the gallstones may come back. Lithotripsy is a new treatment where the stones may be shattered from outside the body using ultrasound beams. Several treatments may be necessary. Treatment has to be combined with giving drugs called bile salts to dissolve the stone fragments because the fragments may escape from the gall-bladder into the bile ducts, causing blockage, which then requires treatment. Patients who are elderly or unfit for surgery and who have jaundice may have their gallstones removed from the bile duct without removing the gall-bladder. This can be done by passing a flexible telescope through the mouth into the part of the intestine called the duodenum (endoscopy). This allows access to the lower end of the bile ducts. This method is occasionally used in patients to improve their general condition and make them fitter for surgery at a later stage.

CHOLECYSTECTOMY is an operation to remove the gall-bladder. This is the treatment of choice for the majority of patients. The gall-bladder can be removed by keyhole surgery or normal open operation. The majority of gall-bladders can now be removed by key hole surgery. This usually involves being admitted on the day of operation and having the gall-bladder removed under general anaesthetic via four small 1-1.5 cm incisions on the abdominal wall. The main advantage of this method is that the period of recovery is far shorter than open operation. The average length of hospital stay is approximately 48 hours, and it is usually possible to return to work within 2 weeks of operation. However, if you have had repeated infections of the gall-bladder and it is heavily inflamed, it may be safer for the gall-bladder to be removed by open operation. If your surgeon anticipates difficulties he will advise you to have an open operation. It may not be possible to assess the gall-bladder adequately except by use of a telescope through a key hole incision. It is important to understand that following this examination, or if any difficulties are encountered during key hole surgery, it is in your interest that your surgeon is free to proceed with the open operation, for maximum safety. For the open operation you will be admitted the day before surgery and will be in hospital for approximately one week. No particular preparation is required. It is performed under general anaesthetic. A cut is made in the upper part of the abdomen. The gall-bladder and gallstones are removed. An x-ray is usually performed during the course of the operation to ensure that gallstones have not escaped into the bile ducts. If there is evidence of the gallstones within the bile duct, they are removed.

After Treatment for Gallstones

Untreated gallstones may continue to cause bouts of severe pain. Gallstones increase the likelihood of inflammation of the gall-bladder (cholecystitis). Rarely, an abscess can develop within the gall-bladder (empyema) or the gall-bladder may burst (perforate). If gallstones get stuck in the bile duct system they may stop the flow of bile from the liver to produce jaundice. Gallstones in the bile ducts may also prevent the release of juices of the pancreas to produce inflammation (pancreatitis). Rarely, a growth in the gall-bladder may occur in patients with long-standing gallstones.

If Gallstones are Left Untreated

After key hole surgery, pain relief may be required for 24-48 hours. A light diet may be started the day after surgery. Discharge from hospital takes place on average 48 hours after operation. Return to work is usual in under 14 days, depending on your occupation. Dissolvable stitches will probably be used; if not, stitches will be removed 1 week after operation. After the open operation, pain relief, consisting of injections, may be needed for the first 48 hours. Fluids must be restricted to prevent the risk of vomiting in the first few days. Therefore a drip will be put into your arm to give intravenous fluids until normal eating and drinking can be resumed. A tube drain will be inserted, separate from the scar, into the abdomen to prevent the accumulation of blood or bile following surgery. You will probably be able to sit out of bed on the day following surgery and will be given routine physiotherapy to prevent the deveopment of any chest infections. The legs must be kept moving to reduce any risk of thrombosis (blood clots). Discharge from hospital usually occurs 5-7 days after surgery. The stitches will be removed before discharge or a few days later. Full recovery from the operation will take place over the following month. Most people need 1 month following discharge from hospital before returning to work. People can live perfectly safely without their gall-bladder. However, in some people eating fatty or fried food may produce a little discomfort in the upper abdomen, because a surge is no longer available.