Introduction:

The gallbladder is a sac under the liver which stores bile to aid in digestion. Bile from the liver and the gallbladder is carried to the intestines by a duct called the common bile duct. The gallbladder is connected to the common bile duct by a thin small duct known as a cystic duct. The role of the gallbladder is to concentrate bile that has been secreted by the liver and squirt it into the intestines when a meal is eaten and reaches the lower stomach and upper intestines. The gallbladder normally stores about 50-75 ml of bile, while the liver produces about 1 litre of bile in 24 hours: hence the role of the gallbladder in digestion is a minor role.

The gallbladder can get diseased, the most common disease of the gallbladder being gallstones. Gallstones are formed by salts that are soluble in bile and excreted out through the liver into the stools. Because the function of the gallbladder is to concentrate bile, these salts too become concentrated in the gall bladder. These salts may then get crystallized and form a stone.

 “A gallstone is a tombstone to the microbe that caused it”.

Risk Factors:

Risk factors for gallstones include obesity, a fatty diet, age, female gender, and certain diseases of the blood and liver. The most important risk factor for gallstones is age. Gallstones are seen only very rarely in the young; in my surgical career spanning 15 years and > 800 laparoscopic cholecystectomies, I have operated on only one child younger than 10 years who had gallstones. Thin adults are less at risk of developing gallstones than overweight and obese individuals. Women develop more gallstones than men, though gallstones are fairly common in men too. People who eat high fat and high energy diet are more at risk of developing gallstones. Certain diseases of the blood that cause the breakdown of red blood cells can cause a type of gallstones. A disease of the liver called cirrhosis too predisposes to the formation of gallstones. Certain types of abdominal surgeries, including some weight reduction surgeries, also cause gallstones.

Gallstones themselves behave a lot like gremlins. In some people they may not cause any problems at all, while in others they may cause a lot of complications, such as inflammation of the gall bladder, obstructive jaundice when they slip down the common bile duct and block it, inflammation of the pancreas, and very rarely large stones may predispose to cancer of the gall bladder.

Symptoms:

Symptoms vary from person to person. So, on the one hand, one patient may not have any symptoms at all because of gallstones, or may have only mild dyspepsia, and on the other, someone may develop severe pain in the upper right quadrant or upper central region of the abdomen, which may be accompanied by fever, nausea, vomiting, jaundice, and/or clay-coloured stools.

The pain associated with gall stone disease may be sharp or dull, colicky, and short-lived, and it may occur only after a meal. On the other hand, the pain may be a severe relentless pain located under the rib cage on the upper side of the abdomen, going up to the right shoulder. If such a pain lasts longer than 12 hours or is associated with nausea/vomiting, you should consult a doctor right away, who might suggest admission to a hospital and an early surgery. The development of associated fever and/or jaundice usually means that gallstones have caused major complications and may require prolonged admission and more than one interventions/surgeries.

Treatment:

There is no effective medical treatment for gallstones, but for carefully chosen patients with small silent stones that are not troubling them at all, certain medicines can help. These medicines usually have to be taken for 6-24 months and their efficacy rate is usually 50-60%. Once the medicine is stopped, gallstones can recur as long as the gall bladder remains.

Surgical treatment is a safe and effective treatment of gallbladder diseases. The first gallbladder removal (cholecystectomy) was performed in 1882 by Dr Langebuch. Prior to this attempt gall bladder stones essentially had no treatment! The second revolution in gall bladder surgery came with the advent of key-hole (laparoscopic) surgery in 1985-87 nearly 100 years later. Developed independently by Dr Erich Mühe and Dr Philippe Mouret, laparoscopic cholecystectomy has become the gold standard of treatment of gall stone disease. Laparoscopy has reduced the discomfort associated with major surgery, leading to short convalescing times and a very short hospital stay which may be shortened to less than a day in favourable conditions.

People with more than two episodes of moderate to severe colicky pain, those with persistent episodes of self-limited pain, those who have ever required admission to a hospital due to pain associated with gallstones, or those who have developed fever or jaundice due to gallstones must consider removal of the gallbladder, preferably by laparoscopy. Patients who have diabetes should consider gallbladder removal (laparoscopic cholecystectomy) even in the absence of symptoms. Patients with solitary cholesterol stones should also consider early cholecystectomy. Young people with a long life expectancy can also consider surgery in the absence of major symptoms.

You should try to go for early surgery in the indications cited above because gallbladder surgery has very good results when performed on a relatively healthy non-inflamed gallbladder. As the duration of inflammation increases, so does the complexity of the surgery, leading to suboptimal results.