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Family Health Magazine
FAMILY MEDICINE

Your Gallbladder
Do you really need it?

You may have a friend or relative who has had abdominal pain from problems with the gallbladder. Perhaps you have experienced it yourself. In either case, you probably know that gallbladder disease can be both painful and serious. Fortunately, it is usually very treatable.

At one time, the most common treatment was the uncomfortable process of removing the gallbladder by major abdominal surgery. Now, gallbladder disease can be treated in a variety of ways, safely, effectively and more comfortably than in the past. New imaging techniques have led to quick and accurate diagnosis of most gallbladder diseases. Techniques include ultrasound, computed tomography (CT) scans and magnetic resonance imaging (MRI studies). Medications and other methods can also dissolve or remove gallstones in certain patients. Happily, the need for major surgery has become much less common since various endoscopic surgical techniques have been developed.

What and where is the gallbladder?

The gallbladder is a pear-shaped sac that varies from three to six inches in length, located in the upper right abdomen just underneath your liver. It connects to the liver and intestine through small tubes (bile ducts). The gallbladder acts as a reservoir that concentrates and stores bile produced by the liver. When fatty foods pass from the stomach into the intestines, a hormone (cholecystokinin) released from the small intestine makes the gallbladder contract. Bile then passes into the intestine from the gallbladder. There it mixes with fatty foods, helping digest and absorb them. After a few hours, the gallbladder relaxes and begins to store more bile again.

What are gallstones?

Gallstones are lumps of hard material made from bile. They form inside the gallbladder or sometimes in the common bile duct. They range in size from a few millimetres to several centimetres, though most are smaller than two to three centimetres. Bile stored in the gallbladder becomes a concentrated, yellowish brown or green liquid. Under certain conditions, components of the bile begin to crystallize, at first forming small sand-like particles. These particles can slowly increase in size, resulting in two main types of stones.

Cholesterol stones - about 80 per cent of gallstones have cholesterol as their main element.

Pigment stones - 20 per cent are made mostly of calcium salts and the pigment bilirubin.

Both types also contain protein, other minor components of bile and varying amounts of calcium. Sometimes gallstones contain enough calcium to be seen on ordinary abdominal x-rays.

Are you at risk of forming gallstones?

About 10 to 15 per cent of all adults have gallstones. Fifteen per cent of men and up to 40 per cent of women over the age of 60 will have gallstones. However, most people with gallstones have no symptoms or complications, and so do not require treatment. Some common factors, including diabetes, obesity, rapid weight loss, pregnancy, use of estrogen preparations, cirrhosis of the liver and certain medications, can increase the risk of gallstones.

Women are twice as likely as men to have gallstones, especially those who have been on the birth control pill or had children. Gallstones are more common in Native Americans, Hispanics and western Caucasians. They appear less frequently in African Americans, natives of South Africa and Japanese populations. Genetics also play a role, as gallstones are more common in some families. Although children seldom have gallstones, those who are obese or have sickle cell anemia are more at risk.

What problems do gallstones cause?

The most common type of problem is biliary colic or the ‘gallbladder attack.’ It occurs when contraction of the gallbladder lodges a stone in the opening of the common bile duct, or when stones form within the duct itself. The gallbladder is unable to empty, and so it and/or the bile duct swell and stretch. Though fatty or large meals can set off an attack, it usually happens several hours after a meal. The pain often awakes the person in the middle of the night, and can be quite severe. It is usually located in the right upper area of the abdomen just under the ribs. There may be nausea and vomiting. Pain may also be felt in the upper back and the right shoulder. These attacks usually lessen within one to three hours.

A second common type of gallbladder attack is called acute cholecystis. With repeated blocking, the gallbladder can become acutely swollen, inflamed, and completely blocked. The resulting intense, prolonged pain is often accompanied by fever, chills, nausea and vomiting. Although inflammation of the gallbladder can come from other causes, 95 per cent of the time it is due to gallstones. This condition is serious since it can lead to gangrene or rupture of the gallbladder if left untreated. Most of the time, attacks lessen after several days of treatment in the hospital but the chance of repeat attacks is high.

Occasionally, gallstones can lead to other problems. Stones blocking the flow of bile out of the liver make it inflamed (called ascending cholangitis). Similarly, flow out of the pancreas can be blocked. The inflammation of the pancreas is called acute pancreatitis. More rarely, a stone can be large enough to block the flow of digested food through the small intestine. Having gallstones constantly has been associated with cancer of the gallbladder.

How is gallbladder disease diagnosed?

Most gallstones do not cause problems but are discovered accidentally when abdominal x-rays or ultrasound studies are done for other reasons. Based on the symptoms, gallbladder problems can often be suspected. They are confirmed through a combination of blood tests and usually an abdominal ultrasound. Sophisticated imaging scans like CT or MRI may be needed in difficult cases.

Stones lodged in the common bile duct can be harder to find. In that case, a useful procedure is ERCP (endoscopic retrograde cholangiopancreatography). In ERCP, a flexible scope containing miniature instruments is passed through the mouth, into the stomach and then into the intestine. Once located, the opening of the common bile duct can be enlarged and injected with dyes that make the duct and its contents visible on an x-ray.

When gallbladder disease is suspected and imaging studies do not show stones, a HIDA scan may be done. This test involves injecting HIDA, a radioactive material, into a vein. HIDA is taken up by the liver and passed into the bile system. A nuclear scanner is used to locate bile in the liver, gallbladder and the common bile duct. Doctors can see how well the gallbladder is working and whether there are blockages.

How is gallbladder disease treated?

When painless gallstones are discovered, the first approach is often waiting to see if symptoms develop. This is safe as long as there are no other risk factors, such as large stones or a serious disease such as diabetes. The first serious attack usually leads to hospital admission for pain management and diagnosis confirmation. If biliary colic (blockage by gallstones) is the diagnosis, stones can be removed by either non-surgical or surgical methods.

Non-surgical removal can be done either by dissolving stones or breaking them into smaller pieces. Oral medication (such as ursodiol) has been in limited use for years to dissolve cholesterol gallstones. It is not suitable for stones that are pigmented, calcified, larger than two centimetres, or blocking a duct. Once the medication stops gallstones often recur, and the drug is expensive (about $180 per month).

Another non-surgical approach is called lithotripsy. With this method, gallstones are broken into smaller fragments, which then naturally pass into the intestine. Stones can be broken using high frequency sound waves or by mechanical crushing during ERCP. Lithotripsy does not work well for stones containing calcium. As well, it requires a working gallbladder and common bile duct system for the stone fragments to be passed. Lithotripsy is suitable for only about 30 per cent of patients.

About ten per cent of those treated form new stones within a year. However, there is less pain and lost work time than with traditional gallbladder surgery. Stones can be removed from the common bile duct using ERCP. Once in place, the scope can be used to remove small stones using a miniature basket or balloon system.

They remove gallbladders, don’t they?

Surgery to remove gallstones or the gallbladder is now usually done using a laparoscope, a fibre-optic scope that allows surgeons to see inside the abdomen. It is inserted through a small incision just above the navel, while surgical instruments are inserted through additional small incisions. The surgeon looks through the scope to remove the gallbladder, so a large abdominal incision is not required.

Patients usually only need one night in the hospital and experience less pain than with open abdominal surgery. They recover more quickly and usually can return to work in a week or two rather than the four to six weeks required after abdominal surgery. Complications are few and those that do occur are often minor. Laparoscopic removal is not successful about five per cent of the time. In this case, the patient must then have traditional abdominal surgery.

Can you get along without your gallbladder?

You probably will not miss it and you certainly will not miss the pain it caused. Most people do very well without their gallbladder. In its absence, bile made by the liver trickles steadily into the intestine rather than being released from the gallbladder on demand. This has little to no effect on digestion, though some people have loose stools and more gas.

Can gallstones be prevented?

There is no sure way to prevent gallstones. High-fat meals can trigger an attack, but avoiding fat has not been shown to prevent gallstones. Since obesity increases the risk, proper diet is important. Rapid weight loss can also encourage gallstones to form. Regular exercise can reduce the risk of both gallstones and gallbladder disease.

Eating lots of fibre, drinking alcohol in small amounts (one ounce per day) and taking vitamin C (ascorbic acid) have been associated with a lower occurrence of gallstones. Eating a lot of sugar has been associated with an increased risk of gallstones. For people who have had stones before, taking the medication ursodiol may help prevent stones from recurring.

Are there alternative treatments?

You can find a great deal of information on the Internet about treating gallbladder disease with alternative medicine. Suggestions include using herbs and supplements, concoctions to flush gallstones, homeopathy, spinal manipulation, and acupuncture. Though some of this information is reliable, sadly much is not.

If you feel you may have gallbladder problems, see your doctor to discuss the various options for diagnosis and treatment available to you. Two useful sites, www.emedicine.com and the patient information section of the American College of Gastroenterology site www.acg.gi.org can provide additional information.