Gallstones

What are gallstones?
Gallstones are solidified materials that form inside the gallbladder, and may be small little specks or be as large as the gallbladder itself. Gallstones form when bile solidifies and hardens under certain disease conditions.

Bile is the yellowish liquid that is secreted by the liver, and stored in the gallbladder. It contains water, cholesterol, fats, bile salts, proteins and bilirubin, and is responsible mainly for the emulsification of dietary fat.

What is the gallbladder, and what are its functions?
The gallbladder is a pear-shaped sac with a muscular wall, measuring 5-15cm long, located under the liver on the upper right side of the abdominal cavity. It is connected by the cystic duct to the bile duct, which is a tube connecting the liver to the small intestine (duodenum) allowing the passage of bile for digestion. When the bile is not required, it flows into the gallbladder, which acts like a bile reservoir. During a meal, the gallbladder contracts, allowing the passage of bile into duodenum through the bile duct, where it mixes with the food and allows digestion.

The gallbladder is not essential for a healthy digestive tract.

What causes gallstones?
It is not entirely clear, but when there is an imbalance of 2 of the constituents of bile, there is a higher risk of developing gallstones.

If your bile contains too much cholesterol, the excess forms crystals that eventually congregate into cholesterol stones. This can possibly occur as a result to hormonal changes, obesity and diet.

If your bile contains too much bilirubin, the excess bilirubin can crystalise into pigmented stones. These are more common in patients with certain blood disorders, infections and liver cirrhosis.

If your gallbladder does not empty completely, the residual bile may become too concentrated, contributing to stone formation.

What are the symptoms of gallstone disease?
Gallstones may cause no symptoms, but when they do become symptomatic, symptoms range from a mild upper abdominal discomfort or bloating to a severe constant abdominal pain associated with yellowing of the skin and fever.

What are the complications of gallstones?
thickened and infected galbladder wall with multiple gallstones
thickened and infected gallbladder with large gallstoneGallstones can cause gallbladder infection, which can be a festering long-term inflammation, to an aggressive acute infection that can lead to gallbladder gangrene and perforation. When a gallbladder is gangrenous and perforated, the infected contents of the diseased gallbladder leaks into the free abdominal cavity causing generalised contamination that can be fatal.

When gallstones drop into the bile duct, they can potentially cause obstruction to the flow of bile from the liver, resulting in jaundice (yellowing of the skin) and infection of the bile duct (cholangitis). As the bile duct shares an opening into the duodenum with the duct from the pancreas, an obstructing stone can occasionally cause a blockade to the flow of pancreatic juices. This pancreatic duct blockade can then lead to inflammation of the pancreas of varying severity (gallstone pancreatitis).

How are gallstones diagnosed?
Many gallstones are discovered incidentally during tests for other problems. However, when gallstones are suspected to be the cause for abdominal or digestive problems, your doctor may ask for an ultrasound examination. An ultrasound examination is a simple investigation employing sound waves to create images of the internal organs.

Alternatively, a CT (computed tomography) scan can also reveal gallstones, and provide further information of the rest of the abdominal organs, which might be useful in the setting of complicated gallstone disease.

Occasionally, further tests might be required for the diagnosis and possible treatment of gallstones that have dropped into the bile duct. This includes the MRI (magnetic resonance imaging) scan of the biliary tract or the invasive ERCP (endoscopic retrograde cholangiopancreaticography).

Do I need to do anything about the gallstones?
Gallstones that do not cause any symptoms usually do not need any treatment.

If you do have any symptoms from the gallstones, surgery will be recommended to remove the gallbladder. You do not need your gallbladder to live, and you will have a healthy and normal functioning digestive tract without it as bile still flows from the liver into the duodenum.

What are the treatment options for gallstones?
Surgery is the standard in the treatment of gallstones. The gallbladder is removed in an operation through keyhole surgery (laparoscopic cholecystectomy).

In laparoscopic cholecystectomy, small stab incisions are made in the belly under GA (general anaesthesia) and through the use of special instruments under magnified vision with high definition telescopes, the gallbladder is carefully and meticulously dissected and removed from the liver bed. Laparoscopic cholecystectomy regularly involves an overnight stay in hospital, but in certain cases, a same day discharge might be possible.

Mini laparoscopy scarsmini laparoscopy for gallbladder removal (cholecystectomy)

Standard laparoscopic cholecystectomy involves the use of one 12mm and three 5mm incisions in the abdominal wall. However, in selected patients, a mini-laparoscopic cholecystectomy is possible, where even more diminutive incisions are made (Three 3mm incisions compared to the standard three 5mm). This decrease in the incision size has the theoretical advantage of being even less painful, with almost invisible scars upon recovery. This mini-laparoscopic cholecystectomy is made possible with special needleoscopic instruments, and Dr Foo has been a pioneer in its use in Singapore.

In about 1 in 10 patients, keyhole surgery might not be possible for various reasons. This might be decided based on the clinical situation before the operation is done, or decided during an attempted laparoscopic cholecystectomy when a proper visualisation of the gallbladder is not possible. In these cases, an open operation (open cholecystectomy) might be proposed or undertaken. In an open cholecystectomy, a longer cut is made beneath the right margin of the rib cage to access the gallbladder for its removal. A longer recovery is expected after the open operation, and a stay of 2 to 5 days in hospital is normal.

What are the possible complications of cholecystectomy?
While there are risks associated with any kind of surgery, the vast majority of cholecystectomy patients experience few or no complications. Complications, as infrequent as they come, include bleeding, infection, pneumonia, blood clots or heart problems. Unintended injury to adjacent structures such as the common bile duct (0.4%) or small bowel may occur and may require another surgical procedure to repair it.

What are the advantages of laparoscopic cholecystectomy?
Laparoscopic (key hole surgery) removal of the gallbladder employs the use of a special camera on a telescopic lens and long skinny instruments operating through small openings in the abdominal wall. Rather than a 10-15cm incision, the operation requires only 4 small openings in the abdomen, which in turn will decrease the amount of pain experienced post-operatively.

As a result, patients have a faster recovery than those with open operations, and are able to go home within one day after surgery and return to normal activities quicker.

How about SILS?
SILS (single incision laparoscopic surgery) is a technique where surgery is performed through a single incision in the belly button. SILS cholecystectomy allows the avoidance of the additional 3 incisions that the standard laparoscopic cholecystectomy requires, for better cosmetic results. However, it has not been shown to confer recovery that is faster than what is already expected for laparoscopic cholecystectomy, and may be associated with a higher risk of complications. Please check with your doctor if you are a suitable candidate.

Why do you need to remove the entire gallbladder for gallstones? Can’t you just remove the stones?
Gallstones are very unlike kidney stones, where stone removal is sufficient to ablate symptoms. In gallstone disease, the gallbladder is almost always inflammed and diseased as a result, such that even in the absence of stones, it will certainly contribute to symptoms and further stone formation if left in-situ. It is therefore standard and sound medical treatment to remove the entire gallbladder for gallstone disease.

There are no long-term nutritional or digestive consequences to the removal of the gallbladder.

How about alternative medicine for gallstones?
No alternative therapy has been proven to cure or dissolve gallstones. Alternative therapies like the gallstone flush and traditional remedies have been expounded by “Ed” in this interesting exposition.

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