• Gallstones
• Surgery
• More pain post-op

Gallstone has logged in the duct connecting the gallbaldder to the main bile duct. This is cause severe pain known as biliary colic


Gallstones

Gallstones

Background information

• About 15% of people in New Zealand will develop gallstones over a lifetime.


• They are more common in;
  • Women.
  • People who are overweight.
  • Family history of gallstones.


• There are several different types of gallstones.
  • Most stones are formed from a supersaturated solution of cholesterol in the gallbladder.
  • Only 10% of gallstones will show on a plain X-ray.
  • Most stones are picked up on abdominal ultrasound.


• Most stones start as a small cholesterol crystal.
  • The crystal slowly grows depending on the saturation of bile salts and cholesterol in the bile.
  • The function of the gallbladder may be important.  Failure to empty normally could an important factor.
    
• Pigment stones (10% of all gallstones).
  • These occur because of increased breakdown of blood.

Biliary colic – gallstone pain.

• Stones in the gallbladder may cause abdominal pain - this is called biliary colic.
  • This pain is usually an “attack” with sudden onset and lasts for 4-6hours.
  • The pain is mainly in the right upper abdomen but can also be in the lower chest and back (over the right shoulder blade).
  • There is often nausea and/or vomiting.
  • The severity of the pain is often enough to want to seek out urgent medical attention.
  • Sometimes the pain is confused for a heart attack.
  • There can be repeated episodes of pain but not usually daily episodes.


• Biliary colic is caused by a stone lodging in the outlet of the gallbladder.
  • Most of the time the stone falls back into the gallbladder and the “attack” is over.
  • Biliary colic may be brought on by a large fatty meal because this causes strong contractions of gallbladder.


• If the pain lasts for more than 6 hours then a complication may have arisen.
  • The main potential complication is inflammation of the gallbladder.  This is called acute cholecystitis.  Hospital admission is essential.
  • Another complication is migration of a stone to the main bile duct. This leads to jaundice;  often infection (cholangitis) or pancreatitis.


• Treatment involves
  • Intravenous fluids, pain relief, antibiotics.
  • Then proceeding to cholecystectomy (removal of the gallbladder) – usually during the same hospital admission.
  • Sometimes there is a preference for waiting for the inflammation to settle down before proceeding to surgery.

Gallstones on ultrasound but no pain.

• This is a common situation. Ultrasound of the abdomen is a common investigation that is done for a wide variety of reasons.
• Many gallstones that are picked up on ultrasound will be causing no symptoms.
  • 60 - 80% of all gallstones cause no problems.
  • About 20% of people with gallstones picked up by chance will develop symptoms due to the gallstones over the next 20 years.
  • Therefore most people would think that watching and waiting is the best response rather than an operation.


• Symptoms of indigestion, fullness or bloating after meals, nausea or heartburn are not due to gallstones.

Gallstone type of pain but no gallstones

• This is also a common situation. Pain in the right upper abdomen may be similar to gallstone pain (biliary colic) but no stones are found when the ultrasound is done.


• The most likely explanation is that the pain does not arise from the gallbladder but from the colon or from the stomach.
  • Pain from the colon is due to irritable bowel syndrome.
  • Sometimes constipation leads to distension of the colon on the right side of the abdomen and right-sided abdominal pain.
  • A gastroscopy should be performed to check for peptic ulcer or acid reflux.
  • Sometimes there is no easy explanation.


• There is a debate as to whether the gallbladder can give rise to pain in the absence of gallstones.
  • There is some suggestion that a “non-functioning gallbladder” is associated with episodes of pain.
  • This means that the gallbladder does not take up the bile coming down from the liver.
  • This “non-functioning” state can be detected by a radionuclear scan called a HIDA scan.
  • A scan showing a “non-functioning” gallbladder predicts a reasonable success rate with cholecystectomy (perhaps 2/3 will have symptom relief).

Gallstones

Gallstone pain and gallstones found.

• This is the easiest situation. There is only one way ahead and that is to have a cholecystectomy - surgery.
• There are no sensible alternatives to this operation.
  • Dissolving gallstones was tried and found not to be a successful approach.
  • Taking out the stones without taking the gallbladder led to a high rate of recurrent stones (forming again in the gallbladder).
  • Crushing/ shattering gallstones with a lithotripter machine, in a manner similar to kidney stones, is technically possible but is not successful in the long term.


• Cholecystectomy is now routinely performed by a laparoscopic approach (keyhole surgery).
  • The average hospital stay is 2 days.
  • Not everybody can be done by this approach – advice from your surgeon is required.


• Surprisingly, digestion of food is unaffected by taking out the gallbladder.
  • The function of the gallbladder is to concentrate bile made by the liver and to deliver the concentrated bile to the small bowel at the time of a meal.
  • Without a gallbladder smaller amounts are delivered to the small bowel (at times unrelated to meals.
  • There is enough reserve function in the digestive process so this problem with bile flow doesn’t seem to matter.


• However about 1% of people develop diarrhoea after a cholecystectomy.
  • This may be due to an irritant effect of bile salts on the colon.
  • It is effectively treated with cholestyramine (specialist review is required).


• There is an association of cholecystectomy with irritable bowel syndrome.
  • It is most likely that this is because the pain of IBS was mistaken for biliary colic (gallstone pain).
    
    

Xray of a stone in the main bile duct - retrieval with a basket (ERCP)

Further attacks of gallstone type pain after removal of the gallbladder

• This may be due to a stone left behind in the main bile duct.
  • The chance of a retained stone after cholecystectomy is about 4%.
  • The treatment will depend on the situation.
  • The most common approach is an ERCP (Endoscopic retrograde cholangiography).
    • This is like a gastroscopy but with specialized equipment to retrieve stones from the bile ducts.
    • It is an outpatient procedure performed with sedation.


• Most often further tests do not show any stones left behind in the bile ducts.
  • The explanation may be that the initial symptoms were not due to the gallstones.
  • Possible diagnoses include irritable bowel syndrome or a “sensitive stomach” or constipation.
  • This needs careful evaluation by a surgeon or gastroenterologist
    


• It is not possible to prove with absolute confidence whether the symptoms did relate to the gallstones.
  • The decision to proceed to a cholecystectomy is always a judgement call.
  • Therefore sometimes a cholecystectomy is performed for what are essentially asymptomatic gallstones.


• A small proportion of people with continuing attacks of biliary colic have an abnormality of the valve at the bottom of the bile duct (where the bile duct enters the duodenum/small bowel).
  • This is called Sphincter of Oddi dysfunction.
  • It is a genuine problem but it is a diagnosis that is difficult to prove or exclude.
  • The only successful treatment is cutting the muscle fibres of this sphincter at the time of an ERCP.
  • This has some risks – particularly causing pancreatitis. Specialist assessment is required.