SIGNS AND SYMPTOMS :
Gallstones cause symptoms when they lodge in the duct or tube
that empties the gallbladder. The most frequent symptom is pain
in the upper abdomen, either in the center of the abdomen just
below the breastbone, or beneath the right ribs. The pain
usually lasts no more than minutes to a few hours, and most
often occurs following meals, especially fatty meals. Sometimes
the pain can awaken the patient in the early morning hours. In
some patients the pain appears to penetrate through to the right
back, and many people experience nausea. If the stone that
blocks the outlet of the gallbladder lodges, infection can set
up in the gallbladder causing the complication of cholecystitis.
This can then lead to the necessity of emergency treatment.
HOW ARE GALLSTONES DIAGNOSED?
Doctor will suspect gallstones from listening to your history,
examining you, and perhaps also blood and urine tests. However, to
prove gallstones requires imaging (scanning):
Ultrasound: More properly called ultrasonographic
scanning (USS), this is the same scanning technique used to observe
the unborn baby in the womb. It uses sound waves and is totally safe
and painless. Sound waves bounce off gallstones and the reflections
show on a video screen.
Depending on the complications which gallstones cause, it may be
necessary to look for gallstones in the bile duct as well as the
gallbladder. This can be done in a variety of ways. The simplest way
is to inject dye into the bile duct during a gallbladder operation,
'intra-operative cholangiography', but it is not necessary to have
an operation to do this. At Endoscopic Retrograde
Cholangio-Pancreatography (ERCP), dye can be injected through a
swallowed telescope (endoscope) backwards up into the bile and
pancreatic ducts. Bile duct gallstones can be removed through the
telescope, but not those in the gallbladder. Because there are some
slight risks of ERCP, and because it is not always possible to
inject dye into the bile duct, a new scanning technique called
Magnetic ResonanceCholangio-Pancreatography (MRCP) has been
WHAT TREATMENTS ARE POSSIBLE?
surgery, diet or drugs:
The treatment is usually surgical, removing gallstones and
the gallbladder which causes them to form. The operation is 'cholecystectomy'
and is safe for most patients.
Living without a gallbladder is perfectly normal, and life is
usually very much improved after surgery. Most surgeons now perform
cholecystectomy using a video camera mounted on a telescope (laparoscope)
passed through the umbilicus (tummy button) and several other small
'keyhole' incisions, avoiding a big, painful scar. The camera sends
a magnified image to a video monitor, giving the surgeon a close-up
view. The operation is performed by manipulating the surgical
instruments through the three other 'keyholes', usually three. The
gallbladder is identified and carefully separated from the liver and
other structures. Finally, the gallbladder is disconnected from the
bile duct and removed through one of the small incisions. It usually
means a day or two in hospital at the most and a further two weeks'
convalescence. It results in less pain, quicker healing, improved
cosmetic results, and fewer complications. One serious complication
which can occur, however the gallbladder is removed, is injury to
the bile duct, which connects the gallbladder and liver. This may
cause a painful and potentially dangerous infection and may require
corrective surgery, but this is rare. Meticulous surgical skill and
training help to prevent, as may the performance of cholangiography
disconnecting the gallbladder from the bile duct. Sometimes
complications such as adhesions, severe inflammation or bleeding
occur, forcing the surgeon to switch to the 'open' cholecystectomy
using a standard incision for safety. This now happens in less than
5% of cases, and in expert centres, less than 1%. A longer
convalescence will be required. A US Consensus Development
Conference panel by the National Institutes of Health, in September
1992, endorsed laparoscopic cholecystectomy as safe and effective,
equal in efficacy to open surgery, but noted that it should be
performed only by experienced surgeons and only on patients who had
symptoms of gallstones. The panel noted that outcome was greatly
influenced by training, experience, skill, and judgment of the
surgeon and recommended strict guidelines for training,
credentialing, determining competence, and monitoring quality.
A diet high in fibre (roughage - fruit and vegetables) and low in
fat may help by reducing gallbladder stimulation, but this is
usually a holding measure for most patients.
Drugs etc: Drug treatments are designed to dissolve
gallstones, but few people respond to this and it may take months or
years to work, whilst the gallstones still symptoms. Mild diarrhoea
is common. They may reform after dissolution. Gallstones in the bile
duct can be treated by ERCP as outlined above. As this does not
remove the diseased gallbladder, operation may still be required.