Gallstones

Bile is produced in the liver and plays a central role in the digestion and absorption of fat. Bile is stored and concentrated in the gallbladder and then released in response to a meal. The body also uses bile to get rid of excess cholesterol. Cholesterol in bile is kept soluble by the presence of bile salts. Any imbalance of the cholesterol: bile salt ratio can lead to the precipitation of cholesterol and the formation of cholesterol stones.

Gallstones are a common problem, increasingly so in females and with advancing age. Gallstones are mostly formed when cholesterol crystallizes in the gallbladder which then leads to it gradually enlarging. Gallstones may also be caused by excess breakdown of red blood cells. The presence of gallstones could affect the functioning of the gallbladder which could lead to the patient experiencing discomfort.

What are the symptoms of gallstones?

Fortunately, gallstones will remain asymptomatic in the majority of patients. When gallstones do produce symptoms, it can be any of the following:

• Biliary (gallstone) dyspepsia
  feelings of nausea, epigastric discomfort and bloatedness can be ascribed to gallstones if no other abnormalities can be found.
• Biliary colic
  when a gallstone blocks the outlet of the gallbladder, it can lead to increased pressure in the gallbladder and produce severe colicky (cramping) pain in the upper abdomen. This usually lasts 30min to 2 hrs and subsides as soon as the obstruction is relieved. The pain is usually accompanied by nausea and vomiting.
• Acute cholecystitis
  when an obstruction is not relieved (see above), the increased pressure can lead to impairment of the blood supply to the wall of the gallbladder. This will lead to inflammation and subsequently, infection of the gallbladder. The patient will experience continuous abdominal pain and fever.
• Obstructive jaundice
  gallstones can enter the common bile duct (a tube that drains bile from the liver to the gut). The gallstones can then cause an obstruction which will lead to jaundice (yellow discolouration of the skin and sclera).
• Cholangitis
  when bile flow is obstructed, bile infection can occur. You may experience jaundice, central abdominal pain and fever or rigours. Cholangitis can be life-threatening if not attended to promptly.
• Pancreatitis
  if a gallstone passes through the common bile duct, it can also lead to obstruction of the orifice of the pancreatic duct which may lead to the development of pancreatitis.

How are gallstones treated?

If gallstones are completely asymptomatic surgery might not be necessary. Dr Cooper may discuss surgery with you if the gallstones become symptomatic (see above). A cholecystectomy is performed in a minimally invasive (laparoscopic) manner as soon as any of the above symptoms / complications develop.

• Laparoscopic cholecystectomy:
  During a laparoscopic cholecystectomy, Dr Cooper will place 4 (2 x 5mm and 2 x 10mm) ports or tubes into the abdomen. He will then insufflate the abdomen with carbon dioxide to create space to work in. A telescope or lens is introduced through one port, and the magnified image of the inside of the abdomen is displayed on a high definition monitor. While observing the monitor, the surgeon then goes ahead and removes the gallbladder.
• Single-incision laparoscopic surgery (SILS):
  This is an alternative method of accessing the abdomen which may be employed to remove the gallbladder in selected cases. Here the surgeon uses a single, highly specialised port which is placed via a 2cm cut in the navel which leads to a near scar-less procedure.

Major cholecystectomy complications are minimal:

• Bile duct injury:
  due to severe inflammation in cases of acute cholecystitis or unusual anatomical variations, occasional bile duct injuries can occur. This can lead to obstructive jaundice or a bile leak developing in the post-operative period. These injuries can be difficult to manage, but fortunately are quite rare, occurring in less than 1% of cases.
• Bleeding:
  injury of the hepatic arteries can lead to major bleeding, which may make it necessary for Dr Cooper to convert to an open procedure. If not dealt with correctly, this can lead to bile duct injuries or occlusion of a major hepatic artery with subsequent ischaemic hepatitis. Fortunately, this also occurs very rarely.