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| English: Opened gall bladder containing numerous gallstones Deutsch: Geöffnete Gallenblase mit zahlreichen Gallensteinen (Photo credit: Wikipedia) |
by Tyrone M. Reyes, M.D.
Over the past few months, you’ve had several bouts of pain in your upper abdomen. Lately, the pain had been more constant, lasting much longer and accompanied by nausea. Tests show you’ve been having gallbladder attacks due to gallstones. Gallstones are common, affecting one in 12 persons in countries such as the United States. They’re also more common as you age. In the Philippines, thousands of new cases are diagnosed each year and cholecystectomy (the surgical removal of the gallbladder), is one of the most common abdo-minal operations done locally. Luck-ily, most gallstones don’t require surgical treatments. But sometimes, they cause painful attacks and lead to more serious complications. It’s important to see your doctors promptly if symptoms of gallstones persist or worsen.
WHAT DO GALLSTONES DO?
Your gallbladder is a small, pear-shaped sac located below your liver in the right side of your upper abdomen (see illustration). It’s part of your biliary tract — the system in your body that transports bile. Bile is a greenish-brown liquid produced by your liver that helps break down fats and remove waste products from your body. Your gallbladder concentrates and stores bile until it’s needed for digestion. After you eat, your gallbladder contracts and releases bile into your small intestine through a series of tubes known as bile ducts. If the bile in your gallbladder becomes chemically unbalanced, solid particles can form. Over time, these particles may grow into stones. Gallstones can be as small as a grain of sand or as large as a golf ball. You can have just one or hundreds.
WHY DO GALLSTONES FORM?
Many factors contribute to gallstone formation. Most gallstones form when too much cholesterol builds up in bile. The extra cholesterol is not properly absorbed and, over time, turns into stones that may block the normal flow of bile. Other types of stones can form from excess salts in the bile. It’s similar to putting too much sugar in a glass of ice tea. The water and tea will only absorb so much sugar, and the rest settles in the bottom. In addition, if your gallbladder doesn’t empty completely or often enough, bile may become too concentrated and contribute to gallstone formation. Other risk factors include:
• Your sex. Women are twice as likely as men are to have gallstones. That’s because the female hormone estrogen causes more cholesterol to be excreted in bile. Pregnancy, which causes estrogen levels to rise, also increases the risk. In addition, birth control pills and hormone replacement therapy increase bile cholesterol levels and reduce gallbladder emptying.
• Being overweight. This increases the amount of cholesterol in your bile and can prevent your gallbladder from emptying properly.
• Diet and dieting. Diets high in fat and cholesterol and low in fiber may increase your risk. In addition, low-calorie crash diets can upset the chemical balance of bile and cause your gall bladder to contract less often.
• Cholesterol-lowering medications. Drugs known as fibrates include fenofibrate (Lipanthyl) and gemfibrozil (Lopid), which slightly increase the risk of gallstone formation, probably by changing the cholesterol composition of bile.
• Your age. As you age, your body tends to secrete more cholesterol into bile.
• Your family history. Gallstones often run in families, pointing to a possible genetic link.
WHEN SHOULD YOU SEEK HELP?
When your gallbladder contracts to expel bile, one or more stones may escape. Small stones may pass through without any problem, but larger stones can get stuck at the entrance to the duct that connects the gallbladder to the main bile duct, or they can lodge at the entrance to the small intestine. Signs and symptoms of problems include:
• Sudden and moderate to intense pain in your upper abdomen, possibly spreading to your back or right shoulder blade and lasting from 15 minutes to several hours
• Nausea and vomiting
• Fever and chills
• Jaundice (yellowing of your skin and whites of your eyes)
• Dark-colored urine
• Pale-colored stools
If you experience any of these signs and symptoms, seek treatment right away. Although gallbladder attacks often pass, your gallbladder can become infected and could rupture if a blockage remains. In addition, an obstruction could block the nearby pancreatic duct, causing inflammation of the pancreas (pancreatitis), a potentially life-threatening condition. Diagnosis of gallstones often includes a blood test to detect infection or indications that bile has backed up into the bloodstream. Ultrasonography is the most commonly used test to find stones in the gallbladder. Other diagnostic studies include endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance imaging (MRI), and endoscopic ultrasound.
WHAT ARE YOUR TREATMENT OPTIONS?
Gallstones that aren’t symptomatic typically require no treatment because, for many people, the risk of taking them out is greater than the risk they’ll cause problems. These stones are called “silent stones,” and they’re often discovered during tests for other health conditions. For problematic gallstones, removing the gallbladder is the most common treatment. Your gallbladder isn’t an essential organ, and new stones usually form if just the stones are removed.
“In 2007, the routine and standard of care for somebody who has symptomatic gallstones is laparoscopic gallbladder removal.” says Dr. Miguel C. Mendoza, head, Section of Laparoscopic Surgery of Asian Hospital and Medical Center.
Unlike open surgery, laparoscopy uses smaller cuts in the belly area. The gallbladder is taken out through one of the small openings. Studies have shown that older adults benefit even more from a laparoscopic approach than younger people.
“Laparoscopy creates less of a physiological insult and people heal and return to normal activities faster than they would with open surgery,” adds Dr. Mendoza.
The reason for this is that laparoscopic surgery follows the principles of minimally invasive surgery. Hence, the advantages of laparoscopic removal of gallbladder stones include a much less painful recovery, less dependence on pain relievers, shorter hospital stay (one day only!), less suppression of the immune system, lower infection rate, earlier return to work, earlier return to usual activities (in one week’s time!), and more cosmetically acceptable small scars, among many others. Currently, laparoscopic removal of the gallbladder may now be performed even for obese patients, patients with scars from previous abdominal operations, and even for an acutely inflamed gallbladder provided that it is done under good and experienced hands.
A medication called Actigal (Ursodiol), which dissolves stones, may be considered for those who are dead-set against surgery. The medicine, however, does not change the imbalance in the body that causes the stones to form in the first place, so there is a big chance that stones will come back. Furthermore, the trouble with the medicine is that it tastes horrible, it’s not available locally, it’s expensive, and you have to take it every day until the stones go away, which can be years. So, few patients stick with this type of therapy.
LIVING WITHOUT YOUR GALLBLADDER
After your gallbladder is removed, your liver will continue to produce enough bile to digest a normal diet. But instead of being stored in your gallbladder, the bile will empty directly into the small intestine. You may notice that you will have more bowel movements than you used to, and that your stools are softer. These changes are often temporary as your body’s digestive system readjusts to the absence of a gallbladder.
WHAT YOU CAN DO TO PREVENT GALLSTONES
Meanwhile, here’s what you can do to minimize your chances of getting gallstones:
• Choose a diet that’s low in fat and high in fiber and complex carbohydrates.
• Cut away on fatty foods and work hard to lower your cholesterol. Ask your doctor about taking statin drugs to help.
• Eat smaller, well-spaced meals, and eat slowly to avoid “piling up” food in your digestive system.
• Get regular exercises to burn off that ingested fat instead of letting it build up — but be slow and steady in your weight loss; rapid reduction can promote stone formation.
Above all, be informed. Don’t let the gall of your gallstones faze you!
A series of tubes
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