Surgical Conditions

Gall Stones

A gallstone, is a lump of hard material usually range in size from a grain of sand to 3-4 cms. They are formed inside the gall bladder formed as a result of precipitation of cholesterol and bile salts from the bile.

Types of gallstones and causes

Cholesterol stones
Pigment stones
Mixed stones - the most common type. They are comprised of cholesterol and salts.

Cholesterol stones are usually yellow-green and are made primarily of hardened
cholesterol. They account for about 80 percent of gallstones. Scientists believe
cholesterol stones form when bile contains too much cholesterol, too much bilirubin,
or not enough bile salts, or when the gallbladder does not empty as it should for some
other reason.

Pigment stones are small, dark stones made of bilirubin. The exact cause is not known.
They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anaemia in which too much bilirubin is formed.

Other causes are related to excess excretion of cholesterol by liver through bile. They include the following

Gender. Women between 20 and 60 years of age are twice as likely to develop
gallstones as men.

Obesity. Obesity is a major risk factor for gallstones, especially in women.

Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or
birth control pills

Cholesterol-lowering drugs.

Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides.

Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.

Symptoms

Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called "silent stones." Gallstone symptoms can mimic those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

Symptoms may vary and often follow fatty meals. They may also occur during the night.

steady pain in the upper abdomen that increases rapidly and lasts from
30 minutes to several hours
pain in the back between the shoulder blades , or under the right shoulder
nausea or vomiting
indigestion & belching
abdominal bloating
recurring intolerance of fatty foods

Diagnoses

Ultrasound is the most sensitive and specific test for gallstones.

Other diagnostic tests may include

Computed tomography (CT) scan may show the gallstones or complications.
Endoscopic retrograde cholangiopancreatography (ERCP). With the patient asleep, the doctor passes and endoscope (a long, flexible, telescope) from the mouth, through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts.
Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

Course of illness

Gallstones are generally not treated unless they are causing symptoms. Once they start causing problems, however, removal of the gall bladder is recommended for most patients. Bile-duct blockage and infection caused by stones in the biliary tract can be a life-threatening illness. With prompt diagnosis and treatment, the outcome is usually very good.

Complications

The most common complications of gall stones are recurring bouts of pain cased by blockage of the gall bladder, (biliary colic) and inflammation of gall bladder (cholecystitis) . Other complications may include

Treatment

Surgery

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones. The most common operation is called laparoscopic cholecystectomy. The surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. In about one out of 30 cases, it is necessary to make an old fashioned larger incision (open surgery) to complete the operation safely. The need to change from laparoscopic to open surgery is not considered a complication, rather good judgement on the part of the surgeon.

If gallstones are in the bile ducts, the doctor may use endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove them before or after the gallbladder surgery.

Potential complications of Gall Bladder Surgery (cholecystectomy)

Complications of General Anaesthesia: heart attack, stroke, pneumonia, blood clots, chipped teeth (rare)
Minor bleeding or infection (~5%)
Leakage of bile fluid after the operation - 5% (typically treated with insertion of a drain tube in the radiology department)
Injury to the bile ducts - (<<1%) rare but serious complication typically requiring further surgery
Injury to intenstine (also rare)
Incisional hernia - possible after any abdominaloperation

Recovery after Gall Bladder Surgery

Most young, healthy patients can go home the same day
Some patients need to stay overnight if they are elderly or frail, or have reacted to the general anaesthesia with nausea and vomiting
Pain and discomfort is treated with prescription pain pills, and lasts one to two weeks.

Most patients are back to normal activity within one to two weeks