GALLBLADDER STONE SURGERY

WHAT IS THE GALLBLADDER STONE ?

Gallbladder Stone is a small pear-shaped organ almost like a decompressed balloon that is situated under the liver on the right side of the upper abdomen.

It hangs below the undersurface of the Liver.Like a pear it is attached to the undersurface of the liver and connected to the cystic duct which connects to the common bile duct.

The parts of the Gallbladder are named as the fundus, Body, neck, and duct.It normally has a capacity of around 100ml even though in some pathological conditions it can expand up to 200 to 250ml capacity like a bottle gourd.

WHAT DOES THE GALLBLADDER STONE DO?

The Gallbladder is a temporary storage organ for a small amount of Bile. Even though more than one liter of bile is produced in the Liver, a small amount of bile is stored in the gallbladder.

And whenever we eat a fatty diet the small intestine secretes some hormones called Cholecystokinin which causes contraction of the Gallbladder and expulsion of the stored bile into the intestines.

When this mechanism is not working properly and the gallbladder contraction is impaired, there is a stasis of the bile leading to gallstones or sludge formation. Gallbladder further helps in the absorption of water for the bile leading to concentration of the bile.

WHAT IS BILE?

Bile is a fluid that is produced and secreted by the Liver.It is a fluid that mainly contains cholesterol and Bile pigments which give it a green or yellow color.

Bile contains water, cholesterol, bile salts and Bile pigments.The liver excretes the unwanted cholesterol in the body into the bile and it is a method of excretion of the bad cholesterol from the body.

The bile pigments-Bilirubin and Biliverdin are the by-product of the breakdown of blood cells-Heme and are a method of excretion of unwanted waste products from the breakdown of old blood cells from the body.

The bile pigments are a mechanism of excretion of unwanted materials from the body.Bile also contains bile salts- Chenodeoxycholic Acid and Ursodeoxy Cholic acid which help in the digestion of fat and lipids.

HOW DOES THE BILE REACH THE INTESTINE?

Bile is produced and excreted from the liver cells- hepatocytes into the biliary ductules which join to form a bigger bile duct called the right and left hepatic duct from the right and left lobes of the liver respectively. These two join to form the Common Hepatic Duct which joins with the cystic duct from the gallbladder to form the Common Bile Duct (CBD) which opens into the duodenum which is the first part of the small intestine along with the pancreatic duct.

So the bile flows from the Liver through the bile duct into the proximal part of the small intestine where it mixes with pancreatic juice and the food and helps in digestion of the food. The region where the Bile duct opens into the intestine is called Ampulla. Significantly,this is the place where the pancreatic juice also opens into the small intestine. This bile helps in the breakage of fat into fatty acids which can be absorbed by the digestive tract.

WHAT ARE GALLBLADDER STONES (GALLSTONES)?

Gallbladder stones also known as Gallstones, are hardened pebble-like particles that form in the gallbladder.

The sizes of the stones may vary from a few millimeters to as large as 3 to 4cm. There could be a single massive Gallstone or a smaller stone or a combination of small and large stones. Sometimes only sand-like particles form which is called Sludge.

WHAT ARE THE CAUSES OF THE GALLBLADDER STONES?

The exact cause may not be identifiable in many cases Causes could be;

• 1,There is too much cholesterol in your bile-
  When there is too much cholesterol in the bile. It can cause Cholesterol Gallstones.This usually happens in patients taking Cholesterol-lowering medicines.
• 2, There is too much bilirubin in the bile which can cause pigmented stones.
  Conditions like cirrhosis, infection, and blood disorders can cause your liver to make too much bilirubin resulting in pigment stones. This usually occurs in young children with blood disorders leading to anemia and gallstones.
• 3, The gallbladder does not empty properly there is a stasis of bile which leads to gallstones formation. This can happen in some patients taking oral contraceptive pills.
  

  The common predisposing causes are;

  ♦ Obesity
  ♦ Oral contraceptives pills
  ♦ Women above 40 years of age
  ♦ Cholesterol-lowering agents
  ♦ Cirrhosis of the liver
  ♦ Rapid weight loss
  ♦ Blood disorders like hemolytic anemia
  ♦ A diet high in cholesterol

WHAT ARE THE TYPES OF GALLSTONES?

• 1, CHOLESTEROL STONES- Usually yellow in color.
• 2,PIGMENTED STONES-Usually black in color.
• 3,MIXED STONES- Mixture of both cholesterol and pigmented stones.

WHAT ARE THE SYMPTOMS OF GALLBLADDER STONES?

SILENT

Most of the time, the gallbladder is silent and is identified by a routine ultrasound for some other symptoms or as a routine checkup.

DIGESTIVE SYMPTOMS

Many times Gallbladder stones present with digestive symptoms like excessive bloating of the abdomen, belching, fullness after food, and excessive flatulence.

BILIARY COLIC

Sometimes the patient may have repeated attacks of right upper abdomen pain mostly secondary to fatty food, which is called Biliary colic.

SEVERE PAIN

The patient many times presents with severe pain in the right upper abdomen radiating to the right back. It may be because of infection in the gallbladder- cholecystitis or a stone migrated into the bile duct- choledocholithiasis with jaundice or pancreatitis where the whole abdomen becomes distended and painful.

JAUNDICE

Sometimes the patient may present with jaundice due to the presence of stones in the bile duct causing obstruction to bile flow.

FEVER

Sometimes patients may present with fever secondary to infection in the gallbladder and bile duct.

VOMITING

Sometimes the infection in the gallbladder can cause vomiting and infection.

WHAT ARE THE COMPLICATION OF GALLBLADDER STONES?

CHOLECYSTITIS

Infection in the Gallbladder due to gallstones can lead to gangrenous cholecystitis and sometimes perforated cholecystitis. This is more common in diabetic patients.The Gallbladder becomes rotten and sometimes burst.This is a serious condition which needs to be tackled immediately.

EMPYEMA OF GALLBLADDER

When the stone is impacted in the neck of the gallbladder leading to infection and distension of the gallbladder with pus.

JAUNDICE

Whenever the stones migrate into the bile duct, the stones cause obstruction to the flow of bile leading to jaundice. This is a complication which leads to severe pain and becomes two problems;

• ♦ Stones in the gallbladder
• ♦ Stones in the bile duct

PANCREATITIS

This is the worst complication of gallstones where the stones migrate into the bile duct and cause obstruction to the pancreas resulting in pancreatitis. This is called BILIARY PANCREATITIS. The whole abdomen becomes distended and pain transfers to the back and the patient becomes sick.

CHOLANGITIS

Where the infection in the bile duct leads to chills, fever and pain.

LIVER ABSCESS

Sometimes the infection spreads to the liver causing pus formation in the liver which is called a Liver Abscess.

MUCOCELE OF THE GALLBLADDER

Where the gallbladder distended hugely with mucous known as White Bile.

CHOLECYSTO-DUODENAL FISTULA

Where a communication happens between the Gallbladder and the Small intestine.

GALLSTONE ILEUS

Where the gallbladder stone becomes erodes into the small intestine and migrated down in the small intestine and gets impacted in the Ileum producing obstruction called Gallstone Ileus.

MIRIZZI

Where there is a communication between the Gallbladder and the Common Bile Duct.

BILE DUCT STONES-CHOLEDOCHOLITHIASIS

Many times there are stones found in the bile duct. Most of the time the stone in the bile duct is secondary to stones migration from the gallbladder.
Sometimes the stones may forms in the bile duct itself called primary bile duct stones which may be associated with severe conditions called choledochal cysts or after cholecystectomy.These bile duct stones present with Jaundice and Cholangitis.

HOW TO DIAGNOSE GALLSTONES?

Usually, gallbladder stones are diagnosed with an ultrasound abdomen.Usually the doctor advises you to do other blood tests like the liver function test.
Sometimes an MRI scan called MRCP (Magnetic resonance cholangiopancreatography) may be necessary to rule out bile duct stones and infection in the gall bladder. In the case of cholecystitis, the gallbladder wall becomes thickened.CT Scan can also diagnose infection in the Gallbladder and severity and associated Pancreatic Infection.

WHAT IS THE TREATMENT FOR BILE DUCT STONES?

ERCP- ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAM.

In this the bile duct stones are removed by passing a tube through the mouth into the stomach called the Endoscope.

Through the endoscope, the stones in the bile duct are removed and then a stent is inserted-Biliary stent.

This procedure ERCP is usually done under sedation or general anesthesia and for treatment of bile duct stones. ERCP cannot treat stones in the gallbladder. Usually 48 to 72 hours after ERCP,Gall Bladder Surgery is performed.