Gallstones

Gallstones are small pebble-like structures that develop in the gallbladder, a pear-shaped sac lying beneath the liver and connected to the bile ducts by the cystic duct.

There are three types of stones: cholesterol stones, pigment stones and “mixed” stones.

Symptomatic gallstone attacks (and other gallbladder problems) requiring hospital admission have a major economic impact in terms of lost working days and costs to the health system. In 2014–15, almost 50,000 laparoscopic cholecystectomy operations were undertaken in Australia.

The gallbladder contains “bile” which is produced inside the liver but is stored and concentrated in the gallbladder. Bile helps to break down and digest food, particularly fatty food. Normally, the gallbladder contracts and empties in response to a fatty meal entering the duodenum.

Symptoms of gallstones

Many people with gallstones have no symptoms – known as asymptomatic or silent gallstones. The risk of developing symptoms in these patients is approximately 2-4% annually but once symptoms start, they usually recur, and the timing is often unpredictable.

Symptoms vary but often follow fatty or large meals, and usually develop late in the evening or in the early hours of the morning. Classic gallstone/gallbladder pain that occurs after a "gallbladder attack" is called “biliary colic” although confusingly it is a constant pain or discomfort rather than severe and spasmodic as occurs in the bowel. Biliary colic usually starts in the upper abdomen (epigastrium) and often radiates under the right rib cage or into the right shoulder blade. It is usually a steady pain that increases rapidly and lasts from 30 minutes to several hours.

Other symptoms may include:

• Fever
• Abdominal bloating
• Recurring intolerance of fatty foods
• Nausea and vomiting
• Pain in the back between the shoulder blades
• Pain under the right shoulder
• Indigestion & belching

Atypical or unusual biliary symptoms

Some patients present with “atypical” pain or they may have other predominant symptoms such as anorexia, nausea, abdominal bloating or vomiting rather than pain. These symptoms may be precipitated by eating fatty foods and this offers a clue that it is biliary in origin. Approximately 20% of patients describe a high epigastric or even retrosternal “discomfort” that may be difficult to differentiate from oesophageal spasm or cardiac (heart) pain. In other patients the predominant symptom may be “reflux” or “heartburn” particularly after large or fatty meals. Left-sided abdominal or left shoulder pain are uncommon symptoms of gallstones.

How are gallstones diagnosed?

A detailed clinical history is important to identify the typical symptoms of gallstones. Frequently, other investigations (e.g. upper endoscopy, cardiac investigations) have already been performed by the time the patient is referred for a surgical opinion. In retrospect, many of the symptoms being investigated were typical of gallstones. In patients with truly “atypical” biliary pain other less common conditions such as peptic ulcer disease or oesophago-gastric malignancy or non- gastrointestinal problems such as cardiac disease should be ruled out.

A simple abdominal ultrasound has the highest sensitivity and specificity for diagnosing gallstones.

Computerised tomography (CT) and magnetic resonance (MR) scans often fail to show the gallstones even though these may be seen on ultrasound.

Patients with uncomplicated biliary colic require pain relief only and do not usually require hospital admission unless their symptoms do not settle quickly. Occasionally, a CT or MR cholangiogram may be required to exclude stones that have moved from the gallbladder into the main bile duct draining from the liver (these stones are known as “choledocholithiasis”). An endoscopic retrograde cholangio-pancreatogram (ERCP) may be necessary to remove these stones if there is a history of repeated episodes of cholangitis. However, this is usually reserved for patients with obstructive jaundice or with a history of severe pancreatitis or in those patients who are unfit to undergo a laparoscopic procedure.

Pre-operative blood tests are helpful to look for signs of infection, obstruction, pancreatitis, or jaundice. They should include liver function tests and a full blood count.

Patients with typical symptoms but no gallstones on ultrasound require a nuclear study called a cholescintigram (HIDA scan) which may diagnose delayed emptying of the gallbladder. This is called a “functional gallbladder disorder” and these patients may also benefit from having their gallbladder removed.

Treatment for symptomatic gallstones

Removal of the gallbladder by an operation called laparoscopic cholecystectomy is the most effective treatment for patients with symptomatic gallstones. This is a “key-hole” procedure done under a short general anaesthetic. The surgeon makes four small incisions in the abdomen and inserts surgical instruments and a video camera (laparoscope) into the abdomen. This provides a close-up view of the organs allowing the gallbladder to be separated from the liver, bile ducts and other structures. Professor Hugh uses a 3D camera system for gallbladder operations which he believes provides more accurate detail than a standard viewing system, thereby increasing the safety of the operation. Patients often ask why the gallbladder must be removed rather than just the gallstones? This is because removing the stones only will not deal with the underlying problem which is the inability of the gallbladder to concentrate and empty in a normal fashion. Symptomatic patients have a non-functioning gallbladder and cholecystectomy improves their quality of life because it removes the diseased organ. In the months after the operation, the intra- and extra-hepatic bile ducts dilate slightly to compensate and deliver more bile when needed.

Do I need to stay in hospital overnight and what can I expect after the operation?

In Australia, most patients remain in hospital for one night only after their operation although there are some units who perform this as a “day only” procedure. In experienced hands, laparoscopic cholecystectomy is associated with minimal morbidity and an extremely small risk of mortality.

Professor Hugh will provide detailed and informed consent about this operation during the pre-operative consultation. He will spend ample time discussing the operation including an explanation of the risks of bleeding, infection and, the most feared but rare complication, injury to the extra-hepatic bile duct. He will also discuss your likely post-operative recovery.

Professor Hugh has performed > 3,000 laparoscopic cholecystectomy operations over the past 20 years, and he has published numerous articles related to his surgical outcomes. Based on prospective data collected over 20 years, the risk of having to convert to an open operation under Professor Hugh is < 1%.

Should every patient have an operative cholangiogram (x-ray of the bile duct) during their gallbladder surgery?

There is ongoing debate about whether a routine intra-operative cholangiogram (IOC, x-ray of the main bile duct) should be performed with every laparoscopic cholecystectomy. Those who advocate a routine cholangiogram argue that approximately 4% of patients have unsuspected common bile duct stones even though there was no suggestion of this on preoperative investigations. Furthermore, IOC allows accurate definition of the biliary anatomy and early recognition of a bile duct biliary injury if it occurs. Conversely, those who oppose routine IOC argue that it simply delays the procedure and that asymptomatic patients with CBD stones do not often have problems post-operatively. However, this latter point is disputed as there is no long-term data in these patients. Specifically, there are no long-term studies following patients many years after their gallbladder surgery and this epidemiological research is urgently needed to resolve whether IOC should be routinely performed. Interestingly, most specialist HPB surgeons in Australia routinely perform IOC while “general surgeons” tend to offer a selective approach with the resultant trend of increasing use of ERCP. Professor Hugh does this routinely in all cases.

What outcome should patients expect after their gallbladder is removed?

After your laparoscopic cholecystectomy Professor Hugh will provide you with a post-operative brochure which outlines what to expect in terms of the early post-operative period, and it also contains advice on diet and exercise in the early post-operative period.

Brochure outlines information regarding:

• After your operation
• Wound Care
• Activities
• Expected Symptoms
• Diet
• Follow Up

If patients develop severe or persistent pain soon after their operation, they should have an ultrasound to exclude a possible bleed or a bile collection. A blood test (full blood count, liver function tests and a serum lipase level) should also be checked. It is important that patients have access to their hospital or surgical team during this early post-operative period if these symptoms occur. Contact information is available on your post-operative brochure.

After a cholecystectomy, there may be slight increase in stool frequency for the first 4-6 months. During this time patients should avoid especially fatty food. Over a period of several months the biliary system adjusts to the absence of a “storehouse of bile” and most patients return to a normal diet. As a rule, all patients should minimise their dietary fat intake whenever possible. In the early post-operative period, some patients experience upper abdominal discomfort like their pre-operative symptoms. These symptoms usually settle quickly and do not require further intervention.

If a thorough history and physical examination have been undertaken, and a patient has typical biliary symptoms with gallstones present on ultrasound, a laparoscopic cholecystectomy will relieve symptoms in 95% of patients. A small proportion (usually < 5%) have ongoing symptoms suggesting either residual stones in the bile duct, biliary dyskinesia or an incorrect and unrecognised diagnosis. The term “post cholecystectomy syndrome” is used to describe patients who have ongoing abdominal symptoms after the gallbladder has been removed. Many patients given this diagnosis either have biliary dyskinesia or a non-biliary cause for their pain. Some may have a missed diagnosis such as peptic ulcer disease, irritable bowel syndrome, hepatic flexure syndrome (adhesions to the ascending colon and hepatic flexure) or even renal tract pathology. In a minority of patients, a cholecystectomy unmasks an underlying upper GIT motility disorder that principally affects the biliary tract (patients may have been told previously that they had “Irritable Bowel Syndrome”). These patients suffer from true “biliary dyskinesia” which is a specific motility disorder requiring further investigation with biliary manometry (pressure readings of the bile duct). Occasionally, an ERCP and sphincterotomy may also be necessary to relieve the extra-hepatic biliary tree pressure in patients with persistent symptoms.

Potential Complications of gallstones

Acute or chronic cholecystitis

Repeated attacks of biliary colic may result in a gallbladder infection (“acute cholecystitis”). This can occur with both small and large gallstones and it is not clear why only certain patients develop this complication. It may be due to the size of the cystic duct relative to the size of the stones. The presenting features of acute cholecystitis include fever, an elevated white cell count and persistent upper abdominal pain. Repeated attacks of infection may result in “chronic cholecystitis” and even the development of a localised liver abscess.

Cholangitis

Cholangitis Stones that move from the gallbladder into the biliary tree or those that develop primarily in the intra- or extra-hepatic bile ducts (rare) can cause a secondary infection known as cholangitis. The obstructing stone increases the intra-ductal pressure leading to bile stasis and secondary multi-organism infection. Symptoms of cholangitis include right upper abdominal pain, jaundice and fevers (known as Charcot's Triad). Patients with cholangitis can become unwell quickly and usually require hospital admission for fluid resuscitation and broad-spectrum intravenous antibiotics. This diagnosis should always be considered in elderly patients who present with confusion and abnormal liver function tests. These stones (known as common bile duct stones) can be removed by endoscopy (called an ERCP). However, if the gallbladder also needs to be removed your surgeon may be able to remove these at the same time by exploration of the bile duct. Acute pancreatitis Gallstones are one of the two most common causes of acute pancreatitis (the other is excessive alcohol). Acute pancreatitis may result from a stone lodged in the distal common bile duct at the site where it meets the pancreatic duct. It is unclear whether the inflammatory process in the pancreas is initiated by a rise in the pancreatic ductal pressure or whether it is due to reflux of bile into the pancreatic duct. The pain of pancreatitis is often severe and is mainly localised to the epigastrium with radiation through to the back. Patients with severe acute pancreatitis can rapidly deteriorate clinically and they usually require hospital admission for urgent fluid resuscitation and further investigation. If an obstructing stone is suspected or identified, then early relief of the obstruction by an ERCP is important. Patients with small stones in the gallbladder, or those that develop primary extra-hepatic stones are most at risk of developing gallstone pancreatitis. The serum lipase is the most sensitive test for acute pancreatitis. Patients who can tolerate general anaesthesia should have their gallbladder removed soon after developing this complication to prevent recurrence.

Non-surgical options for patients with symptomatic gallstones include:

• Oral dissolution therapy (only suitable for a small proportion of patients)
• Mechanical disruption, e.g. extra-corporeal shock-wave lithotripsy or laser ablation. These are relatively invasive procedures that have the potential for side-effects such as injury to the adjacent liver or bile ducts. Also, the production of small stone fragments that can then pass into the main bile duct may increase the risk of pancreatitis. For these reasons, mechanical disruption is not used for the treatment of gallstones.
• Percutaneous cholecystostomy. This is a short-term solution only involving percutaneous drainage and insertion of a catheter into the gallbladder which is usually done under radiological guidance. This is usually reserved for frail or extremely ill patients with acalculous cholecystitis and who are unable to tolerate a cholecystectomy procedure