Gallstones and Gallbladder Disease

By Ross Simafranca, M.D.

What is a gallbladder?

The gallbladder (GB) is a small balloon located under the right side of the liver, right underneath the rib cage. It is a storage tank for bile, which is a fluid that the liver makes to help digest fats. Bile is transported from the liver and GB through a tube called the common bile duct (CBD).  The CBD empties into the small intestine where it mixes with food to aid in digestion.There is a muscle at the end of the CBD that closes off when we are not eating. This forces the bile to then back up into the gallbladder for storage. When we eat, the signals of digestion relax the muscle, allowing the bile to enter into the intestine, as well as squeezes the gallbladder for emptying.

What are gallstones?

Bile is made up of a few different components.  When there is an over abundance of a certain component, usually cholesterol, they tend to clump together forming what is called GB sludge and then progressing further to form gallstones.  Gallstones are rocks that can vary in size from tiny grains of sand to golf balls. 

How do I get gallstones?

A few risk factors that seem to be associated with developing gallstones include: female, obesity (likely due to high levels of fats in the blood), pregnancy (likely from hormonal changes), rapid changes in weight, and age (the risk of developing gallstones increases with age; by age 75, 35% of women and 20% of men have gallstones).

What types of symptoms do people with gallstones have?

Not all people with gallstones will have problems. However, the usual presentation is upper abdominal right sided pain, sometimes traveling to the back. Many patients also complain of nausea or vomiting. They feel bloated and have no appetite.  If the GB inflammation progresses, they may begin to have a fever or chills.  These symptoms usually start within a few hours of eating a fatty meal.

This is because when the gallbladder is squeezed for digestion of fatty foods, the stones can cause irritation of the gallbladder, or the stones can get stuck. The stones can get stuck in the GB, on the way out through the tube, or get stuck in the tube.  Sometimes the stones get stuck in the tube that drains the pancreas, and patients can present with pancreatitis. Symptoms of pancreatitis include severe back pain or yellowing of the eyes or skin called jaundice.

Many times, the stone unplugs itself from blocking the GB and flow is reestablished and the symptoms resolve over a few hours or so.  This is called biliary colic.  Unfortunately, the stones don’t just disappear.  If you’ve experienced a painful episode once; it is highly likely that you’ll experience another, and another, and another.  

What is the treatment for gallstones?

If symptomatic, then the entire gallbladder should be removed surgically. A cholecystectomy is mostly done using a laparoscopic approach, in which small incisions and a camera are used to remove the gallbladder.  If we are unable to do it that way for whatever reason, then a larger incision (‘open’ approach) in the right upper abdomen under the ribs is required.

If you’ve developed gallstones but have never had symptoms before, it would probably be fine to hold off on surgery but close monitoring is highly recommended.  I would also suggest eating a low fat, high fiber diet and continue to maintain a routine exercise schedule.

Unfortunately, many patients have fallen victim to various non-surgical cures advertised on the internet claiming that the stones can be dissolved if only you drink a certain dietary blend of liquids.  I recommend caution in trying these homemade remedies, not because they’re dangerous; but primarily because they just don’t work. In fact, in my practice, some patients try these alternative therapies, with no changes in follow-up GB ultrasounds. They usually end up having surgery for symptoms.

How long is surgery and what is the recovery like?

Symptomatic patients who have delayed surgery and whether or not the gallbladder is actively inflamed plays a role in the difficulty of surgery.  Each time a patient has a painful episode, the GB gets thicker and scarred which can make surgery much more challenging.  On average, a laparoscopic cholecystectomy takes about 30-90 minutes.

Most outpatients go home the same day with prescriptions for pain medicine, stool softener, and maybe even a medicine for nausea. For those patients who are actively in pain, being seen in the ER with maybe fever/chills, having an elevated infection count on their blood test, evidence of acute inflammation on some imaging test, and those needing to have emergency surgery, postoperative hospitalization may be needed.

How long will I have to be out of work?

Most patients can expect to be out of work anywhere from 2-4 weeks depending on how active their job is.  I usually recommend no heavy lifting >10-15lbs, no strenuous exercise/activity, and no swimming/bathing for 2-3 weeks.  The incisions need time to heal and doing too much too early will likely cause more pain and increase the risk of complications.

Are there any risks and side effects of having gallbladder surgery?

Any surgery has risks including bleeding, pain, scars, injury to other nearby structures, and need for further surgery or procedures.  For the most part, those risks are minor and quite rare and shouldn’t be the reason to delay or not have surgery altogether.  Gallstones can develop into a life-threatening condition and shouldn’t be taken lightly. 

Many patients ask if there are any dietary restrictions after the surgery.  Most patients actually see little change in their bowel movements.  However, some do develop loose stools after eating oily/fatty foods. Everyone reacts differently though.  Some patients can have ice cream while others can’t.  It all sort of depends on how each person’s body reacts.  I encourage patients to avoid spicy or fatty foods at least for about 2 weeks and then to slowly introduce in small amounts different types of foods and see how their body responds.

What are the risks if I don’t have surgery?

We strongly recommend having surgery for symptomatic gallstones.  If there is a delay, it is important to know the possibilities of what could happen.  Usually, symptoms get worse over time.  Pain increases in severity.  Episodes may begin to last longer than usual and they may occur more frequently.  As mentioned before, each episode of inflammation causes scarring of the GB to some degree.  This could make things much more difficult during surgery thereby increasing the chance of open surgery which also increases the risk of having complications and possibly more procedures. Therefore, it is much safer to have surgery when the GB is not acutely inflamed.  Waiting until a GB infection and having to have emergency surgery increases the risk of complications. Lastly, repeated bouts of GB inflammation increase the risk of developing GB cancer, which carries with it an extremely poor prognosis. 

DR. ROSS SIMAFRANCA is a general surgeon practicing in West Oahu since 2007.  He finished his medical degree at UH -JABSOM and general surgery residency at UH Department of Surgery.   He currently serves on the Philippine Medical Association of Hawaii Board of Governors.

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