One of the functions of the liver is to produce bile. Bile is required by the intestine to digest fat. Bile is made in the liver and brought to the gut via the bile duct.
The gallbladder is a small pear-shaped organ on the underside of the liver just off the bile duct. It is used for storing bile until fat is eaten when it contracts, pushing bile down the bile duct to help absorb the fat.
The cause of gallbladder disease
The most common cause of pain arising in the gallbladder is gallstones. Gallstones become stuck in the small tube connecting the gallbladder to the bile duct (the cystic duct) and this often results in cholecystitis or inflammation of the gallbladder.
Less frequent causes of gallbladder disease are polyps. Polyps are warty growths on the gallbladder wall. Even rarer is gallbladder cancer.
What are gallstones?
All bile is very thick and gallstones form when the bile is in a stagnant gallbladder and crystalises into small stones. These gallstones grown from cholesterol, bile salts and Calcium, may be small and multiple or large and single or any combination in between.
Who is at risk of developing gallstones?
Gallstones are very common although many people with gallstones have no symptoms. Gallstones are more common in-
- Older patients
- Obese patients with a family history of gallstones
- Patients with high blood cholesterol
- Patients with diseases which affect the bile such as Inflammatory Bowel Disease
- After certain surgical procedures in the bowel
- Haemolytic anaemia (e.g. seen in those with sickle cell disease).
What are the symptoms of Gallbladder Disease?
The characteristics of pain suggestive of gallbladder disease are:
- Pain located in the right upper quadrant or epigastrium.
- Pain radiating to the back or into the right shoulder.
- Pain worsened by eating, particularly fatty foods.
- Intermittent pain, suddenly severe or colicky or varying in intensity.
These symptoms are usually associated with nausea and vomiting.
The frequency and intensity of attacks is very variable. Large stones may give less trouble than small ones as they are less likely to get stuck in the small ducts.
Acute gallbladder infection (cholecystitis)
Gallbladder infection usually associated with stones is a serious emergency and is called cholecystitis. Usually there is severe right upper abdominal pain associated with nausea and vomiting. The patient's temperature is raised and shaking or rigors may occur.
The upper abdomen is tender to touch or press. In the very elderly, confusion or drowsiness may be the only sign of cholecystitis. Usually there is no jaundice or yellowing of the skin.
Cholecystitis usually requires admission to hospital, intravenous fluids, pain relief and antibiotics. Emergency surgery to prevent an abscess forming may be required but surgery is often delayed until the infection has settled down and the gallbladder is less inflamed.
If gallstones have moved into the main bile duct to the intestine (the common bile duct) then infection is even more serious and may result in jaundice, dark urine and pale motions in addition to the symptoms of cholecystitis. This is the even more serious condition of cholangitis or infection of the bile duct. Gallstones based in the gallbladder or bile duct may result in pancreatitis or inflammation of the pancreas.
It is important to remember that symptoms can arise from the gallbladder even if there are no stones. On the other hand, gallstones are common and just because they are present, does not mean they are causing the patient's symptoms. Careful evaluation of each case is required.
How are gallstones diagnosed?
A detailed accurate history should lead to the suspicion of gallstones.
Tests may show abnormal liver blood tests although this is not invariable if the stones are in the gallbladder alone.
Ultrasound of the abdomen is the most common way of diagnosing gallbladder stones. However, ultrasound may miss up to 30% of gallstones.
MRI scan of the biliary tree is useful particularly in detecting gallstones in the bile duct rather than in the gallbladder. Endoscopic Ultrasound (EUS) is also used to identify stones in the bile duct and occasionally in the gallbladder. X-ray techniques are not now currently used to diagnose gallstones.
How are gallstones treated?
A decision whether to treat a particular patient's gallstones depends on a number of factors.
How certain is the doctor that the pain is coming from the gallstones and therefore will improve with treatment? This will often depend upon the detailed history:
- How frequent and severe are the attacks? If there are no symptoms, it can be difficult to justify surgical treatment.
- How old and healthy is the patient? Will they withstand the surgery and possible complications?
- Have serious complications occurred? For example, Cholecystitis, Cholangitis or Pancreatitis.
- What are the patient's wishes?
- Alternatives to Gallbladder surgery?
Medical treatment with dissolution therapy has been very disappointing and is rarely used. Similarly, Lithotripsy or breaking the stones with sound waves is not currently standard treatment and has not produced good results.
If the gallstones are in the main bile duct and are causing infection or jaundice, removal can be successful using ERCP, an endoscopic technique with a tube inserted through the mouth to the point at which the bile duct joins the small bowel in the first part of the small bowel (duodenum). This may be all that is required to relieve symptoms. This technique will not remove the gallbladder stones however.
Surgery for gallstones
The most effective treatment for gallbladder disease is surgery. Ideally, modern surgery involves keyhole and laparoscopic surgery to remove the gallbladder entirely. This operation is called a Cholecystectomy. Although keyhole surgery is more difficult to perform, patients recover much more quickly and encounter fewer complications. If the diagnosis is correct, cholecystectomy will result in complete resolution of symptoms.
An increasingly controversial new area of gallbladder disease is the correct way to manage gallbladder polyps. The improved definition of ultrasound has resulted in many more gallbladder polyps being diagnosed. Polyps may cause problems in two ways:
Firstly, the polyps may cause similar symptoms to stones. If there is a convincing case, surgery to remove the gallbladder can be advised. If the gallbladder polyps are found by chance, the concern is that the polyps may grow into gallbladder cancer. Therefore, if the polyps are 10 mm or bigger then these are more likely to become malignant and surgery is often indicated.
A surveillance ultrasound at 12 months is indicated in the presence of gallbladder polyps and if the polyps are growing, surgery may also be advised.
Gallbladder cancer is relatively rare but is more common in patients with gallstones or polyps. It can be found by chance when the gallbladder is removed for either of these reasons. If Gallbladder Cancer is present, a more extended surgical operation to remove the gallbladder and part of the liver may be required.
Last updated: 02/06/2016