GALLSTONES - Full extract 

The gallbladder is a small pear-shaped sac that sits in the upper abdomen on the right side, just under the rib cage. It is about 7 cm in length and its main function is to store and concentrate bile that is made in the liver. 

Bile is necessary to digest food. It has a green-brown colour and contains cholesterol and bile salts. After a meal the gallbladder contracts and bile passes down the bile duct to enter the duodenum, the beginning of the small bowel. If too much cholesterol accumulates in the bile it crystallizes out as stones, either by itself, or mixed in with bile pigments. This can form a sludgy gravel or stones as big as chestnuts. The only way out for the stones is to travel down the bile duct and into the bowel. If they are too big they will get stuck and cause severe pain and a number of other problems. 

There are several factors that predispose to gallstones. They tend to run in families and are twice as common in women. Being overweight can also contribute. About 10% Australians have gallstones, with a much higher incidence in older people. Although they are often noticed as an incidental finding when an X-ray is being done for another reason, there are some classic symptoms that point to gallstone disease. 

The most common complaint is recurrent abdominal pain, especially after eating a large or fatty meal. This is called biliary colic. The pain can be very severe and it usually comes and goes in waves. I have been called out at night many times to see patients with biliary colic. Often the pain will settle with analgesics and antispasmodic medication and the person is able to have the appropriate investigations for gallstones a few days later. 

Sometimes a condition called acute cholecystitis occurs. The gallbladder becomes very inflamed, causing a constant severe upper abdominal pain. The person may have a high fever and be quite sick, requiring admission to hospital for urgent investigation and treatment. 

If a gallstone gets caught in its path down the main bile duct, blockage of bile may occur. A substance called bilirubin builds up in the bloodstream and the person may become quite jaundiced; the skin goes a yellow colour and the urine might be very dark. These are always symptoms that need prompt investigation. Gallstones can also cause infections in the main bile duct, leading to high fevers and septicaemia. 

The pancreas is another important digestive gland. It produces insulin and several digestive enzymes and its duct joins the small bowel at the same spot as the bile duct. Gallstones can cause a condition called pancreatitis, where the pancreas becomes acutely damaged. In severe cases the person can become critically ill. Whenever pancreatitis occurs investigations are performed to see whether gallstones are present. 

If there is a history to suggest gallstones, or if there is other evidence of gallbladder disease, there are several investigations to help with the diagnosis. An upper abdominal ultrasound is a simple non-intrusive test that gives a soundwave picture of the gallbladder and surrounding structures. Gallstones usually show very clearly on an ultrasound. If there is doubt about the diagnosis, special X-rays of the gallbladder can be arranged. 

When gallstones are diagnosed the person is usually referred to a specialist surgeon to discuss whether surgery is required. If the gallstones happened to be picked up on a test for something else, or if there are absolutely no symptoms, it might be decided to leave them alone and just take care to avoid fatty meals. 

However, if there are episodes of biliary colic or other gallstone complications, surgery is usually advised. Because the gallbladder is not an essential organ, the usual procedure is a cholecystectomy, removal of the gallbladder and the stones that it contains. For straightforward cases there is an increasing trend for laparoscopic cholecystectomy. Using an operating telescope with its own light source, the gallbladder is able to be directly visualized and removed. Recovery time is much quicker and patients are often discharged only two or three days after the operation. 

Health Tip:
* Recurrent indigestion and bouts of abdominal pain might be due to gallstones. However, several other conditions could cause similar symptoms.

* Avoid fatty foods if you have gallstones or if there is a suspicion of gallstones. Biliary colic is frequently triggered by a rich meal.

Dr. Andrew Pattison: Common Consultations
North East Valley Division General Practice, Melbourne, Australia.   Disclaimer
  - Last modified: August 18, 2001