What are gallbladder diseases?
Gallbladder diseases affect a large number of people and are among the most common causes of abdominal pain. Most gallbladder problems stem from the presence of gallstones, which may be present in as many as one of every ten adults. In the past, anyone with gallstones was advised to have the gallbladder taken out, but this is no longer the case. It is now known that many people with gallstones never experience difficulty because of them.
A common gallbladder disease is biliary colic. This is usually manifested by severe right-sided, upper abdominal pain that is fairly repetitive. The pain may literally take the patient’s breath away, but an episode usually lasts less than thirty minutes. The patient may also complain of right-sided shoulder or back pain, often caused by irritation of the diaphragmatic nerves, which are located just above the liver on the right side. Many people may confuse the pain of biliary colic with indigestion, because in some patients it may be experienced in the middle of the upper abdomen. This pain is almost always brought on by eating, since the gallbladder contracts in response to food in the intestinal tract. The meal triggering such an episode often is described as rich and fatty, and many patients soon learn what types of food to avoid. Biliary colic does not occur unless gallstones are present, because they tend to obstruct the outflow of bile from the gallbladder. The initial treatment for biliary colic usually consists of dietary manipulation, that is, the avoidance of fatty foods or other foods known to trigger the pain, but eventual recurrence and complications are likely, and elective removal of the gallbladder (cholecystectomy) is usually recommended.
When a diagnosis of gallstones is suspected, the physician will take down the patient’s medical history and perform a physical examination. In most cases, however, such actions will yield no physical findings that are indicative of gallstone disease. Thus the diagnosis is usually confirmed by an imaging study of the gallbladder, in which the gallstones are either directly or indirectly visualized. The most commonly used imaging modality is the ultrasound test, which can be easily and rapidly performed with very reliable results. While the gallstones cannot actually be seen, they have a density that reflects, rather than transmits, sound waves. As a result, they create specific echoes and shadows that can be interpreted by the radiologists as gallstones. No patient should be treated for gallstone disease without such imaging to confirm the presence of gallstones.
A potentially serious type of gallbladder disease caused by gallstones is acute cholecystitis. In this condition, the outflow of bile is obstructed, usually by a gallstone that is stuck in the outflow tract, and severe inflammation and infection may develop. A patient with acute cholecystitis often complains of pain that does not go away promptly, may have chills or fever, and is usually found to have a very tender abdomen on the upper right side. The treatment of this condition is not controversial, and most physicians would probably recommend removing the gallbladder surgically. The only question remaining is whether the gallbladder should be removed immediately or electively, at a later date, if the patient recovers from acute cholecystitis with conservative management, including the use of antibiotics and the avoidance of eating until the inflammation subsides.
Inflammation and infection can also occur, although rarely, in gallbladders that do not produce gallstones. This happens in very select circumstances and is called acute acalculous cholecystitis. It usually afflicts very ill patients who have been in an intensive care unit for a long time, patients who have needed a heart-lung machine as a result of open heart surgery, or patients who are unable to eat for an extended period of time because of other problems. These patients are often fed only intravenously, which can lead to severe gallbladder problems. The exact mechanisms are not entirely known, but alterations in blood flow and an impaired ability to fight infection may play a role. Whatever the cause, the treatment often remains the same: removal of the gallbladder that does not respond to conservative therapy.
Gallstones can also move out of the gallbladder and cause serious problems. The main outflow tract of bile from the gallbladder and liver is the common bile duct, and this is a place gallstones frequently lodge. The end of this duct is surrounded by a small muscle called the sphincter of Oddi, which may not allow the passage of gallstones. If they become stuck there, they can completely obstruct the biliary system, and the patient will appear jaundiced. Removal of the gallstones will cure the problem. The presence of gallstones in the common bile duct is also associated with the development of pancreatitis, an inflammation of the pancreas that can be severe and life-threatening. Removal of the gallbladder at an appropriate time will prevent future bouts of pancreatitis.
The gallbladder can also be a source of cancer. Although cancer of the gallbladder is not common, it is estimated that one of every one hundred gallbladders removed will contain cancer. Therefore, all specimens removed must be examined by a qualified pathologist and all reports must be reviewed in their entirety by the surgeon. If the disease is limited to a minor thickness of the gallbladder, no further therapy is needed, but if the tumor is larger, further surgery—including removal of part of the liver—may be necessary. Gallbladder cancer grows silently in many patients, and it is often not detected until late in its course.
Because there is no simple way to prevent gallbladder problems, surgery plays a large role in their management. Removing the gallbladder, a relatively routine operation, results in a complete cure, with acceptably low complication rates and few long-term problems. While several exciting new ways of treating gallbladder and gallstone problems have been developed, the classic and standard method of therapy for gallbladder disease has been open cholecystectomy. This procedure entails making an incision across the upper right side of the abdomen a few inches below and parallel to the bottom of the rib cage. The muscles of the abdominal wall are cut, and the abdominal cavity is opened. The gallbladder, which is usually located right under this incision, is then removed and the incision closed in layers. This method of gallbladder removal has acceptable complication rates and is relatively safe and extremely effective. It allows the surgeon to inspect the entire abdomen and rule out other problems. One must consider, however, that this procedure constitutes major surgery. Most patients need to be in the hospital for a minimum of three to five days, and there is a considerable amount of pain with this incision. These problems have prompted surgeons to find a less invasive way of removing the gallbladder, thereby achieving better pain control and reducing the length of the hospital stay and the time lost from work and other activities.
A laparoscope is an optical instrument, composed of a tube connected to a telescopic eyepiece, that allows the surgeon to perform a procedure inside the patient’s body. It has been employed in surgeries for many years, mainly in gynecological procedures, and has been widely adapted for removal of the gallbladder and for other types of surgeries. Laparoscopic cholecystectomy has become a procedure that all surgeons must know to stay current with the profession. The laparoscope and other surgical instruments are inserted directly into the abdomen through several small incisions, and the gallbladder is removed without a large incision having been made. The patients are often discharged the same day of the surgery, and they return to work much faster than with the open technique.
Despite its advantages, there are some pitfalls with laparoscopic cholecystectomy, and it cannot be used for all patients. There is an increased incidence of certain injuries to other organs and bile ducts at the time of the operation because less of the area can be seen than with an open operation. In addition, patients who have had previous upper abdominal surgery are not candidates for this procedure, and for those with acute cholecystitis, severe inflammation may make this technique unsafe. For most patients, however, laparoscopic cholecystectomy can be performed easily and safely with minimal complications and excellent results. It is becoming the standard of care and will continue to change the way gallbladder surgery is performed. The laparoscope is also being used to perform appendectomies, ulcer surgeries, cancer surveillance, and all types of intra-abdominal surgery.
Radiologists and internists may play an important role in the management of gallbladder disease. In certain circumstances, the techniques performed by these specialists may be indicated for extremely ill patients who might not be able to tolerate an operation, or for whom the anesthesia might be too hazardous. Invasive radiologists can actually place a tube into the gallbladder with help from their imaging equipment and remove infection or troublesome gallstones from the gallbladder. This procedure can alleviate symptoms in some patients, who may not even require any additional intervention. These practices are not common, however, and they are usually reserved for the very ill patient who might not survive an open operation or is at extremely high risk to develop a certain complication.
Gallstones can migrate out of the gallbladder and cause problems if they lodge in and obstruct the common bile duct. This places the patient at high risk for developing jaundice and infection in the biliary system. The standard method for dealing with this problem continues to be open surgery. In this procedure, the gallbladder is removed through an incision and the common bile duct is also opened. The gallstones are removed through a variety of techniques, and the duct is then closed. A tube is placed in the duct to keep it open, because otherwise it could scar and become narrowed. Many of these patients must be hospitalized for a number of days, making this surgery an expensive one.
Internists who specialize in the diseases of the abdomen have become proficient at performing endoscopic techniques. These techniques came about after the development of fiber optics, which allow one to see through a tube, even if it is bent at a variety of angles. An endoscope, composed of surgical instruments, a light source, and fiber-optic cables, can be used to examine the lining of the stomach and intestines, allowing the diagnosis of many conditions.
Endoscopy is performed by inserting the endoscope through the mouth and into the patient’s stomach and the first part of the intestines. From this location, the area where the common bile duct opens into the intestines can be seen, and this is often where gallstones become lodged. The gallstones can be removed with instruments attached to the scope, thus solving the patient’s problem. Unfortunately, this technique does not remove the gallbladder, the source of the gallstones, and the patient is at some risk for a recurrence. This risk can be minimized by enlarging the opening where the duct enters the intestinal tract. This technique, too, is advantageous for patients who are elderly or ill and cannot withstand the trauma of surgery and anesthesia.
There are other options besides surgery or dietary changes for the treatment of patients with gallstones. Medicines are available that can dissolve the gallstones by changing the chemical nature and solubility of bile. Such drugs, however, are not ideal: They work only for certain types of gallstones, are expensive, and may produce side effects. In addition, there may be a recurrence of the gallstones when a patient stops taking these medicines. Such a result indicates that the bile-concentrating action of the gallbladder combines with a given patient’s bile composition to create a gallstone-forming environment. Thus, gallstones will continue to form unless the gallbladder is removed or the bile is again altered when the taking of such medicines is resumed. Patients can also have the gallstones broken up into very small pieces, as is often done with kidney stones, by high-frequency sound waves aimed at the gallstones. This procedure, however, known as lithotripsy, has drawbacks: It works in only a small percentage of patients (those with a limited number of small gallstones), and the results have not been uniformly consistent or satisfactory.
Diseases of the gallbladder and biliary system are common in modern industrialized societies. The exact etiologies are not entirely clear, but they may involve dietary mechanisms or other customs of the Western lifestyle. There is also evidence that genetic factors are important, as gallbladder disease often runs in families. Traditionally, the treatment of non-life-threatening gallbladder disease has been conservative, with dietary discretion being the most important factor. When that failed, or if the condition was more serious, the gallbladder was removed.
Open cholecystectomy was long considered the best method for dealing with these problems. This operation has been recently challenged by endoscopic and laparoscopic techniques, which have become widely available and enjoyed great success. These new treatment options will become more important as increasing medical costs promote the refinement of less invasive and better techniques. Nevertheless, open cholecystectomy is sometimes the only option for a patient, and less invasive techniques can have limitations as well as complications.
Basic scientific research is also important in this field. Investigations into the mechanisms of gallstone formation are critical to the understanding of gallbladder diseases, as gallstones are the cause of many of these problems. As with many other diseases, prevention might be the key to eliminating many gallbladder diseases, making biliary colic, cholecystitis, and common bile duct diseases rare.
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