Dr. Hemendra Shah
 
Gall Bladder
 
WHAT IS GALLBLADDER?
The gallbladder is a small saclike organ in the upper right part of the abdomen. It is located under the liver, just below the front rib cage on the right side.
The gallbladder is part of the biliary system, which includes the liver and the pancreas. The biliary system, among other functions, produces bile and digestive enzymes.

Bile is a fluid made by the liver to help in the digestion of fats.
It contains several different substances, including cholesterol and bilirubin, a waste product of normal breakdown of blood cells in the liver.

Bile is stored in the gallbladder until needed.
When we eat a high-fat, high-cholesterol meal, the gallbladder contracts and injects bile into the small intestine via a small tube called the common bile duct. The bile then assists in the digestive process.
Normal-Anatomy
Normal-Anatomy
Relation Between Liver Gallbladder, Stomach
     
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Urolap Superspeciality Clinc

617, Crystal Paradise,
Off Veera Desai Road, Opp. Skoda Showroom,
Above Aromas of China Restaurant.
Andheri (West), Mumbai - 400054.

Cell no.: 9869346201

Timing. : 6 PM to 9 PM

E-mail: drhemendrashah@yahoo.co.in


What are Gallstones?
There are two types of Gallstones:
Cholesterol stones
Patients with cholesterol stones are more common in the United States, making up approximately 80% of all gallstones. They form when there is too much cholesterol in the bile.
Pigment stones

Pigment stones form when there is excess bilirubin in the bile.

Gallstones can be any size, from tiny as a grain of sand to large as a golf ball.

Although it is common to have many smaller stones, a single larger stone or any combination of sizes is possible.

If stones are very small, they may form a sludge.
 
 
Cholesterol stones
Pigment stones
 
Gallstones can block the normal flow of bile if they move from the gallbladder and lodge in any of the ducts that carry bile from the liver to the small intestine. The ducts include the:
Hepatic ducts, which carry bile out of the liver
Cystic duct, which takes bile to and from the gallbladder
Common bile duct, which takes bile from the cystic and hepatic ducts to the small intestine
 

Bile trapped in these ducts can cause inflammation in the gallbladder, the ducts, or in rare cases, the liver. Other ducts open into the common bile duct, including the pancreatic duct, which carries digestive enzymes out of the pancreas. Sometimes gallstones passing through the common bile duct provoke inflammation in the pancreas—called gallstone pancreatitis—an extremely painful and potentially dangerous condition.

If any of the bile ducts remain blocked for a significant period of time, severe damage or infection can occur in the gallbladder, liver, or pancreas. Left untreated, the condition can be fatal. Warning signs of a serious problem are fever, jaundice, and persistent pain.

What causes Gallstones?

Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty completely or often enough. The reason these imbalances occur is not known.

The cause of pigment stones is not fully understood. The stones tend to develop in people who have liver cirrhosis, biliary tract infections, or hereditary blood disorders—such as sickle cell anemia—in which the liver makes too much bilirubin.

The mere presence of gallstones may cause more gallstones to develop. Other factors that contribute to the formation of gallstones, particularly cholesterol stones, include:

Sex. Women are twice as likely as men to develop gallstones. Excess estrogen from pregnancy, hormone replacement therapy, and birth control pills appears to increase cholesterol levels in bile and decrease gallbladder movement, which can lead to gallstones.
Family history. Gallstones often run in families, pointing to a possible genetic link.
Weight. A large clinical study showed that being even moderately overweight increases the risk for developing gallstones. The most likely reason is that the amount of bile salts in bile is reduced, resulting in more cholesterol. Increased cholesterol reduces gallbladder emptying. Obesity is a major risk factor for gallstones, especially in women.
Diet. Diets high in fat and cholesterol and low in fiber increase the risk of gallstones due to increased cholesterol in the bile and reduced gallbladder emptying.
Rapid weight loss. As the body metabolizes fat during prolonged fasting and rapid weight loss—such as “crash diets”—the liver secretes extra cholesterol into bile, which can cause gallstones. In addition, the gallbladder does not empty properly.
Age. People older than age 60 are more likely to develop gallstones than younger people. As people age, the body tends to secrete more cholesterol into bile.
Ethnicity. American Indians have a genetic predisposition to secrete high levels of cholesterol in bile. In fact, they have the highest rate of gallstones in the United States. The majority of American Indian men have gallstones by age 60. Among the Pima Indians of Arizona, 70 percent of women have gallstones by age 30. Mexican American men and women of all ages also have high rates of gallstones.
Cholesterol-lowering drugs. Drugs that lower cholesterol levels in the blood actually increase the amount of cholesterol secreted into bile. In turn, the risk of gallstones increases.
Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides. These fatty acids may increase the risk of gallstones.
 
Who is at risk for Gallstones?

People at risk for gallstones include:

Women—especially women who are pregnant, use hormone replacement therapy, or take birth control pills
People over age 60
American Indians
Mexican Americans
Overweight or obese men and women >
People who fast or lose a lot of weight quickly
People with a family history of gallstones
People with diabetes
People who take cholesterol-lowering drugs
What are the symptoms of Gallstones?

As gallstones move into the bile ducts and create blockage, pressure increases in the gallbladder and one or more symptoms may occur. Symptoms of blocked bile ducts are often called a gallbladder “attack” because they occur suddenly. Gallbladder attacks often follow fatty meals, and they may occur during the night. A typical attack can Cause:

steady pain in the right upper abdomen that increases rapidly and lasts from 30 minutes to several hours
pain in the back between the shoulder blades
pain under the right shoulder
Notify your doctor if you think you have experienced a gallbladder attack. Although these attacks often pass as gallstones move, your gallbladder can become infected and rupture if a blockage remains.
How are Gallstones Diagnosed?

Ultrasound Examination

Many gallstones, especially silent stones, are discovered by accident during tests for other problems. But when gallstones are suspected to be the cause of symptoms, the doctor is likely to do an ultrasound exam. Ultrasound uses sound waves to create images of organs. If stones are present, the sound waves will bounce off them, showing their location.

USG showing gallbladder stones

USG showing sludge in the gallbladder

   

Cholecystogram

c t scan
Rarely (15%) gallstones are seen on
plain X-ray abdomen
Cholecystogram or Cholescintigraphy

CT scan showing an enlarged and infected gallbladder

This is what can happen if a stone blocks the drainage duct to the Gallbladder

Endoscopic retrograde cholangiopancreatography (ERCP)

Blood tests:
Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

   
What complications can these stones cause?

Recurrent severe abdominal pain or vomiting

Pus formation in the gall bladder (Empyema)

Cholangitis (life threatening infection of biliary system)

Gangrene and perforation of the gallbladder

Acute pancreatitis (swelling of pancreas) which can have catastrophic sequele of multi-organ failure and other serious complications.

Jaundice due to blockage of the common bile duct due to stones

Associated with Cancer of gall bladder in the long term

right left hepatic
Infected gallbladder
Right Left Hepatic

         Infected Gallbladder

What is the Treatment?

Medical
Treatment of symptoms of pain with injectable or oral painkillers.

No medical therapy available for gallstone as such which can cure the disease. Injectable or oral antibiotics and supportive medication for infection.

Surgery
There are two major techniques to remove the gallbladder and stones
Open surgery
Laparoscopic surgery
open surgery gallbladder
Laparoscopic surgery
Involves making a large incision(6-15inches)
just below the ribcage on the right side so that the surgeon can place his hand inside the body to remove the gallbladder
Several small incisions(5mm -1cm) are made in
the tummy through which a telescope
attached to TV camera and small instruments
are used to perform the surgery.
laparoscopic cholecystectomy procedure
open cholecystectomy procedure
Laparoscopic cholecystectomy procedure
Open cholecystectomy procedure
Various instruments used
Various instruments used

Surgery to remove the gallbladder is the most common way to treat symptomatic gallstones.The Standard surgery is called laparoscopic cholecystectomy.

For this operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts, and other structures. Then the cystic duct is cut and the gallbladder removed through one of the small incisions along with the stones

Cystic duct cliiped and cut bed
GB removed from the liver
Cystic duct cliiped and cut bed
GB removed from the liver
Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer complications than they would have had after surgery using a large incision across the abdomen. Recovery usually involves only one night in the hospital, followed by several days of restricted activity at home.

If the surgeon discover any obstacles to the laparoscopic procedure, such as infection or scarring from other operations, the operating team may have to switch to open surgery. It is called "open" surgery because has to make a 5 to 8 inch incision in the abdomen to remove the gallbladder. This is a major surgery and may require about a 2 to 7 day stay in the hospital and several more weeks at home to recover. Open surgery is now required in less than 2 percent gallbladder operations, in specialized canter.

The most common complication in gallbladder surgery is injury to the ducts. An injured common bile duct can leak bile and cause a painful and potentially dangerous infection. Mild injuries can sometimes be treated non surgically. major injury, however, is more serious and requires additional surgery.

 
Advantages of Minimal acess surgery or Keyhole surgery or Laparoscopic surgery for Gallstones
Small incisions
Less postoperative pain
Excellent Cosmesis
Early ambulation and recovery
Low risk of DVT and Pulmonary complication
Less postoperative ileus
Short hospital stay
Day care procedure
Early return to normal activity    
Less wound related complications
Wound infection
Postoperative adhesions
Incisional hernia
 
   
Non-Surgical Treatment

Nonsurgical approaches are used only in special situations such as when a patient's condition is not fit for anaesthesia and surgery. They do not cure the patients but only provides symptomatic relief.

What Happens if Gallbladder is Removed?

Fortunately, the Gallbladder is an organ that people can live without. Losing it won't even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder. However, because the bile isn't stored in the gallbladder, it is flows into the small intertine more frequently, causing diarrhea in some people.

 
   
What if stone has slipped in CBD?

Slippage of stone/s in CBD may cause pain or jaundice or both.These slipped stones may partially or completely block the flow of bile from the liver to the intestine. This situation requires an endoscopy (ERCP) for removing the stone/s.

This should preferably be done before surgery.

However it may also be done after the operation.

 
   
How do we confirm if stone is in the CBD?

Sometimes a stone in the CBD may not show on ultrasound, however patient may have symptoms which are suspicious of the same. In this event the patient requires magnetic resonance cholangiopancreatogrphy (MRCP - an MRI scan) which shows the presence of stones in the common bile duct.

 
What is ERCP?
The surgeon may use endoscopy in removing CBD stones before gallbladder surgery. Once the endoscope is in the small intestine, the surgeon locates the affected bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope.This two-step procedure is called ERCP and endoscopic sphincterotomy.
ercp1
Ercp Showing presence of Gallstone in the main bile duct
ERCP and Sphincterotomy for stone extraction
 
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