Yes, those are a whole heap of gallstones right
there. I’m not saying you have gallstones but if
you’ve been having belly pain on the right side and
a little nausea and vomiting well. . .you might want
to keep reading. NO JUMPING TO CONCLUSIONS!

What and where is the gallbladder?
      The gallbladder is a small pear-shaped organ on the underside of the liver that is
used to store bile. Bile is made in the liver and is stored in the gallbladder until it is
needed to help the digestion of fat.

What is gallbladder disease?
     Gallbladder disease is a common condition that affects mainly women, although men
can suffer too.

      The symptoms vary widely from discomfort to severe pain which mainly begins after
food. In severe cases the patient can suffer from jaundice, nausea and fever. The
most common reason for gallbladder disease is gallstones.

What are gallstones?
     Gallstones are solid stones formed in the gallbladder from cholesterol, bile salts and
calcium. They can vary in size from a few millimeters to a few centimeters.

What causes gallstones?
     Gallstones are formed when bile contains too much cholesterol. The excess
cholesterol forms crystals from which gallstones are made.

Who is at risk of developing gallstones?
     Gallstones are seen in all age groups but they are rare in the young. The possibility
of developing gallstones increases with age. The following groups are considered to
be at increased risk:

• people who have relatives with gallstones.
• obese people.
• people with a high blood cholesterol level.
• women who take drugs containing estrogen, eg contraceptive pills.
• people with diseases such as chronic intestinal inflammation (Crohn’s disease
  and ulcerative colitis).

What are the symptoms of gallstones?
     Not all gallstones cause symptoms and those detected during a scan performed for
other reasons do not usually require treatment. This, however, should be discussed
with your doctor. The symptoms, when present, can be extremely variable but
usually present in one of three ways:

Chronic cholecystitis (biliary colic)
     This is a chronic inflammation of the gall bladder and causes:

• sporadic pains in the middle of the upper abdomen, or just below the ribs on
  the right side.
• pain which becomes worse over an hour and then stays the same.
• the pain may spread to the right shoulder or between the shoulder blades.
• the pain can be accompanied by nausea and vomiting and sometimes
  excessive wind.
• the attack can last from a few minutes to two to three hours before getting
  better.
• the frequency and severity of attacks is very variable.
• attacks can be triggered by eating fatty foods such as chocolate, cheese or
  pastry.
• it can be difficult to distinguish the pain from other diseases, such as: gastric
  ulcer, back problems, heart pains, pneumonia and kidney stones.

Acute cholecystitis (acute inflammation or infection of the gall bladder)
     This condition results in:

• persistent pain and a temperature lasting more than 12 hours.
• pain and tenderness under the ribs on the right side.
• the pain is made worse by movement or coughing.
• patients with acute cholecystitis may not always have gallstones but usually
  do.
• the condition must be treated by a doctor and usually requires admission to
  hospital.
• the treatment consists of a course of antibiotics but if this is not effective
  emergency surgery may be required to remove the gall bladder.

Jaundice (yellow discoloration of the skin and whites of eyes)
     This is caused when there is an obstruction to the flow of bile from the liver.
Jaundice is not always caused by gallstones. The symptoms are:

• increasingly yellow eyes and skin.
• the skin can become itchy.
• pale bowel motions and dark urine.
• the condition is often preceded by symptoms similar to those of cholecystitis.
• fever and shaking chills are serious symptoms and must be treated by a
  doctor – they are suggestive of infection traveling through the bile duct system.

What can be done at home?
     Recurrent painful attacks, if mild, can be treated with over-the-counter painkillers.
Placing something warm on your stomach may be helpful, taking care not to scald
the skin. The frequency of attacks may be reduced by a low-fat diet.

How are gallstones diagnosed?
     Blood samples are often taken to test if the liver is working normally. The most
accurate method of detecting stones is by using an ultrasound scanner. This
technique is quick and painless.

     If the result of ultrasound scanning is inconclusive, other possible tests include a CT-
scan and an MRI.

     CT stands for computerized tomography and is a method of taking X-ray ‘slices’ of
the body.

     MRI stands for magnetic resonance imaging and pictures of the internal organs can
be obtained without X-rays. MRI is very useful for looking at the bile ducts.

     An oral cholecystogram. This is an X-ray examination with films taken over two days
which will show if the gall bladder is still capable of contraction. This gives a good
indication of the function of the gall bladder. If a gall bladder is diseased it may not
function or contract properly and this will be seen using the oral cholecystogram.

     ERCP (endoscopic retrograde cholangio-pancreatography) – this is used if it is
suspected that the patient has gallstones in the bile ducts.

     A small tube or endoscope is introduced down the gullet and into the duodenum
under sedation. The bile duct is identified where it enters the duodenum and a very
thin tube is placed into the duct. A dye is then injected into the duct and an X-ray
taken to look for gallstones. Any gallstones detected may be removed at the same
time which means that an operation may not always be necessary.

How are gallstones treated?
     Gallstones which do not cause symptoms do not need any treatment. If a low-fat
diet is not successful in controlling the symptoms some other form of treatment is
required – this usually, but not always, means surgery.

     Some people are able to manage mild symptoms with a combination of a low-fat diet
and painkillers to control their abdominal discomfort.

Alternatives to surgery
Dissolution therapy – sometimes a specific type of gallstone can be dissolved using
medicines. If the patient is unfit or unwilling to have an operation, dissolution
therapy with ursodeoxycholic acid (Urdox tablets) is occasionally possible although it
takes a long time to dissolve a gallstone and it often comes back after the treatment
is stopped.

     To be suitable for dissolution therapy the gallstones have to be small to medium in
size and ‘radiolucent’, ie they do not show up on plain X-rays. Gallstones that do
show up on plain X-rays do not dissolve. The gall bladder also needs to still show
the ability to contract.

     Lithotripsy – single gallstones in the gall bladder or bile ducts can sometimes be
‘shattered’ by a technique called lithotripsy, which uses a ‘beam’ of sound energy.
This method is commonly used for treating kidney stones but is only rarely useful for
gallstones. The fragments of shattered stone will still need to be removed by ERCP
or dissolution therapy.

Surgery for gallstones
     When an operation is required for gallstones in the gall bladder it is usual to remove
the gall bladder and gallstones together – this is called cholecystectomy.

     If the gall bladder is left behind it is quite likely that further gall stones will form in it.
There are two ways of removing the gall bladder and nowadays more than 90 per
cent are removed by laparoscopic or keyhole surgery.

     This involves making four small cuts less than 1cm long in the abdomen and the use
of a tiny camera inserted though one of these cuts to see the gall bladder.

     Other instruments are placed in the abdomen through the other cuts. If the
operation is successful most patients are able to go home the day after surgery and
return to normal everyday activities within two weeks.

     In some cases laparoscopic surgery is considered too dangerous or too difficult and
it is then necessary to do a traditional or ‘open’ cholecystectomy. This involves
making a cut in the abdomen between 9 and 18cm long. The patient will usually
need to stay in hospital for at least five days and will not be able to return to work
for six to eight weeks.

Will the patient notice any difference after surgery?
     After the gall bladder has been removed most people will be aware that their pain
has completely disappeared and they no longer need to avoid fatty food.

     Complications following gallbladder surgery are very rare and there are usually no
long-term effects from having a gall bladder removed.