Gallstones are common conditions which are usually found in the gallbladder. The gallbladder is located in the right upper abdomen tucked under the liver. The gallbladder stores and concentrates bile secreted by the liver and then releases it following a meal to aid digestion especially fat digestion.

What causes gallstones?

Bile is composed of various chemicals and when there is imbalance of these chemicals, it leads to formation of gallstones. There are different types of gallstones which include cholesterol stones (commonest type) and pigment stones. It is not clear why some people develop gallstones more than others however, some people are more at risk of forming gallstones:

Women between the ages of 20 and 60years are twice more likely to form gallstones than males. This may be because the female hormones cause more cholesterol to be excreted in the bile.
Overweight and obese individuals
Age - chance of developing gallstones increases with age
Ethnicity - American Indians have the highest incidence of gallstones in the world
Rapid weight loss and low-calorie diet may increase the chances of forming gallstones

What are the symptoms of gallstones?

Gallstones may not cause any symptoms and only discovered by chance while testing for other conditions. They can sometimes cause symptoms such as:

Sudden and moderately intense attack of abdominal pain located in the right upper abdomen or the centre of the upper abdomen. This is often referred to as biliary colic (gallbladder pain). The pain may go through to the back and to the shoulders. The pain occurs one to two hours after a meal but sometimes at other times. It can last for several hours sometime and subsides leaving you with a discomfort as if you have been kicked in the tummy. Gallbladder pain may be associated with nausea and vomiting.

Sometimes gallstones manifest themselves as chronic indigestion which may include abdominal bloating, flatulence and nausea especially after a fatty meal. However these symptoms may also be associated with gastro-oesophageal reflux.

What are the complications of gallstones?

The complications of gallstones may include

Inflammation of the gallbladder or acute cholecystitis. This is similar to the attack of gallbladder pain except that you may in addition have fever and chills.
Blockage of the main bile duct (common bile duct) causing yellowing of the whites of the eyes and skin (jaundice), dark urine and pain in the upper abdomen. If you have fever and chills you may also have infection in the bile duct (cholangitis) which must be treated as a matter of urgency. You must consult your doctor immediately.
Inflammation of the pancreas (acute gallstone pancreatitis) may occur when a stone blocks the common bile duct where it meets the pancreatic duct before it enters the intestine. Acute inflammation in the pancreas is characterised by intense upper abdominal pains which may radiate to the back and tend to be associated with nausea and vomiting. It is a potentially life-threatening complication of gallstones.

How is gallstones diagnosed?

Gallstones may not cause symptoms and only discovered incidentally while testing for other conditions.

Ultrasound: The most sensitive test performed when gallstones are suspected is the ultrasound examination. Ultrasound machine utilizes sound waves to create images of the gallstones and other organs. The sound waves from the machine bounce off the gallstones and other organs and the images are captured on a video monitor.

Magnetic resonance cholangiogram (MR scan): is used to diagnose suspected bile duct stones. It is non-invasive and is used when the suspicion of bile duct stone is low.

Endoscopic retrograde cholangiopancreotogram (ERCP): can be used to diagnose and remove stones from the bile duct. It involves passing a flexible camera tube down the throat into the small intestine. The flexible camera has a working channel through which fine instruments can be passed to inject a special dye to locate bile duct stones and then remove the stones using special instruments or crushing them. It is usually performed under sedation but may be performed under general anaesthesia. ERCP has a very small but potentially serious complication of inducing acute pancreatitis.

Computed tomogram: sometimes is used mainly in the evaluation of complications of gallstones.

What is the treatment for gallstones?

Asymptomatic gallstones do not require any treatment. The only satisfactory treatment for symptomatic gallstones is surgery. The surgery involves removal of the gallbladder with the stones.
The procedure known as cholecystectomy is performed using the keyhole technique (laparoscopic cholecystectomy) under general anaesthesia. Four small incisions are made in the abdominal wall where a miniature camera and special thin instruments are inserted. The abdominal organs are inspected and the gallbladder identified. Everything is done inside the abdomen and the gallbladder and the stones are removed. The skin is closed using dissolving stitches. In some people there may be some minor bruises in the first week which usually settles down.

The advantages of laparoscopic approach include:

Less postoperative pain
Less hospital stay
Quicker physical recovery
Less wound scarring

Occasionally as happens in 2% of patients, it may not be possible to complete the procedure using the keyhole approach. The operation will therefore be converted to an open procedure. Your surgeon will discuss this with you prior to surgery.

What happens after surgery?

You will be able to eat and drink on the day of the operation. The operation is usually straightforward and most people are usually well enough to go home within twenty four hours. Most people should be well enough to engage in gentle sporting activities in 7 to 10 days.

There is no special dietary restriction following gallbladder removal and you can live without your gallbladder. In a small minority of individuals (1%), there may be increased bowel frequency following gallbladder removal because bile flows directly into the intestine from the liver but this usually settles down most of the time.

Driving can be resumed after 7days but do check with your insurance company first for appropriate cover.

Are there risks associated with gallbladder operation?

Like any operation there are risks attached to gallbladder operation but thankfully these are rare. Damage to the common bile duct can occur in less than 1% of cases.
Excessive bleeding may occur but blood transfusion is very rarely required.