Gallstones -- Does Everybody Need Surgery?

GALLSTONES

 What are the causes of gallstones? 

It is difficult to tell what causes gallstones as there are so many associated risks. Its more in females (3:1 compared to men). Incidence increases with age.Morein

overweight/obese patients. Can be familial. Its also more in people who starve for long time or have drastic weight loss. Commonly associated with people who eat lot of oily food. As you can understand there is no specific reason.

What is the incidence of gallstones in India?

 Incidence of gallstones varies in different parts of the world. In India there is huge variations in different parts of the country. North East and Bengal (10%) has highest incidence and south india has lowest (2-3%). In North east and Bengal gallstones can be detected at very early age compared to south India.

Is there any medicines for gallstones?

Main question which worries the patients is what to do when diagnosed with them. It is more confusing as they get different answers from different doctors.

If one tells them they can be resolved then should be very careful. If there was ever medicine to dissolve gallstones permanently then the person who discovered it would probably get Nobel Price and can be richest man as western counties spend billions on surgery and complications. In short, there is no medicine to dissolve them permanently.

What are the complications of gallstones?

Before answering the question whether one needs surgery or not we need to understand risks of gallstones and surgery.  They are

PAIN (BILIARY COLIC): Normally comes after food especially fatty foods. Across upper abdomen and can radiate to back. Can last upto few hours. If any one experiences these symptoms repeatedly and is found to have gallstones then it is symptomatic gallstones. Patients are strongly advised to have surgery (Laparoscopic Cholecystectomy -- Key hole procedure to remove gall bladder with stones) before having any of other complications listed below.

INFECTION -- CHOLECYSTITIS: This is infection of gall bladder usually happens when gallstone blocks the cystic duct (See Picture). This would need admission and prompt treatment with intravenous antibiotics atlas for 48 hours and surgery (Laparoscopic Cholecystectomy -- Key hole procedure to remove gall bladder with stones) on same admission.

INFECTION  -- CHOLANGITIS: This happens when there is infection  with blocked bile duct caused by the stone in the bile duct. This is very serious condition as infection can spread to blood in very short term and cause serious organ damage (Renal failure/cardiac failure/liver failure). This is associated with high risks so patients would be in ICU. Patient will need ERCP ( Camera procedure to remove stone in bile duct). Once recovered from the infection will need surgery (Laparoscopic Cholecystectomy -- Key hole procedure to remove gall bladder with stones) on the same admission. 

JAUNDICE: This can happen when gallstone slipped from gallbladder to common bile duct causes obstruction to flow of bile (See picture). patient will need ERCP ( Camera procedure to remove stone in bile duct). Some times stone can pass on its own. This will be determined by serial blood tests. Once recovered from the infection will need surgery (Laparoscopic Cholecystectomy -- Key hole procedure to remove gall bladder with stones) on the same admission.

PANCREATITIS: Most serious complication of gallstones with serious threat to life depending on the severity of pancreatitis. Most patient will need ERCP ( Camera procedure to remove stone in bile duct). Vary rarely stone can pass on its own. Once recovered from the pancreatitis will need surgery (Laparoscopic Cholecystectomy -- Key hole procedure to remove gall bladder with stones) on the same admission. 

GALLSTONES

What is the function of the gallbladder?

Function of Gall bladder: Its main function is to store bile and release it when needed (usually after food). Losing it will not interfere with digestion. Aftersurgery main bile duct takes over the function of gall bladder. 

Contrary to belief there is restriction of food after surgery to remove gall bladder (Laparoscopic Complications)

What are the complications of gallbladder surgery/Laparoscopic Cholecystectomy and what percentage have complications?

Complications of Gall bladder surgery (Laparoscopic Cholecystectomy): These happen in 0.2% of cases. That is 1 in 500 cases of Laparoscopic Cholecystectomy world wide. Complications include bleeding, bowel injury and bile duct injury. The complication risks are higher in people who have had one of the above discussed complication from gall stones.

Who needs gallbladder surgery/Laparoscopic Cholecystectomy?

Now consider whether to have Laparoscopic Cholecystectomy -- Key hole procedure to remove gall bladder with stones). You can make educated decision.

If the gallstones are symptomatic or you had any one of above complications then there is absolute indication for surgery on same admission or as soon as possible before you have other complications.

If gallstones are incidental (This is the controversial part which patient needs to take decision)-- found on scan for some other reason and are not causing any complications then you have to decide whether to have surgery or not. The above article will help you to make that decision. If someone is diagnosed with gall stones then they have 2%-5% risk of above complications every year Vs 0.2% risk of complication from surgery to remove gallbladder. If have complication then you would need atleast 3-5 days admission, more time to recover and cost of treatment also increases with each complication.  It is ones decision whether to risk complications then face complicated surgery with higher risk of complications and prolonged recovery with added extra expenditure or have elective surgery where you can go home same or next day. 

If one does not live in select few cosmopolitan cities with access to all the healthcare facilities then it does not make sense to wait till the complication happens as it will be difficult to deal with them in small cities with limited resources and facilities. One's life is put to serious risk then.

Is there any food restrictions after surgery?

 Absolutely nil. One can start having food few hours after surgery and can eat all the food throughout the life without any restriction and malabsorption. 

By

Dr. Maruthesh Gowda

MBBS , FRCS - Laproscopic Surgery , M.R.C.S-General Surgery