Originally published in The Ottawa Citizen July 22, 2003
Original Title: The Stones Wrong Address Part II; Washing away that yellow stain

Part 1
Part 3

Last week’s column reviewed the risk factors, symptoms and causes of gallstone related disease. What are the complications if this disease remains untreated?
For those without any discomfort or gallstone attacks (about 60 per cent with gallstones), there is little need to intervene. For some people with heart, lung or other chronic disease that puts them at high risk of death during surgery, there are other non-surgical treatment options. Some may opt for medications to try to dissolve the stones. Oral medications do take time to work. However 50 per cent of patients experience stone recurrence within the first five years after treatment.

Your surgeon may recommend the use or sound wave therapy (lithotripsy) in an attempt to break up the stones. However one of five people can have this treatment due to strict medical criteria and it is not altogether successful. People who undergo this treatment often form new gallstones after a few years.

People with symptoms require more definitive treatment because they are at risk of serious complications. Symptoms indicate the stone is mobile and has the potential to obstruct anywhere within the bile duct system. They will likely require surgical removal of the gallbladder (cholecystectomy).

The type of complications seen with mobile gallstones depends upon where the stone obstructs within the bile duct system in its journey from the gallbladder into the intestine. Most of these instances warrant emergency medical and surgical evaluation and treatment.

Blockage of the cystic duct or neck of the gallbladder can cause inflammation and infection (acute cholecystitis). The initial presurgical treatment includes pain medications, intravenous fluids and antibiotics. There is concern that the gallbladder will rupture emptying its contents into the abdominal cavity. This contamination leaves the bile acids to degrade the surrounding tissues akin to the corrosive acid spewed by the creature in the movie Alien.

Cholecystectomy is the treatment of choice under these urgent circumstances. Most procedures are done through a laparoscope, a small thin tube with a video camera and surgical instruments built into its end. Five small abdominal incisions are made and used as access points. Patients recover within days barring any infection or rare complication.

Open cholecystectomy involves a larger abdominal incision leaving a four to six inch scar under the lower margin of the right rib cage. Patients usually require three to five days of hospitalization and several weeks of recuperation. The surgeon’s choice of laparoscopic or open cholecystectomy depends upon their assessment of the patient’s clinical condition.

Digestion continues to function well after cholecystectomy. Loose stools, gas, and bloating may develop in about half the patients, but most do not require any dietary changes.

Complete blockage of the common bile duct (beginning from where the ducts from the liver and gallbladder meet to about the entrance of the small intestine) does not allow bile to empty into the intestine. Akin to a blocked drainpipe, the bile will back up into the liver and lead to the accumulation of bilirubin (a bile component) within the blood causing jaundice. High levels of bilirubin are toxic to the brain.

The bile duct may become infected (acute cholangitis) causing pain, chills, and fever. It requires immediate treatment using a procedure that removes the gallstone by way of an endoscope inserted through the mouth down to the intestine (a procedure known as endoscopic retrograde cholangiopancreatography or ERCP).

If the stone travels further down into the duct within the pancreas, the digestive enzymes within the pancreas can accumulate and begin to breakdown the organ causing inflammation (pancreatitis) and severe abdominal pain. Pancreatitis treatment does not require surgery but can be fatal. It is aggressively managed with intravenous fluid replacement, complete restriction of food and liquids, pain medication and the stone may be removed by ERCP.

Prevention of gallstones requires lifelong lifestyle modification especially in those at increased risk:

• Three meals a day each containing some fat to promote good gallbladder contraction. This can help prevent the accumulation of the material that creates the stones.
• A diet high in fiber and calcium and low saturated fat.
• Regular exercise and maintenance of normal body weight. Obese people on a rapid weight loss plan require medical supervision because of the increased risk of stone formation.
• Surgery remains the best way to cure gallstones for many people. Discuss your options with your physician. We move on to kidney stones next week

References:

National Library of Medicine (http://www.nlm.nih.gov/medlineplus)
National Institutes Diabetes and Digestive and Kidney Diseases (http://www.niddk.nih.gov/)
The American Gastroenterological Association (AGA) (http://www.gastro.org)
The American College of Gastroenterology (ACG) (http://www.acg.gi.org/)

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© Dr. Barry Dworkin 2003