It is the last consultation of a gruelling afternoon. The secretary enters the patient and greets, going away. Mrs Y is a 38-year old fair and a bit overweight lady. Long curly hair, she reminds me vaguely the Flora by Titian. She walks with her husband, pushing a stroller with a child who surely has less than a year. Mrs Y was referred to me by his general practitioner, for the evaluation of a probable gastritis. “First things first,” I say, and start collecting a thorough history. The patient goes back to the beginning of symptoms well before pregnancy, about three years ago when, after a hearty lunch, he had an episode of intense pain in the epigastrium, radiating under the right costal arch and back to the apex of her shoulder blade, accompanied by nausea and vomiting.
The pain lasted about two hours, and was resolved only after a neighbour, a nurse, has given her a vial of Buscopan intramuscularly. The patient then has neglected this first episode, judging it just occasional and maybe related to something she had eaten, and has enjoyed a period of good health. At the fifth month of pregnancy, she had another similar episode, also in this case regressed after taking an antispasmodic. And also in this case Mrs Y preferred to forget the incident.
After giving birth, the pain episodes recurred quite regularly, approximately once a month, and they were often at night. At this point her husband, silent until now, adds a fundamental piece to the puzzle. “Do you remember,” he says to his wife, “that a couple of months ago, when you were sick after dinner at Luke’s house and were waiting for the Buscopan to have effect, I told you looked a bit pale yellow?” “But it surely was the neon light !! What are you thinking … ” she replies quickly. My initial suspected diagnosis is beginning to have some confirmation …
The clinical picture hereby presented is quite typical of gallstones, ie the presence of stones in the gallbladder and / or bile ducts, ie those ducts that carry bile from the liver to the intestine. The bile is essential for the absorption of fatty acids, but between a meal and the other, rather than ending up wasted, it is stored in the gallbladder, a kind of bag placed below the liver and bound to it. Actually, the gallbladder does not only acts as a reservoir, but changes the composition of bile. If this processment is not conducted properly (just for a primary defect of the gall bladder), the bile can become “supersaturated”, that is, its components are no longer in solution but tend to precipitate, such as when we put too much sugar our tea , and a semi-solid granular residue can be seen at the bottom of the cup. Subsequently, this biliary sludge tends to consolidate into stones.
Often, the stones remain asymptomatic for all the patient lifespan, and can be discovered during an investigation performed for other reasons. Just as often, however, they may give symptoms. The first and most common sign of the presence of stones in the gallbladder is the so-called “biliary colic”: a sudden intense stabbing pain, starting from the right upper quadrant and radiating back to the apex of the shoulder blade, and comes usually after a meal. It lasts a few hours. Sometimes, in 10% of cases, there is a complication, such acute cholecystitis, pancreatitis or jaundice. Acute cholecystitis is the inflammation of the gallbladder: the typical biliary pain is associated with fever and signs of peritonitis, which may be initially localized in the upper abdomen, but it may spread as the infection progresses.
Acute pancreatitis is an inflammation of the pancreas due (often but not always) to the presence of small stones migrated from the gallbladder down the common bile duct to obstruct the pancreatic duct, causing the accumulation of the secretion of the pancreas and the activation of its enzymes . Finally, jaundice is due to obstruction of the bile duct by stones impacted in it. In such situation the bilirubin accumulates in the liver and passes into the blood, going especially to the skin and to the sclera of the eye.
While “simple” biliary colic may be easy to manage, and usually settles down with common antispasmodics, complications can be more or less serious and always require admission to the hospital and sometimes and emergency operation. Gallstones are more common in females of fertile age, but almost everyone is more or less at risk, regardless of the diet he does. The typical subject is described by the “5 F”: female, forty, fertile, fat, fair.
So I visit the patient, who is in good general condition, has no jaundice, but some tenderness in the right upper quadrant of her abdomen. I request an ultrasound and blood tests to check in particular liver function tests and blood counts. To rule out peptic ulcer, I request also an oesophagogastroduodenoscopy. When she returns, about 15 days later, she tells me she had another episode of colic, but this time the yellow colour of the eyes was evident and lasted two days at least. Blood tests are substantially all normal, except GGT, which slightly increased.
Ultrasound confirmed my suspicion of gallstones (multiple stones in the gallbladder); the intrahepatic bile ducts are not dilated, but the common bile duct has a diameter at the upper limit of normal (9 mm). The OGD shows a small hiatus hernia, but nothing more.
The diagnosis of gallstones is quite simple; medical history is usually very typical and a liver ultrasound confirms the clinical impression. Blood tests are needed to rule out a biliary obstruction due to stones in the common bile duct (which also should have been suspected based on the presence of dilated bile ducts proximally to an obstruction).
In the presence of stones in the common bile duct, this should be cleared before removing the gallbladder or at the same time. This is usually done with a procedure called endoscopic retrograde cholangiopancreatography (ERCP), which is a camera test where the endoscopist goes from the mouth to the duodenum, cannulate the biliary duct and clean it with very long instrument. ERCP, however, is considered a real surgery, which has its risks. For this reason it is indicated only if we are certain of the presence of stones in the bile duct. The confirmation in this sense – or rather, a strong suspicion – is given by magnetic resonance cholangiopancreatography (MRCP) that is a magnetic resonance targeted on the biliary tree.
Investigations carried out confirm the impression of gallbladder stones, but there is also a strong suspicion of a recent passage of stones in the bile duct – history of recent transient jaundice, modest enlargement of the common bile duct and increased GGT. Even if the patient is currently asymptomatic and definitely not jaundiced, I cannot exclude that some debris is still in the bile ducts. I request an urgent MRCP. This investigation, diligently performed two days later confirmed the patency of the biliary tract and the absence of stones.
The common bile duct diameter is back to normal. We just need to treat her gallstones by removing her gallbladder. Mrs Y is frightened by the proposed surgery so she asks me if we can dissolve her stones with drugs or shock waves, as she read on the Internet. I am very firm in my denial and accurately explain my reasons. She is still scared but she understands the reasons to perform the operation and agrees to have cholecystectomy.
The treatment of symptomatic cholelithiasis – as in the case described – is only surgery. The so-called chemical litholysis with bile salts can be useful only if there are no proper stones but only a bit of sludge in the gallbladder or as a temporary measure in patients who can not undergo surgery for the presence of other serious diseases. However, therapy with bile salts, although it may be occasionally effective has a high incidence of recurrence of stones, just at its suspension.
If there is no evidence of stones, the therapeutic choice is difficult. In those cases, the symptoms can be due to another condition, such as peptic ulcer, bowel problems, left lung pneumonia… But often in the presence of a typical biliary pain, the cause of the pain is to be searched in the biliary tree. Sometimes there is only sludge in the gallbladder. This can give the same symptoms of gallstones – and as such should be treated – but ultrasound can be negative. Or there can be a general malfunctioning of the biliary tree, what we call biliary dyskinesia. In this case, cholecystectomy can be useful, but the rate of positive results is not more than 50% and the patient should be informed of this.
On the other side of the coin, the casual discovery of gallbladder stones not associated with specific symptoms is not per se indication for surgical operation. But we know how every case of stones has a risk to become symptomatic (about 10% each year), often with a “simple” biliary colic but sometimes with a complication (cholecystitis, jaundice, pancreatitis). For this reason, the choice of whether to remove the gallbladder or not depends on the preference of the patient, his/her lifestyle, his/her medical history.
Surgical treatment of cholelithiasis is cholecystectomy, ie the removal of the gallbladder. It makes no sense to remove only the stones (it’s a common question of patients …), as it is the gallbladder that is diseased, not its content; the stones are only a consequence of an abnormality of the gallbladder. Nowadays cholecystectomy is performed almost always laparoscopically, that is, with 3-4 small keyholes on the surface of the abdomen.
A camera is inserted into the belly button, and the other ports are used to introduce long instruments to mobilize and remove the gallbladder. As in all keyhole operations, there is always the risk of not being able to complete the operation by laparoscopy and having to convert to laparotomy (ie in the classical access with a more or less wide subcostal incision). In symptomatic cholelithiasis simple this risk is quite low (on the order of 2-3%), but it goes up to 20-25% if we operate during an episode of acute cholecystitis. The risk of complications is low.
The most feared complication is iatrogenic lesion of the common bile duct – approximately 0.01-0.1% of cases depending on the experience of the operator and the local conditions of the patient – which can often be resolved with an endoscopic approach, but sometimes requires a real surgery. Bleeding is a rare complication but always possible. It usually occurs during surgery and often requires a conversion laparotomy. Also an injury to the bowel is a possible rare occurrence which can be recognized in the course of surgery and treated by laparoscopy or laparotomy with a conversion. Diarrhoea is quite a frequent side effect of cholecystectomy.
It is due to the rearrangement of the so called bilio-enteric circulation, as liver-produced bile has not longer a reservoir and is discharged straightaway in the bowel causing an osmotic diarrhoea. Fortunately, the biliary tree undergoes anatomical changes to compensate for the absence of the gallbladder and usually diarrhoea settles down within a couple of weeks. It is up to the surgeon to explain to the patient the surgical technique, its expected outcome and possible complications, and make sure that the patient retained the information given. Fortunately the risk of those complications is very low and in the vast majority of cases (about 99%) surgery and postoperative period are uneventful. Immediately after surgery the patient is allowed to eat and drink and can be discharged few hours afterwards. Return to work can take place as soon as the patient feels able to perform common tasks, usually within 3-7 days (depending on the type of work and especially the motivation to return; normally independent and free professional resume well before!!!).
The duration of surgery is 20 minutes, and it is very straightforward, with no difficulties or complications. Mrs Y has a nice cup of tea with a toast immediately after recovering from anaesthesia and goes home 3 hours later. The minimally invasive treatment allows her to return to work three days later. She goes to her GP for a week check to her small wounds 7 days after surgery and everything is fine. I meet her at a local shop 1 year later. She has lost some weight and looks happy