Cholelithiasis (Gall Stone Disease) – An Overview

What Is the Gall bladder?

The gall bladder is a digestive organ which is situated at the upper right side of your abdomen, beneath your liver. It serves as a reservoir for bile which is secreted by the liver. Bile helps in dissolving the cholesterol secreted by the liver and aids in digestion.

What Are Gall Stones or Cholelithiasis?

When your gall bladder is filled with hard deposits or concretions of the digestive fluid, we call it gall stones or “cholelithiasis”.

How Are Gall Stones Formed?

Gallstones might form mainly due to three major reasons:

• Cholesterol Supersaturation – When the liver produces more cholesterol than what the bile can dissolve, it leads to crystal or sludge formation inside the gall bladder which results in gall stones.
• Excess Bilirubin – Haematological conditions causing increased breakdown of red blood cells, result in excess bilirubin which results in gall stones.
• Gall Bladder Hypomotility – Gall bladder doesn’t contract effectively, causing concentrated bile resulting in gall stones.

What Are the Risk Factors for Gall Stone Formation?

• Age more than 40
• Females in their reproductive age group have a higher chance for gall stone formation as oestrogen increases cholesterol supersaturation & progesterone decreases the motility of the gall bladder resulting in bile stasis
• Pregnancy and oral contraceptive use
• Obesity & diabetes mellitus – due to insulin resistance
• High fat and low fibre diet
• Rapid weight loss – intermittent fasting, bariatric surgery
• Genetic preponderance
• Hematologic diseases

What Are the Symptoms of Gall Stones?

Gall stones can cause vague pain in your abdomen, especially around the right upper side and also to your back. You might also have problems like cramping abdominal pain, indigestion, bloating sensation & nausea. In case of complications, it can give rise to severe abdominal pain, jaundice and fever. Gall stones can also remain asymptomatic in up to 80% of the population.

How Do You Diagnose Gall stones?

When your physician suspects gall stones, he might recommend an ultrasound of the abdomen. It detects gallstones with 90% sensitivity & 99% specificity. It is the first investigation of choice.

Also, liver function tests and complete blood counts are needed to rule out any complications.

In case of suspected complications, additional blood investigations like s. amylase, s. lipase & imaging investigations like CECT abdomen/MRCP will be needed.

What Are the Complications of Gall stones?

• Recurrent Abdominal Pain – Gall bladder colic
• Cholecystitis – Inflammation of the gall bladder
• Mucocele – Stone obstructing the neck of the gall bladder causing mucous accumulation
• Empyema – Pus in the gall bladder
• Choledocholithiasis – Stones in the common bile duct, results in obstructive jaundice
• Pancreatitis – Inflammation of the pancreas
• Gall Bladder Cancer – Rare but yes if genetic preponderance (+)

Do All Patients with Gall Stones Need Surgery?

All patients with symptomatic gall stones (higher chance of developing complications) need to undergo surgery to remove the gall bladder. Removing the gall stones alone will cause a recurrence of gall stones & it is always advised to remove the gall bladder completely.

Patients who have no symptoms have a lifetime risk of up to 25% of developing complications due to gall stones. The clinician and the patient discuss the potential risks of observation (watchful waiting) and surgery, and then make an informed decision.

Patients with larger gall stones (> 2 cm), multiple small gallstones with diabetes, non-functional or porcelain (calcified) gall bladder, and patients with haemolytic conditions, cirrhosis & portal hypertension are usually offered surgery rather than watchful waiting because of the increased risk of complications.

What Is Cholecystectomy (Gall Bladder Removal)? What Is Laparoscopic/Robotic Cholecystectomy?

Surgery to remove your diseased gall bladder is called cholecystectomy.

If cholecystectomy is performed with a large incision to the upper right side of your tummy, it is referred to as an open cholecystectomy.

When we use multiple small incisions (usually 4) of less than 1 cm, to enter into your abdomen, and remove the gall bladder with the help of a small camera (which shows the abdomen on a screen) and other long specially designed narrow instruments, it is termed as laparoscopic cholecystectomy.

When the surgeon guides a robot to do the same (instead of the narrow long instruments), it is termed a robotic cholecystectomy.

How Is a Laparoscopic/Robotic Cholecystectomy Performed?

You will be given general anaesthesia for your laparoscopic/robotic cholecystectomy which means that you will be asleep during the entire procedure.

Your abdomen will be filled with gas (carbon dioxide) to create the space necessary for the surgery and subsequent small incisions are made to insert a device called a port.

Then, with the help of the small camera and the long narrow instruments of laparoscopy or robot, the surgeon completes the procedure.

What Are the Advantages of Laparoscopic/Robotic Cholecystectomy?

• Shorter duration of stay in the hospital
• Faster return to work
• Less pain after surgery
• Having normal bowel movements sooner
• Better cosmetic outcome due to smaller scars

What to Expect After Surgery?

You should be able to go home the day you have your surgery, or you might need to stay in the hospital overnight. You need to be able to drink liquids and take some soft diet before you go home.

In case the gall bladder has already perforated or if the infection is severe, you might need to be in the hospital for a longer period of time.

You might feel nauseated or you might vomit after your surgery because of the anaesthesia and surgery. Some discomfort and pain at the incision sites, shoulder, and in your abdomen are also common for 24 to 48 hours. However, you should feel normal in 2 days.

Are There Any Long-Term Side-Effects of Gall Bladder Removal?

Removing the gallbladder usually does not cause any long-term issues and you can live a normal life without your gallbladder.

A small percentage of patients have temporary side effects like fatty food intolerance, nausea, flatulence & bloating post-surgery.

How to Prevent Gall Stone Formation?

• Never skip meals
• Slow progressive weight loss (1kg/week)
• Eat fibre-rich foods – whole grains, vegetables & fruits
• Avoid foods rich in oil & cholesterol
• Increase physical activity
• Maintain a healthy weight