Gallstones, Cholecystitis

What are gallstones and why do they occur?

Bile, which is stored in the gallbladder, is produced by the liver and is transported to the gut via the biliary tracts. This greenish fluid is very useful in helping the breakdown of food and in addition it enhances the absorption of nutrients.In the gallbladder, which is situated below the liver, the bile is not only stored, it is as well getting highly concentrated there. After food intake the bile gets secreted into the duodenum. A gallstone occurs mostly due to an imbalance of the elements of bile (mostly calcium salts, cholesterol and bile pigments) . These stones can be of different size and can be found at different locations. In case of gallstones we use the term cholelithiasis. Choledocholithiasis is describing stones being located in the common bile duct. Looking at the indicidence rate, it can be observed that 10-15% of the industrial population is affected by bile stones. The risk groups are Fertile, Females, Fair skinned, over Forty years old whith a Fatty Food intake. ( “ the 5 F´s”).

How is a Cholelithiasis diagnosed?

Only in one fourth of cases with Cholelithiasis, patients show symptoms and in these cases a treatment is recommended. Typical symptoms are colic pain in the upper abdomen, radiating to the back and the right shoulder; especially after food intake. If a Gallstone obstructs the bile flow it can lead to icterus (jaundice). Here the patient shows a yellowish discoloration of the skin, brownish urine, pale stools and has increased liver parameters. In the case of an obstruction due to gallstones in the papilla of Vater, it not only leads to an obstructed bile flow, as well it affects the flow of pancreatic secretions. This situation can lead to so called biliary pancreatitis. Cholelithiasis is not only diagnosed by the clinical symptoms, as well the diagnosis is based on using an ultrasonography, computertomography and/or magnetic resonance cholangiopancreatography (MRCP). As well an ERCP( Endoscopic retrograde cholangiopancreatography‬) can be done, here i is as well possible to remove stones situated in the common bile duct.

Which complications can occur due to a Gallstone?

Cholecystitis (inflammation of the gallbladder) may occur. In an acute and severe form of this inflammation , it can lead to peritonitis and can cause a life threatening situation. Moreover an accumulation of Bile occurs, which leads to a dilation of the gallbladder called gallbladder hydrops. A chronic Cholecystitis leads often to chronic pain and may lead to the formation of a porcelain Gallbladder (increased calicification).If untreated this might lead unfortunately to the development of cancer, cholangiocarcinoma. Another complication of cholecystitis which might occur is the gallstone perforation. Here the stones perforate and can move “freely” in the gut and/or can cause even a gallstone ileus (intestinal obstruction)

How is Cholelithiasis treated?

There are several ways of treating gallstones. One possibility is to dissolve the stones by taking special drugs containing for example ursodeoxycholic acid (UDCA). The disadvantage of this therapy is that it does not affect all kinds if Gallstones and there is a high risk of recurrence (up to 50% in the next 5 years). Almost the same rate of reoccurrence is seen with the lithiotripsy (breakdown of the stones with ultrasonic waves). The therapy of choice is the laparoscopic cholecystectomy. With this technique only three small incisions are made into the abdominal wall. Via these opening the instruments are inducted into the abdominal cavity. A little camera shows the picture of the inside of the abdomen and so the surgeon can remove the gallbladder. The conventional surgery is rarely practiced now, since the laparoscopic surgery is much less invasive and safer. In suitable cases SILS- singular incision laparoscopic surgery it preformed. Here there is one incision made at the umbilicus, the advantages of this technique is that no scarring is seen after surgery. Another possible choice can be the microlaparoscopic technique, where the incisions made are only of 3-12 mm length. If gallstones are found in the bile duct the therapy is splitted into two parts. First is an endoscopic (with the ERC) removing of the Gallstone. During this procedure a papillotomy (incision of the papilla Vater) might be done if necessary. The second step is the “SILS-technique” or a traditional laparoscopic Gallbladder treatment. Complications with these techniques are very rare, when preformed by experienced surgeons the incidence of complications is less as 1%.

Autor: Dr. Andreas Franczak, Facharzt für Chirurgie, Gefässchirurgie und Visceralchirurgie

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