THE GALLBLADDER

The gallbladder is a pear-shaped organ located on the underside of the liver. It stores, concentrates and releases bile to aid in fat digestion. The most common gallbladder disorder is gallstones. Gallbladder polyps and cancer occur less often.

GALLSTONES: SYMPTOMS, CAUSES & GALLBLADDER SURGERY

Symptoms of gallstones

Gallstones (cholelithiasis) are often asymptomatic but can trigger abdominal pain, nausea and/or vomiting (biliary colic) on consumption of fatty foods as the gallbladder contracts against the stone(s) to release bile. If this obstruction is not relieved, the gallbladder may become inflamed (cholecystitis). If the gallstones travel and get lodged further down the biliary tree (choledocholithiasis), they may cause complications such as inflammation of the pancreas (gallstone pancreatitis) or of the bile ducts (cholangitis). These manifest as some combination of pain, jaundice, fevers, dark urine and light stools.

Causes of gallstones

Gallstones usually form when there is an imbalance in the chemical composition of bile - cholesterol, bilirubin, and bile salts - causing them to precipitate into crystals. Therefore, conditions that alter this balance, such as obesity, a high-cholesterol diet, rapid weight loss and prolonged fasting, increase the likelihood of gallstones. Women are more susceptible to gallstones than men due to the influence of oestrogen on cholesterol levels. Likewise, oestrogen-containing contraceptives and hormone replacement therapy are risk factors for gallstones.

Gallstones diagnosis

Gallstones are easily diagnosed in most cases on an abdominal ultrasound. Other investigations such as a CT, MRCP, or HIDA scan are useful when the diagnosis is unclear.

Indications for gallbladder surgery

Surgery to remove the gallbladder, a cholecystectomy, is recommended when patients experience symptoms or complications from gallstones.

A vast majority of the time, the gallbladder can be removed via keyhole surgery, a laparoscopic cholecystectomy. This involves three small cuts (5-6mm) in the abdomen for the insertion laparoscopic instruments, and one larger cut (12-15mm) around the belly button for the camera and extraction of the gallbladder specimen.

If a stone migrates into the biliary system, an attempt can be made to retrieve it via a bile duct exploration during the same operation. But if the stone has ventured further, a separate procedure at a separate time, an endoscopic retrograde cholangiopancreatography (ERCP) would be needed.

Surgery is not usually indicated in patients with asymptomatic gallstones.

Risks of gallbladder surgery

A cholecystectomy is a widely performed and generally safe procedure. Nevertheless, there is a small risk of complications which include bleeding, infection, damage to surrounding structures (bile duct, liver, small bowel), and conversion to open surgery. The risk of complications is higher where gallbladder is severely inflamed, or scarred/contracted due to repeated attacks over time.

Foods to avoid

Maintain a low-fat, high-fibre diet and look out for red-flag symptoms - fevers, pain, jaundice, inability to eat. Go to your GP or closest ED if these occur.

Recovery after gallstone surgery

Many patients feel well enough to go home on the same day after laparoscopic cholecystectomy, so long as they have adequate support at home. On average, patients are back to work and driving in about one week post surgery.

Most patients do not experience any long-term effects from having their gallbladder removed, and resume a normal life after surgery. A proportion of patients experience post-cholecystectomy diarrhoea as their body adjusts to processing fats without a gallbladder. A fat-free, high-fibre diet helps, and most of the time, this is transient and self-resolves within 4-6 weeks. A minority of patients (0.05%) may need medication to manage chronic diarrhoea.

GALLBLADDER POLYPS

Most gallbladder polyps are pseudo polyps, i.e., not true polyps. They are more often inflammatory polyps, a collection of cholesterol crystals.

True polyps, i.e., adenomas are rare and account for ~10% of all gallbladder polyps. Most gallbladder polyps are harmless but larger polyps have the potential to harbour or develop malignancy. All polyps should be monitored with yearly ultrasounds. Gallbladder surgery is indicated in the following settings:

Polyps between 5-10mm in patients with risk factors for gallbladder cancer
All polyps larger than 10mm or with suspicious features
Polyps that change with surveillance (increase in size by ≥2mm/year)
Symptomatic polyps of any size. Polyps can act like gallstones, blocking the release of bile into the intestines.

GALLBLADDER CANCER

Rare but aggressive, gallbladder cancers usually need more extensive surgery than a cholecystectomy, and more a comprehensive treatment strategy.

***The content on this website or linked web pages are intended for educational purposes only and should not be relied on to make healthcare decisions in the absence of a consultation with a healthcare professional