One of the most common surgical procedures in the United States is gallbladder removal. When gallstones form and the gallbladder swells up, removal of the gallbladder is a quick easy procedure that relieves the severe discomfort caused by the condition. Generally the first sign of gallstones is a feeling like indigestion after meals. Eventually, the indigestion feeling also includes sweating, nausea, and shortness of breath. These symptoms usually lead the sufferer straight to the doctor. Surgery is usually quick with remarkably fast recovery.
The gallbladder is a small muscular sac about the size and shape of a pear. The gallbladder stores bile, a digestive fluid, from the time it is produced by the liver until it is ready to be used. After a meal, the gallbladder contracts to release bile into the upper part of the small intestine to help break down fatty acids. If the gallbladder doesn’t empty completely enough or if there is a chemical imbalance, the bile can become too concentrated and crystallize into a stone. If the stone obstructs proper flow of the fluid, pain and other symptoms occur. A stone typically contains hardened cholesterol plus calcium and bilirubin. Bilirubin is residue from the breakdown of red blood cells. About 20 percent of stones are composed of bilirubin only.
Is it a pebble or a stone?
A gallstone can be as small as a grain of sand or as large as a golf ball. The larger the stone, the greater the risk of symptoms and complications. Gallstones are twice as likely to occur in women age 20 to 60 than in men the same age. This is because estrogen, the female hormone, causes more cholesterol to be excreted in bile. For the same reason, pregnancy, birth control pills and hormone replacement therapy all increase the risk of gallstones.
Body mass is also a factor. Excess weight increases the level of cholesterol in a person’s bile. Cholesterol excess changes the chemical composition of bile. This reduces the frequency with which the gallbladder contracts and empties.
High-fat, high-calorie diets increase the risk of gallstones, but so do very low calorie, rapid weight loss diets. If your diet causes you to lose more than three pounds a week, your gallbladder is not going to be contracting very frequently. As a result, you’ll have a higher risk of gallstones.
Inflammation of the bladder itself can cause prominent symptoms and an urgent need for surgery. However, many individuals with gallstones find out only after a routine test–usually an ultrasound or CT scan–performed for another medical condition. Gallstones take up to eight years to develop and about 90 percent produce no symptoms. Symptoms such as excessive gas or a feeling of being unduly full or bloated are usually due to other digestive problems. But when the flow of bile is being obstructed enough to cause inflammation and pain, it’s important to see a doctor. Once an infection develops, serious complications can follow rather quickly.
In addition to the pain, other symptoms include a yellowing of the skin (jaundice) or the whites of the eyes, dark urine and yellow stools. Some patients have chronic diarrhea, with bowel movements 8 to 10 times a day. When gallstones are suspected because of such symptoms, a blood test and scanning tests can confirm the diagnosis.
For small stones that are not causing severe symptoms, nonsurgical options such as bile salt tablets or shock wave therapy (lithotripsy) may be tried to dissolve the stones. In most cases, however, stones usually recur, and when they continue to cause pain and other problems, the solution is usually surgery. Once the gallbladder has been removed, bile empties directly into the intestine and stones can no longer form.
The introduction of minimally invasive laparoscopic surgery for gallbladder removal in the 1990s may have prompted doctors to recommend surgery more frequently than watchful waiting. Of more than 750,000 gallbladder procedures (known as cholecystectomies) performed each year, 80 to 90 percent use laparoscopic tools and techniques.
Through a small incision, the surgeon inserts a thin, lighted tube with a miniature video camera at the end inside the abdomen to visualize the procedure on a video monitor. He or she then removes the gallbladder with tiny instruments inserted through other small incisions in the abdomen.
If difficulty arises, the surgeon can switch to open surgery, which requires a larger incision. Open surgery may also be used for severe cases, older patients, or when the gallbladder is clearly infected.
When there are stones in the bile duct as well as the gallbladder, these may have to be removed through a separate procedure.
Open vs Laparoscopic Surgery
Because of the size of the incision, open surgery requires a longer recovery–up to a week in the hospital followed by several weeks’ recovery at home. Laparoscopic surgery, on the other hand, allows a return to normal activities within a few days with less scarring and less post-operative pain.
After removal of the gallbladder, people are usually able to continue eating the same foods as before. The liver continues to produce enough bile to digest a normal diet. Following gallbladder removal, patients often have more bowel movements than usual, and stools may have a less solid consistency. After gallbladder surgery, a very small percentage (about one percent) of persons end up with chronic diarrhea. To avoid such problems, adding fiber to the diet and avoiding excessive intake of dairy products, fats and spicy foods are recommended. As to whether it is advisable to eat rich, high-calorie meals day after day, that is another question. For many reasons, everyone should consider the benefits of eating more vegetables, fruits and whole grains.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director
Richmond Apothecaries
