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Surgical Conditions

Gall Stones

A gallstone, is a lump of hard material usually range in size from a grain of sand
to 3-4 cms. They are formed inside the gall bladder formed as a result of precipitation
of cholesterol and bile salts from the bile.

Types of gallstones and causes

Cholesterol stones
Pigment stones
Mixed stones- the most common type. They are comprised of cholesterol and salts.

Cholesterol stones are usually yellow-green and are made primarily of hardened
cholesterol. They account for about 80 percent of gallstones. Scientists believe
cholesterol stones form when bile contains too much cholesterol, too much bilirubin,
or not enough bile salts, or when the gallbladder does not empty as it should for some
other reason.

Pigment stones are small, dark stones made of bilirubin. The exact cause is not known.
They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary
blood disorders such as sickle cell anaemia in which too much bilirubin is formed.

Other causes are related to excess excretion of cholesterol by liver
through bile. They include the following

Gender. Women between 20 and 60 years of age are twice as likely to develop
gallstones as men.

Obesity. Obesity is a major risk factor for gallstones, especially in women.

Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or
birth control pills

Cholesterol-lowering drugs.

Diabetes. People with diabetes generally have high levels of fatty acids called
triglycerides.

Rapid weight loss. As the body metabolizes fat during rapid weight loss, it
causes the liver to secrete extra cholesterol into bile, which can cause gallstones.

Symptoms

Many people with gallstones have no symptoms. These patients are said to be
asymptomatic, and these stones are called "silent stones." Gallstone symptoms
are similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome,
hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

Symptoms may vary and often follow fatty meals, and they may occur during the night.

• abdominal bloating
• recurring intolerance of fatty foods
• steady pain in the upper abdomen that increases rapidly and lasts from
  30 minutes to several hours
• pain in the back between the shoulder blades
• pain under the right shoulder
• nausea or vomiting
• Indigestion & belching

Diagnoses

Ultrasound is the most sensitive and specific test for gallstones.

Other diagnostic tests may include

• Computed tomography (CT) scan may show the gallstones or complications.
   
• Endoscopic retrograde cholangiopancreatography (ERCP). The patient
  swallows an endoscope--a long, flexible, lighted tube connected to a computer
  and TV monitor. The doctor guides the endoscope through the stomach and into
  the small intestine. The doctor then injects a special dye that temporarily stains
  the ducts in the biliary system. ERCP is used to locate and remove stones in the
  ducts.
   
• Blood tests. Blood tests may be used to look for signs of infection, obstruction,
  pancreatitis, or jaundice.

Course of illness

Bile-duct blockage and infection caused by stones in the biliary tract can be a
life-threatening illness. With prompt diagnosis and treatment, the outcome is
usually very good.

Complications

The obstruction caused by gall stone may lead to Biliary colic, Inflammation of
gall bladder (Cholecystitis). Other complications may include

• Cirrhosis- Cirrhosis is the result of chronic liver disease that causes scarring
  of the liver (fibrosis - nodular regeneration) and liver dysfunction.
• Cholangitis- Cholangitis is an infection of the common bile duct, which
  carries bile (which helps in digestion) from the liver to the gallbladder
  and then to the intestines.

Treatment

Surgery

Surgery to remove the gallbladder is the most common way to treat symptomatic
gallstones. The most common operation is called laparoscopic cholecystectomy. For this
operation, the surgeon makes several tiny incisions in the abdomen and inserts surgical
instruments and a miniature video camera into the abdomen. The camera sends a magnified
image from inside the body to a video monitor, giving the surgeon a close up view of the
organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully
separate the gallbladder from the liver, ducts, and other structures.

If gallstones are in the bile ducts, the physician (usually a gastroenterologist) may
use endoscopic retrograde cholangiopancreatography (ERCP) to locate and remove
them before or during the gallbladder surgery.