Introduction

The gallbladder is a hollow, bag-like organ, several centimetres long that is situated beneath the liver within the abdomen. This is on the right side of the body, approximately where the lower border of the ribcage crosses an imaginary line between the umbilicus (belly-button) and right shoulder tip. The main function of the gallbladder is to store the digestive juice bile, which is produced in the liver. Bile is an important factor in the digestion and absorption of fat within foods. It is continually manufactured by the liver and secreted into the digestive tract through the bile ducts, which join together to form a single pipe, the common hepatic duct that leads out of the liver. The gallbladder leads off the common hepatic duct, connected to it by a small pipe, the cystic duct. The continuation of the common hepatic duct beyond this junction is now referred to as the common bile duct which then weaves behind the pancreas, usually joins the pancreatic duct (releases digestive juices from the pancreas) and then enters the duodenum (part of the small bowel, leading directly from the stomach), at a point known as the ampulla (of Vater), and the release of these combined digestive juices is under the control of a sphincter (circular) muscle (the sphincter of Oddi). Bile, produced in the liver is conveniently stored in the gallbladder. This can then be released through contractions of the gallbladder, which occur in response to the presence of large amount of food in the stomach and duodenum and controlled through the release of gut hormones.

Bile is a mixture of different chemicals (including cholesterol), and it is normally a liquid when stored in the gallbladder. However, under certain conditions, this liquid can form small crystals that then precipitate into solid material. This can take the form of sludge, multiple small stones or several large stones depending on their composition. It is uncertain as to what might cause stone formation in this way, but it is probably a consequence of stagnation of the fluid in the gallbladder combined with bacteria migrating in from the gut itself.

The presence of gallstones is very common in adults, and in some cases they appear not to cause any problems at all; these are referred to as incidental or asymptomatic gallstones. In the majority of people however, gallstones inevitably declare themselves, and they can cause a variety of medical problems. Gallstones do run in families, and their incidence in women is greater than men.

The symptoms depend on the exact problem the gallstones are causing, but can include: abdominal pain (severe acute or dull chronic) typically but not always after eating fat containing foods, nausea, vomiting, fevers, and jaundice.

Gallstones can simply irritate the gallbladder itself, causing inflammation. This can be both sudden and severe in onset, referred to as acute cholecystitis, symptoms of which include pain in the right-hand side, upper portion of the abdomen, fever, nausea and vomiting, or chronic in nature which gives rise to dull, aching discomfort, often radiating to the back and persistent; this is referred to as chronic cholecystititis. In severe cases, the gallbladder may become filled with pus (empyema of the gallbladder) or mucus (mucocele of the gallbladder) giving exquisite tenderness at the location of the gallbladder beneath the ribs on the right-hand side. Ultimately, severe inflammation of the gallbladder may cause an area of it to become ischaemic (lose it blood supply) and necrotic (dead), causing it to perforate. Perforation may result in severe and life threatening peritonitis, requiring emergency surgery, or can form an abnormal communication with the bowel called a fistula, through which stones enter the gut, and then may get trapped causing bowel obstruction.

If small gallstones or sludge escape from the gallbladder and enter the common bile duct, other problems may occur. Biliary colic is the name given to the very severe, but intermittent pain caused by a stone stuck in the cystic duct. If stones become stuck in the common bile duct, they can cause blockage of the bile ducts, and the bile then becomes trapped, causing jaundice (yellow skin discoloration) and darkening of urine in which some of the bile now is released.

Stones trapped in the biliary system can provoke severe infections of the bile duct, referred to as cholangitis, and patients suffering from this become very sick very quickly.

Bile normally reaches the duodenum through a small duct whose opening is controlled by a sphincter muscle. If stones get stuck here, they can block the outflow of digestive juices from the pancreas, causing the potentially life-threatening condition of pancreatitis. Finally, long-term irritation of the gallbladder may give rise to cancer of the gallbladder.

A diagnosis of gallstones and gallbladder disease is made on the basis of a clinical history and examination consistent with some of the above features, and then confirmed on ultrasound scanning of the abdomen. This usually highlights the presence of gallstones and diseases of the gallbladder itself. It can give an indication as to whether stones have escaped into the bile ducts. Blood tests looking a liver function (LFTs) may also be useful in this matter, and if there is doubt about the presence of stones within the biliary sytem, a more detailed scan known as an MRI (magnetic resonance image) can be performed, and this investigation is referred to as an MRCP (magnetic resonance cholagio-pancreatography).

Diseases that have similar symptoms to gallstones include reflux disease, hiatus hernia, ulcers, and irritable bowel syndrome amongst others. It may be important to exclude these diagnoses before undergoing surgery, because if the gallstones are merely an incidental finding then there will be no improvement, and even deterioration in symptoms afterwards. It is important therefore to seek expert advice before receiving any treatment.

Keyhole surgery to remove the diseased gallbladder and the stones within it is the only safe and reliable means of effectively curing the problems associated with gallstones. This operation is referred to as laparoscopic cholecystectomy.

There have been many attempts in the past to simply dissolve gallstones with drugs, or shatter them with ultrasound like kidney stones, but these have all failed and ending up causing other problems and complications.

Serious medical problems such as acutecholecystitis, cholangitis, peritonitis and pancreatitis can cause severe illness and are potentially life threatening. These conditions warrant urgent hospital admission for treatment including intravenous antibiotics and fluid resuscitation and may even require emergency surgery. It is recommended therefore that symptomatic gallstones are treated by laparoscopic cholecystectomy sooner rather than later to avoid the potential development of these serious complications.

Laparoscopic Cholecystectomy