Monday, 25 July 2011

Treating Gall Stones

Published in Panorama

Surgery, the only treatment for Gallstones

Gallstones and gall bladder disease are one of the commonest entities world over, says Dr.Khalid Nasser, Specialist Gastroenterologist, Welcare Hospital. More than a million gall bladders are taken out every year and most of them involve stone formation.

What are gall stones and why do they form? The commonest are the cholesterol stones which does not happen necessarily because someone has high level of cholesterol but because the cholesterol is concentrated in the gall bladder where it tends to make stones, explains Dr.Nasser. “Of course, there are certain other kinds of stones called bilirubin stones,” continues Dr.Nasser, “which come from different kinds of blood diseases like sickle cell anaemia. These kinds of stones may be a little bit more common in this part of the world and the condition involves the haemoglobin being weak and then getting destroyed. So if there is more destruction of the blood cells, the liver cannot process it rapidly enough and it tends to make them stones in the gall bladder area, getting attached to calcium.”

Four times more women than men are predisposed to gallstones. Explaining this phenomenon, Dr.Nasser remarks, “it used to be the classic teaching that these stones occur after 35-40 years of age and more commonly after the first or second pregnancy. But today, we are seeing more and more stones come even in earlier ages and many a time, even without pregnancy. The reason for women being more prone than men is not definitely known but believed to be secondary to some hormonal factor making for slower motility of the gall bladder which predisposes them to stone formation.”

The good news is, “Children do not get affected with gall stones except in rare cases where some genetic factor like sickle cell anaemia is involved,” says Dr.Nasser.

There exist no risk factors predisposing one to gall stones as such. Western diet rich in cholesterol and high protein have a greater tendency to formation of gallstones than a diet comprised of more greens. However even this has not been conclusively proved says Dr.Nasser and hence in the absence of proven risk factors, it is not possible to prevent gallstone formation.

Gall stones may not be harmful by themselves, and oftentimes people may have them without even being aware of their presence, feeling no symptoms at all, according to Dr.Nasser. However, problems occur if one of them clogs the bile duct, the bile can become trapped in the gall bladder causing it to become inflamed. This can also prevent the flow of the pancreatic juice from the pancreas, leading to a painful condition called pancreatites, explains the doctor. In such instances jaundice like symptoms may show up. Left untreated, gallstones can lead to serious conditions, including blockage of the bile duct, inflammation and bacterial infection of the gall bladder.

In 50% of cases, says Dr.Nasser, people present with typical symptoms. They have intermittent bouts of abdominal pain, on the right side of the stomach, just below the ribs, which may be brought on by a fatty meal. The pain may last a number of hours, and then disappear as suddenly as it appeared. This "biliary colic" usually subsides without causing major discomfort. The pains may often appear similar to the pains from indigestion and be followed by bloating of the stomach, burping and reflux of food. In acute cases, there may be vomiting. Dr.Nasser cautions, “It is very important to differentiate gallstone pain from that of indigestion or acidity. Because ulcer pain from acidity can appear just like gallstone pain. Hence it is important to have a complete investigation done to ascertain the exact problem.”

Taking a good history of the patient, says Dr.Nasser, would be the first step in diagnosing gallstones. This apart, Ultrasound scanning of the abdomen is the commonest and simplest test to identify the presence of stones in the gall bladder. Blood test including testing for liver enzymes may be done particularly when stones are suspected to be blocking the duct. Once in a while we may have to do an endoscopy to assess the symptoms, opines the specialist.

For some time, shock wave treatment (lithotripsy) and dissolving medications were used to treat gallstones without much success. While surgery remains the mainstay of treatment of gallstones, having gallstones doesn't always mean that surgery is indicated, clarifies Dr.Nasser. Surgery for the problem depends largely on the location of the stones, and whether or not the gallbladder is inflamed. If the stones block vital organs such as the liver or pancreas, or if the gallbladder is inflamed, then urgent intervention is required.

Dr.Nasser dispels any notions that removal of the gallbladder may interfere with the proper functioning of the liver or normal flow of bile from the liver to the intestine.

Surgical removal of the gall bladder is the most effective means of curing gall bladder disease, declares Dr.Nasser because the effects are immediate and recurrence of the condition is prevented. “Fortunately, unlike until a few years back when the only treatment modality for removal of the gallbladder was open surgery involving opening up the stomach by a vertical or oblique incision, we now use keyhole surgery or what is called Laparoscopic Cholecystectomy, to achieve the same results but with little scarring, less pain and hospitalization of the patient”.

Elaborating on the treatment modality, he explains, “If the stone is causing a blockage of the bile duct, we go in with an endoscope. Through the procedure we go through a wire in the bile duct and inject a dye to see the exact location of. We then open up the bile duct and by using the wire or a basket of fine wire mesh to engage the stone, we drag it out. Most commonly we attach rubber balloons to the wire to drag the stone out. If this is done successfully, then we have at least relieved the obstruction and can allow the patient to rest a while. However, the gall bladder needs to be taken out by surgery and this surgery becomes simpler because the stone has been removed. Because all that the surgeon now has to do is use the key hole or laparoscopic surgery to remove the gall bladder. The patient in most cases can go home the same day. Now if this doesn’t work, the conventional type of surgery is done which is to open up the abdominal region and remove the gall bladder.”

Which implies that the endoscopic treatment may not be always successful? The doctor agrees, “Yes, if there has been some prior abdominal surgery, where a part of the stomach may have been removed. Or, sometimes if the stone is too large that even by splitting open through the wire will not bring it out. Or, in some instances, the patient may not tolerate endoscopy. However, in more than 90% of cases, endoscopy is successfully used to remove the stones.”

Laparoscopic surgery for removal of gall bladder however, is contraindicated in cases where the patient has prior bleeding disorders, is pregnant or if there has been prior abdominal surgery.

The risks from the surgery according to Nasser are no different from laparoscopy for other conditions. There is risk of excessive bleeding, increased risk of infection and injury or damage to surrounding organs.



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