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Anatomy

The gallbladder is a small sack-like, teardrop-shaped organ, about the size of a chicken egg.  It is located on the undersurface of the liver, where it is adherent as though one of its sides was “glued” to the liver.  Both the liver and gallbladder are located in the upper right side of the abdomen, tucked under the right side of the ribcage. (Fig.1) 

Fig. 1

Normal Function

The liver makes about a quart of bile each day.  Most of it flows through the bile duct system, gathering in the Common (main) bile duct, and emptying directly into the small intestine, in a region of the intestine known as the Duodenum. (Fig.2)    A small portion of the total daily bile output flows backwards up the Cystic duct and enters the gallbladder, which is a blind pouch.  In the gallbladder, water is removed from the bile, making it more concentrated.  When a meal is consumed, especially a fatty meal, a hormone is released from the stomach, which circulates through the bloodstream, eventually finds its way to the gallbladder, and stimulates the gallbladder to contract.  This causes an extra amount of concentrated bile to enter the duodenum, usually about a half hour after eating.  However, the gallbladder does not contract after every meal.  Furthermore, the total amount of bile entering the duodenum each day from the gallbladder is small compared to the total output from the liver. 

Fig. 2

Symptoms

An inflamed gallbladder can cause abdominal pain, nausea, a sensation of bloating or gaseous distension, and diarrhea.  Most often the pain is experienced in the upper right side of the abdomen, and feels as though it radiates into the right side of the back.  However, frequently the pain is experienced in the upper midline of the abdomen, or even on the left side, and often it feels as though it is coming from under the breast bone.  When this problem first starts, it is typically provoked by eating.  When the gallbladder contracts after a meal, if it is inflamed it will produce the symptoms outlined above.  As the condition worsens, the gallbladder becomes so inflamed that it starts to produce symptoms with every meal, not just fatty foods.  It can also begin to contract even without being stimulated by a meal.  Further down the road to disease, the gallbladder will hurt all the time, and “attacks” will no longer be experienced.  However, if one focuses on what it was like when it first started, one can usually make the association between eating, and the gallbladder attack.  This is the hallmark of gallbladder trouble.  People with gallbladder trouble frequently learn that if they would just not eat, they would feel fine.  In contrast, people with ulcers and similar problems find that it hurts more when the stomach is empty, and eating provides temporary relief.  Food is a good antacid!  The most common meal to provoke a gallbladder attack is the evening meal.  It is very common for a gallbladder attack to be delayed after the evening meal until after the person has gone to bed.  Such attacks seem to always occur in the early part of the night, before 1 or 2 AM.  It is very unusual for an evening meal to provoke a gallbladder attack at 4 or 5 AM in the morning.

Causes

Gallbladder problems and especially gallstones are inherited.  But it isn’t necessary to have gallstones to have gallbladder attacks.  Even gallbladder sufferers without gallstones come from families with a history of gallbladder trouble.  It certainly is not rare to see someone with gallbladder trouble when no one else in the extended family has ever had gallbladder trouble.  However, most often there is a clear history of inherited trouble.  An inflamed gallbladder will contribute to the formation of gallstones.  And returning the favor, gallstones cause mechanical trauma to the gallbladder wall, which also leads to inflammation of the gallbladder.  The tendency to form gallstones in the first place, though, is a clearly inherited condition.  Bile is composed of many different chemicals.  Bile acids, bile salts, cholesterol, and bilirubin are just a few of the things found in bile.  People who make gallstones have liver cells that are genetically programmed to make bile that has too much of one of the chemicals dissolved in it.  The chemical has a hard time staying dissolved, especially in the gallbladder where water is removed from the bile and it becomes even more concentrated.  When this happens, the chemical in oversupply comes out of solution, forming crystals that grow over time into stones.  Since the gallbladder never fully empties itself, by chance some of these crystals stay there for a long time, and grow into stones.  Once they reach 3 or 4 mm in size, they are too large to fit through the gallbladder duct (Cystic duct), and they are now trapped inside, to grow even larger over time.  If the gallbladder contracts in response to a meal, and one of the stones gets stuck in the neck of the gallbladder, then the continuing contraction of the gallbladder produces pressure inside the gallbladder.  This is usually experienced by the person as an intense pain or pressure.  Such an attack can last 15 minutes, to 15 hours.  Occasionally such an attack won’t stop until a patient has surgery to remove the gallbladder!

Tests

There are two ways to prove that a person’s symptoms are coming from the gallbladder.  One of these is to perform a gallbladder ultrasound study.  This is an imaging study.  An ultrasound machine is used to bounce low intensity sound waves off the target tissue and the reflected waves show the shape of things inside.  If the gallbladder is inflamed to the point that the wall of the gallbladder is thickened, or if there is fluid around the gallbladder, this can be seen.  Of course if there are gallstones of at least 1-2 mm in size, they can be seen too.  When a patient has symptoms that are pretty typical of gallbladder trouble, and the ultrasound shows these things, especially gallstones, we usually stop right there.  Treating this as a case of gallbladder attacks will eliminate the symptoms in over 99.9% of the cases.  Only rarely will we find the pain was really being caused by something else.

Many people have gallbladder symptoms for years before their gallbladder ever changes to the point that it looks abnormal on an ultrasound.  For these patients, we test the function of the gallbladder with a radioisotope gallbladder scan.  In this test, the patient receives an intravenous injection of a radioisotope.  The total amount of radiation administered is less than that received from a chest x-ray.  This circulates in the blood, and is removed by the liver.  It is then excreted in the bile, flows down the Common bile duct into the intestine, and all of it ends up in the toilet in a day or two.  Some of it should also enter the gallbladder.  Using a gamma camera, this radioactivity can be seen.  The flow of the bile is observed, and counts are taken to quantify the amount in the gallbladder.  Then the patient is given an intravenous injection of the same natural hormone that the stomach releases.  The gallbladder should contract in response to this.  Counts are then taken again to see how much the gallbladder emptied itself.  Anything less than about 35–40% is considered abnormal.  More importantly, if a good contraction is obtained, and if during the contraction the patient’s symptoms are reproduced, then it is absolutely proven that the symptoms are coming from the gallbladder.  Most often the patients will say that they felt the same type of pain, in the same location, although it was milder than usual.  Occasionally the pain will be more intense than usual. 

Treatment

Generally, the best thing to do with this situation is to remove the gallbladder.  The gallbladder is a completely superfluous organ and digestion is not changed a bit by its removal.  The genetic makeup of the liver cells cannot be changed, but you certainly will not make stones if your gallbladder is gone, and all of the bile made each day enters the intestine and exits the body in a day or two.  Even if the attacks are mild, there are risks to keeping a gallbladder that is inflamed.  There are a few lucky people whose gallbladders will quiet down and be symptom free for years, but I wouldn’t count on it.  Even a gallbladder without stones can become infected and produce a serious illness.  When there are stones, the risks are much greater.  In some people, passing gallstones can obstruct the Common bile duct producing jaundice, liver injury, terrible bile duct infections, perforation of the gallbladder, and even death.  There is also the problem that the pancreatic duct joins the bile duct just as the two of them enter the duodenum. (Fig.3)  Depending on just how the connection is formed, passing a gallstone can provoke an attack of pancreatitis.  This is seldom trivial, and on occasion can be devastating, with renal failure, respiratory failure, and death, in spite of the very best of ICU care.  It is perhaps best to do something about gallbladder trouble and not just put up with it, waiting for “the big one” to occur.

Fig. 3

Twenty years ago, I began doing gallbladder surgery using a technique I developed which was a version of something called mini-laparotomy.  In this case, the gallbladder is removed through a two inch incision in the upper abdominal midline.  It worked very well.  Then in about 1988, I brought laparoscopic gallbladder surgery to Idaho.  At the time, everyone thought this was nonsense, but I have done two thousand cases myself since then, and it is now the gold standard for the treatment of gallbladder disease.  Using a scope, and four small puncture wounds, the surgery can be performed and the gallbladder removed, without actually opening the abdomen.  Patients go home the same day and are able to care for themselves the next day.  Most patients return to work in a week.  I place no restrictions on activity after laparoscopic gallbladder surgery. 

Lithotripsy

This word is a mouthful!  It refers to the use of high-powered ultrasound to create shock waves that can break apart gallstones.  Getting the stones to break into pieces small enough to pass is not easy but it can be done.  Waiting for all the pieces to pass can take forever.  There is a way to dissolve gallstones, using a drug called Actigal.  It doesn’t work for all gallstones but it does work for some types.  When the stones are large, it can take two years or more to get them to dissolve completely.  However, combining these two techniques has given some impressive results.  First the stones are crushed with lithotripsy until the fragments are 3 – 4 mm in size.  Then the patients are placed on Actigal and followed with serial diagnostic ultrasound (low power).  About 50 % of the patients are stone-fragment-free in 6 months, and 85% in 12 months.  Complications are minor and not very frequent.  There is a risk of pancreatitis which occurs in about 1% of cases from passing a stone fragment.  However, in the clinical trials that were performed, there were no deaths from pancreatitis, and the FDA has now approved lithotripsy for general use in the population.  I offer lithotripsy for those patients who absolutely will not consider having surgery.  However, one should remember that as long as the gallbladder remains, gallstones will certainly form again given enough time.  Lithotripsy is only available for patients with at most two gallstones, and the stones must be between 4mm and 20mm in size.

Risks

When nothing at all is done about gallbladder trouble, there is the risk of complications and death from liver injury, infection, pancreatitis, etc.  Treating patients for this with surgery of any kind also carries the same risks, although when large populations of people are studied, by far the most harm results from doing nothing.  Of course, removal of the gallbladder is a permanent solution to this problem.  Lithotripsy avoids many of the risks of surgery, but it does have some risks of its own.  Furthermore, given sufficient time, as long as the gallbladder remains, gallstones will certainly form again.  However, there is nothing preventing a patient from having it done more than once! 

      © 2002 F. J. Fazzio, Jr. MD.

Board Certified Surgeon
Diplomate of the American Board of Surgery

I've spent over 25 years studying and perfecting ways to turn big operations into small operations
 

Minimally Invasive Treatments For

Acid Reflux, Hernia, Varicose Veins, Hemorrhoids, Gallstones

Endoscopy, Laser, Radiofrequency, Ultrasound, Lithotripsy, Laparoscopy
 

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