Hi, this is Dr. Buck Parker, General Surgeon, and in this post I’m going to talk about the gallbladder.  Many people ask: “What is a gallbladder and why is it causing me problems!?”  Alright, here’s the deal….

I like starting with a nice mental image that will explain a few things first before we get into the problems with the gallbladder.  The liver makes bile.  Bile helps digests fats in our food.  The liver continuously makes bile, which then travels down the bile ducts (or bile tubes) from the liver to the first part of the small bowel.  There is a little valve at the junction of the end of the bile tube and the small bowel.  That valve is usually closed, so the bile that is continuously being made by the liver, will hit that closed valve and back up into the gallbladder. This is because the gallbladder is connected to the bile ducts between the liver and the small bowel.  The gallbladder then stores and concentrates the bile for when it’s needed.  When we eat something fatty, hormones stimulate the gallbladder to contract (it’s like a little muscular bag), and the valve at the end of the bile duct to open.  The concentrated bile is then squirted into the small bowel, where it meets the fat in our food and helps us digest the fat.

Here’s a nice little video of that anatomy and “Acute Cholecystitis” which I will explain later.

So, if there are certain imbalances in the bile, the bile in the gallbladder will form stones.  These stones can be fairly small, or as big as the entire gallbladder.  Sometimes these stones get ejected out of the gallbladder with the bile.  If the stones are smaller than the bile ducts, the stones go right through into the small bowel and you’ll never know they were there.  If the stones are the same size or even larger than the bile ducts, then you can experience pain from the stone being stuck in the tubes.  The gallbladder will try to force the  stone down the bile duct.  When a stone is being forced through the duct, and finally ends up in the small bowel, a person will experience “waves” of pain, every time the gallbladder contracts.  The gallbladder contracts to squeeze the bile and push the stone, and you will experience pain on the right side just under the bottom of your ribs. When the gallbladder relaxes, you’ll feel relief.  This can go on until the stone is passed into the small bowel, and then the pain will be gone.  People often interpret this pain as “gas pain”.  Since it goes away, often times people don’t seek medical attention.  This whole scenario is what we call “Biliary Colic”.

If the stone should get stuck in the bile tubes and cannot be passed, the gallbladder can become infected.  This is called “Acute Cholecystitis”.  If the gallbladder becomes “inflamed” from biliary colic, then heals, then inflamed, then heals, this situation is often termed “Chronic Cholecystitis”.

Alright, that’s your medical lesson for the day:).

So, how the heck are we gonna know something’s wrong with the gallbladder?

First,  there are a few tests we can use to diagnose this problem besides just a history of the problem and a physical examination.  First are blood tests.  We often look at the white blood cell count (or infection fighting cell count).  An elevation of these are  a sign of inflammation or infection.  Next are the “liver function tests”. These include the “bile numbers” (Bilirubins).  If these are elevated this could mean the bile duct is blocked and there is a build-up of bile going on.  Lastly is the “Alkaline Phosphatase”.  This is released from the gallbladder cells and the bile duct cells, and can be an indication that the bile duct or the gallbladder cells are being injured.

Pictures of your organs are a great way to find out what’s going on too.  The ultrasound is the best imaging test for the gallbladder.  This can often see if there is a thickened gallbladder wall, fluid build up around the gallbladder, and the diameter of the main bile tube.  All of these can help give doctors a picture of what exactly is going on in your situation.  Although not the best imaging test for the gallbladder, sometimes a CT scan can clearly demonstrate a gallbladder problem, other times, a CT scan will not see the gallbladder problem, but the ultrasound will.  This is why you may experience both imaging examinations in certain situations.

Ok, so I’m sure your wondering what exactly we are going to do with this bad little behaving gallbladder. Here’s the deal….

If you are experiencing “biliary colic”, this means your body is making stones in the gallbladder.  In the U.S., these are most often cholesterol stones.  So, in theory, if your cholesterol is managed, the stones should go away….right?  Unfortunately this is often not the case, as some people have a “normal cholesterol blood test” and gallstones.  Many doctors used to offer “lithotripsy”.  (Breaking up the stones with ultrasound waves.)  The problem with this is, if your body is making stones, it’s going to make more.  So, you could prolong removal of the gallbladder with the lithotripsy, but ultimately, if you are having problems with your gallbladder, you are going to need your it removed.  As you are probably now aware, the treatment for this problem, is surgery.

Removal of the gallbladder can be done in a couple different ways.  There is the “open cholecystectomy” or the “Laparoscopic Cholecystectomy”.

Time for a quick Latin lesson….I know, you’ve been dying for a Latin lesson.

“chole” means “bile” in Latin

“cyst” means “sac” in Latin

“ectomy” means “removal” in Latin

cholecystectomy = bile-sac-removal

You are now fluent in two languages (providing you can read this article).

In the open procedure (the old-fashioned way), the surgeon makes an incision just below the bottom of your ribcage on the right side, then removes the gallbladder.  In the “Laparoscopic Cholecystectomy”, the surgeon makes 4 small incisions.  One incision close to or in the navel, one just below your sternum, and two just below the bottom of the rib cage on the right side.  A small camera is placed in the navel incision and small surgical instruments are placed in the other incisions and the gallbladder can be removed this way.  The Laparoscopic Cholecystectomy offers a faster recovery and less pain in the immediate post-operative period.

I’d like to talk about the risks of having your gallbladder removed, because of course anytime we do a procedure or surgery in medicine, there is a certain amount of risk involved.  Fortunately, both the open and Laparoscopic Cholecystectomy are very common operations in the U.S. and enjoyed a fairly low complication rate.  The major risks involved when having your gallbladder removed are bleeding, infection, injury to the major bile ducts and bowel injury.

Let’s talk about each a little more in depth. Bleeding can range from self limiting (it stops on it’s own), to requiring a blood transfusion, to requiring a second operation to stop the bleeding.

The gallbladder is removed sometimes when it’s infected and sometimes when it’s not infected (Biliary Colic). If you have an infected gallbladder, that will put you at a little higher risk for developing an infection than if your gallbladder is not infected during the surgery.  The treatment for the infection can range from simple antibiotic use, to an opening of the incisions, to a image guided (ultrasound or CT scan for example) drainage of the infection, and even to additional surgery to remove the infection.

The third specific risk to this operation is injury to the main bile ducts.  Although the doctor books make the anatomy seem fairly simple to see the different between the gallbladder duct and the main bile duct, it’s not so simple in real life.  Most of the time these are easily differentiated, but in some people the relationship between these two are different, or either chronic or acute infection makes for a very different location than expected.

For this reason, the main bile duct can be injured and research tells us that it happens in about 0.5% of patients.  If this happens, you will require the “old fashioned” open incision to fix this injury.  If it’s recognized during the operation, it will be fixed during that operation, but if it’s not recognized until after the operation, you will require an additional operation.  Injury to the main bile duct occurs in approximately 0.1-1.0% of patients in the U.S.

Anytime you have an incision in the abdomen, there is a chance to develop a hernia sometime down the road. If you are unfamiliar with hernias, please see my posts on hernias for more information.  Although Laparoscopic surgery provides for a lower hernia rate, it does not eliminate it all together.  There are many different factors that go into developing a hernia.  Some are doctor related (improper placement of a suture) and some are patient related (obesity, poor nutrition, smoking and early rigorous physical activity).  So obviously some people are more prone to hernias than others, but if you follow my post-operative instructions, you will minimize your risk for a hernia down the road.

Lastly, is injury to the bowels.  During the surgery the bowels are positioned out of the way of our instruments, but since we are handling them, they also have a small change of being injured.  If this happens and it’s recognized right away,  most of the time they can be fixed even through the small Laparoscopic incisions.  If the bowel injury is not recognized until after the operation, you will require an additional operation to fix the bowels.  Sometimes this can be Laparoscopic, and sometimes this needs to be done with the “open” technique and larger incision.

You may think to yourself “Wow, 0.5%, why is Dr. Parker bothering telling me about this?”.  Well, as one of the Cardiothoracic Surgeons in Detroit used to tell me, “The specific risk to an operation may be very low, but when it happens to you, it’s 100%…..remember that Parker”.  I remembered that, because it’s very true.  Every operation I do, I am constantly looking out to avoid complications, but they still happen, it’s just the nature of surgery.  It’s kind of like playing football…..you can be REALLY good and REALLY fast…but sooner or later, you’re going to get tackled.

After the operation some people can go home the same day, and others may need to stay in the hospital.  This will all depend on what type of gallbladder problem you have.  If it is a “biliary colic” problem, this can be an outpatient surgery  (have surgery in the morning, go home in the afternoon).  If it’s “Acute Cholecystitis” where your gallbladder is infected and you come in because you can’t take the pain anymore, you will need to stay at least one night in the hospital, and some people may need to stay more.  Acute Cholecystitis can range from very mild to life threatening, so obviously your hospital stay is dependent on your certain situation, but for the most part people stay in the hospital on average from 24-48 hours after surgery for “Acute Cholecystitis”.

If you have the Laparoscopic Cholecystectomy, you will have plastic water-tight bandages over your incisions (well….that’s if you have me do your operation) so you can take a shower the same day of the operation.  You should leave those on for 72 hours.  After  72 hours, you may remove the plastic bandage and underlying gauze. There are still little tape strips (Steri-trips) over the incisions.  Leave those Steri-strips on the incisions for a total of 7 days after the operation.  You may wash with soap and water over the Ster-strips in the shower.  Just be sure to dry them off well after your shower.  Do not bathe or go into a pool for about 2 weeks after your surgery, as this can make the incisions prone to infection.   If the Ster-strips have not fallen off after 7 days themselves, you may remove them.

As far as your activity goes after the surgery, I ask that you do not lift much more than about 15lbs for 6 weeks after the surgery.  This will give the incisions enough time to heal so that the risk of a post-operative hernia down the road is minimized.  After 6 weeks, the incisions are about 60% strength of the original tissue, so even though you will forget you had an operation at that time, the incisions are not full strength.  Even after 1 year, the strength of the tissue is still not 100%, but as long as you are aware of this, it shouldn’t be a problem.

I hope you now have much more information regarding your gallbladder diagnosis and you are now able to make an informed decision about your surgery.

Talk to you next time.

 

-Dr. Buck

P.S. Please leave comments or questions for me below.  Thanks!

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