The gallbladder is a small pear shaped organ that lies in the upper right part of the abdomen just underneath the liver and close to the diaphragm and rib cage. It acts as a reservoir for bile which is a digestive juice made by the liver and excreted down the bile duct which is a narrow tube coming out of the liver.
The gallbladder is connected to the bile duct by a tube called the cystic duct. Bile enters and leaves the gallbladder via this connecting tube. The bile duct runs down to the bowel where it enters the duodenum. The valve where the bile duct meets the duodenum is called the ampulla (ampulla of Vater) it is also known as the sphincter of Oddi.
When you have a meal the sight and smell of food causes a complex chain of events to start which control release of bile into the duodenum from the gallbladder and bile duct via the ampulla. Food, particularly fatty food, entering the gut is a further strong stimulus for release of bile, which continues to be released until food and digestive juices reach the next part of the bowel.
If you do not have a gallbladder (e.g. following surgery) it makes very little difference to this process since bile is stored in the bile duct instead of the gallbladder. A normal gallbladder holds only around 25-40ml of bile. An average person makes 500-800ml of bile per day.
Gallstones are extremely common, as many as twenty per cent of the UK population may get them during their life time. Most people with gallstones get no symptoms and need no treatment.
Gallstones are usually made from cholesterol or bile pigments, both of which are normal constituents of bile. They may develop for several reasons, either because of an excess of one or other constituent in the bile or because the gallbladder is not emptying properly thus allowing sediment to form or because there are abnormal proteins in the bile triggering precipitation of cholesterol or pigment stones.
Most stones are just a few millimetres across although occasionally they may reach 4-5cm
When gallstones start to cause problems they usually give some of the following symptoms:
Pain, this is usually felt under the ribs on the right hand side of the abdomen (tummy), it may be felt across the whole of the upper abdomen in some patients.
It may last minutes or hours. It can be very severe, it is usually a sharp, cramping or aching pain that cannot easily be relieved except by strong medication. Women often compare it to labour pains. It is often called biliary colic by doctors . The pain may travel into the back or shoulder. It is usually worse after eating fatty foods.
Bloating / indigestion , uncomfortable distension of the abdomen after fatty meals Jaundice, yellow pigmentation of the skin and eyes, often accompanied by very dark urine and pale bowel motions. This is usually caused by passing a stone. Itching / fever / rigors. Patients with stones in the bile duct often get itchy skin, a high temperature and episodes of shaking / tremor (rigors). Anyone with these symptoms should seek urgent medical advice.
Bile Duct Stones , Bile duct stones can cause severe symptoms and trigger some quite dangerous illnesses such as pancreatitis (inflammation of the pancreas) and cholangitis (bile duct infection / inflammation). We always remove bile duct stones (unless they are very tiny), there are several ways of dealing with them.
Laparoscopic Bile Duct Exploration , This is a keyhole technique used to remove stones from inside the bile duct by passing baskets and other instruments into the bile duct and fishing the stones out under X-ray guidance. It is mainly suitable for cases where the bile duct is dilated and there are only a few small or medium sized stones lying in it. It can be a technically very difficult procedure and it is only successful in around 60% of cases. However in experienced hands it is a low risk procedure about as safe as ordinary keyhole gallbladder surgery.
Open Bile Duct Exploration , This is used for cases where the stones in the duct are large, impacted or cannot be removed by other methods. It is an open operation involving a 15-25cm incision in the top right hand side of the abdomen beneath the rib cage to allow access to the bile duct. Most patients stay in hospital for around a week after the surgery and take 8-12 weeks to return to full normal activities. In complicated or recurrent bile duct stones the operation may include a drainage procedure replumbing the bile duct to improve the flow of bile into the bowel and prevent stones reforming. This is major surgery and carries an increased risk of postoperative complications when compared with keyhole surgery, however it is extremely effective.
ERCP and sphincterotomy, this is an endoscopic technique where a flexible telescope is passed via the mouth into the duodenum and used to extract stones from the lower end of the bile duct by cutting open the muscular valve (sphincterotomy) at the ampulla (see diagram of anatomy above) and passing baskets and balloons up the duct from below. It is a relatively safe procedure but it still has risks including pancreatitis, haemorrhage, duodenal perforation and cholangitis. The mortality for this procedure is generally quoted as being between 1:250 and 1:500 across the UK..
PTC , this involves passing needles and tubes through the wall of the abdomen to gain access to the bile ducts in the liver. It is rarely used for retrieving gallstones, usually in patients not fit for surgery in whom ERCP has failed.
Common Questions After Surgery
How Long Do I Need Off Work?
For keyhole surgery you will need a couple of weeks off unless your job is a very heavy manual job (e.g. labourer / hod carrier / nurse / farmer) when you are better advised to take 3-4 weeks off in total. If you have open surgery then for an office job you will need around four to six weeks off work and for a heavy manual job 2-3 months.
When Can I Drive?
For any operation the key question is can you safely control the car and do an emergency stop? For keyhole surgery most people are comfortable enough to achieve this 7-10 days after surgery. For open surgery it is more like 4-6 weeks.
When Can I Play Sport Again?
The same answer applies as for return to work, relatively gentle sports (swimming / jogging) can be resumed a fortnight after keyhole surgery if you feel comfortable, but very physical or contact sports (e.g. circuit training / weight training / rugby / martial arts) should be left for a month or so. After open surgery gentle sporting activity can be resumed after 4-6 weeks and more strenuous physical exertion after 8-12 weeks.
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