The Gall to Have Your Gallbladder Attack You!

Gallbladder disease: This isn’t your parents’ Rolling Stones!

Whether you’re like me or not, the Rolling Stones are iconic, and everyone knows at least one tune they’ve done. The one that reminds me most of patients’ and doctors’ struggles with gallbladder disease is “ (I Can’t Get No) Satisfaction”. Because even in clear cut cases where stones are found in the gallbladder, there is uncertainty and frustration what to do, when to do it, and how to do it.  You’ll get my observations and advice on how to deal with gallbladder issues in several contexts.  But first, a little about the gallbladder and what it does.

The gall bladder is the small flask shaped sac nestled in the liver, under the right diaphragm and your ribcage. It is a reservoir for bile, produced in the liver, ready to release it when needed to help in digestion and absorption of fats and fat-soluble vitamins, neutralization of stomach acids entering the intestine, and as a chemical antibiotic, eliminating many bacteria that can contaminate food. This last function can be a negative in helping repopulate a colon with probiotics, which is why the ones you take should be bile and acid resistant…. they have a bumpy ride down to their ‘home’ in the colon. But I digress.

Bile is mostly water, 10% bile salts and about 1% fat, mostly cholesterol. Bile salts have a dual personality: One end is water friendly, the other fat friendly, so like a detergent they disperse fats in the intestine into droplets, preparing them for further digestion and absorption in the intestinal lining. Continuing the detergent metaphor, the gallbladder is a ready holding tank just like the one in your washing machine, ready to release bile on command when it receives the ‘fire’ signal as you eat fat containing food. Here’s where problems can occur.

In an unlucky few, roughly 5-10% of Americans, bile clumps up, forming stones that may or may not cause problems. That’s right. Not everyone with stones has problems, and strangely, it doesn’t take stones to have a bad gallbladder either. So as the song says, there’s little satisfaction when there’s controversy about what to do in different situations. What are some of the no-brainer decisions?

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First, if the stones block the outlet duct to the intestine, gallbladder contractions can be strong and painful, lasting hours, until the stone moves out of the way or is passed.

This is the classic scenario:

• Every so often, the patient has intense pain under the ribcage, often with nausea and vomiting, sometimes with back and right shoulder blade pain.
• Typically it’s with fatty meals predominantly.
• In between attacks there may be no pain, or just an ache.

In these settings, an ultrasound shows stones, or sludge (nothing than an amalgam of microtones that appear like thick syrup) in the gallbladder. Many stones are picked up incidentally, when a CT scan is done for other reasons, and the patient has been getting along without any problems. In fact, most people with stones will not develop symptoms over long periods of time. Even better, among stone carriers with symptoms, over half will be asymptomatic 9 years later if simply left alone, according to good research.

Treatment?

For some, a pattern of progressive and frequent attacks, or even infrequent but severe ones, is good reason to have the organ removed. For others, an attack gets worse, doesn’t clear in a few hours, and fever develops. This signifies a complication called acute cholecystitis, and often ends in surgery right away, or delayed enough to cool down the infection with antibiotics. On other occasions, and depending on if the stones reroute bile to the pancreas (it shares the duct leading to the intestine with the gallbladder), a rapidly painful pit of the stomach, fever, nausea and vomiting raise concern over pancreatitis.

These non-garden variety manifestations of gallstones need aggressive acute care and can be fatal if left unattended, particularly in patients with other chronic problems like diabetes or pre-existing liver or kidney disease. Perhaps the most feared, though frankly rare, complication of gallstones is gallbladder cancer. This is a particualarly nasty one that is usually discovered late and has a poor prognosis.

For bothersome stones, the choice is almost always cholecystectomy, or gallbladder removal. These days, 90% are done with minimally invasive scopes, though if there is acute infection, lots of scarring from old or chronic disease, or a complication like bleeding happens during the procedure, the old fashioned open procedure is absolutely legitimate and on target. Post op, most people go home the same or next day, and overall there is about a 3% rate of complications like bile leak, bile duct injury, infection or bleeding. Are there ways to dissolve stones without operating? The answer is sometimes but why?

Over 3 decades ago, researchers found a way to dissolve stones-which are cholesterol plus or minus some pigments-by giving oral bile acids over long times. Success is slow, only about a millimeter diameter a month, so for small stones in patients who are high surgical risks or simply don’t want surgery, it’s a choice but not my first one. Why? Ursadiol, or ursodeoxycholic acid (UDCA) is the 2nd generation pill used today, and is most effective in pure cholesterol stones. The rub is that most gallstones either have some bile acids mixed in or have a rim of calcification, like an egg, or more. Good luck there.The best studies suggest that the 90% of small, cholesterol-only stones (CT can help determine composition) will dissolve within 2-3 years, but overall most patients should expect a less than 50/50 chance of success, given the diversity and size range of actual scenarios. That said, UDCA does seem to reduce the likelihood of symptoms-1/3 fewer in patients with infrequent, mild attacks, and 1/2 in those with stones but no symptoms. Some limited information suggests that a weak stone dissolver, Rowachol, that is available from natural health suppliers, may increase success rates when added to UDCA, but as a stand-alone…good luck!

You don’t want to incur the risks of surgery then still have the pain!

For those folks who have intermittent upper belly pains, or right upper quadrant pains that seem like gallbladder but without imaging evidence of gallstones, the game gets tougher. This is where experience, some high tech testing and a bit of luck are needed. Some folks have normal looking but dysfunctional gallbladders, and they can experience symptoms mimicking gallstone-generated problems. It’s reasonable to have an upper GI endoscopy if heartburn is a problem, and some will just try acid-secretion inhibitors like omeprazole (Prilosec) or lansoprazole (Prevacid) to see if the attacks diminish or disappear. Ultimately, though, a study of gallbladder emptying may be the ticket. Giving a radiolabeled tracer that is secreted in bile and emits energy captured by a large camera does it. You’ll lie under the camera with a full gallbladder to measure volume, then after stimulating it to empty, a comparison shot is taken. If less than 40% emptying is seen, the gallbladder is not emptying enough, and many surgeons would say this ‘functional gallbladder disease’ is grounds for removal. Of course, strong efforts to eliminate other sources should be undertaken before proceeding. You don’t want to incur the risks of surgery then still have the pain!

Avoiding Gallbladder Disease

At the end of the day, you now see that avoiding gallbladder disease by modifying the things you can BEFORE you get it is the best idea. That’s always a good plan, regardless of the malady. Of course, the nature-nurture dyad is always at play in human illness, and there are risks,-like a family history of stones, or being a woman, or being older than 60, or a Mexican-American or American Indian-that you can’t modify.

Here’s a table of some lifestyle changes you might want to make to reduce your risk of gallstones, particularly if you are have one or more of the unavoidable risk factors.

So you see why “I Can’t Get No Satisfaction” applies to patients and doctors when it comes to gallbladder disease.

The diagnosis is not always crystal clear, especially when no stones are found but symptoms are typical, and lowering your risk of stones means towing the line. No funnel cakes at the county fair? Yes, that’s true. And watch out for low carb crash diets high in fats, and often allowing high cholesterol foods, you’ll lose weight quickly but may precipitate a gallstone problem.

Summary

If you’re having upper abdominal pain of any kind that persists, especially if you have risk factors for gallstone disease, see your doctor and find out what’s wrong. You’ll be feeling better in no time and can get on with work, family and play without troubles.[/private]