Stones in the gall

As medical students, we were taught that gall stones or gall bladder stones typically occurred in "fat, flabby, fertile females" over the age of 40. Many of us thought this was a chauvinistic generalisation in a profession dominated by male surgeons. But later, we realized that the dictum was true to some extent. About 20 per cent of women and 10 per cent of men over the age of 60 develop gallstones. Removal of the gall bladder -or cholecystectomy -is the commonest laparoscopic surgery performed worldwide.

Gallstones are found in a seven to eight centimeter long pear-shaped organ called the gall bladder, which is situated under the liver on the right side of the abdomen. It contains bile, an aid to digestion, secreted by the liver. It contracts and discharges the bile into the intestines periodically after food is eaten.

Stones are formed if the bile contains too much cholesterol (90 per cent of gallstones are cholesterol stones) or pigment (from the breakdown of red blood cells), or if the gall bladder does not empty properly.

The propensity to form stones may be genetic. Women are more likely to develop stones because of the effect of the female hormones on the com position of bile and the gall bladder. Women who take estrogen in the form of oral contraceptive pills or hormone replacement therapy are at higher risk. Stones are also more likely with obesity , frequent fasting, rapid weight loss (crash diets), lack of physical activity, diabetes, diseases associated with increased haemolysis (breaking open of red blood cells and release of contents into the plasma, such as in sickle cell disease), alcohol abuse and certain medications.
 

Most of these of risk factors are preventable as they are the result of an unhealthy lifestyle.

Although gallstones are believed to cause "biliary colic", in reality about 80 per cent of them are asymptomatic and remain so during the patient's lifetime. Pain, when it does develop, is not colicky or intermittent. It is a sudden severe pain which usually develops in the night.
It starts in the midline or slightly to the right side and radiates to the right shoulder or shoulder blade. It usually subsides within three or four hours. Non specific symptoms like bloating, belching, nausea, vomiting and upper abdominal pain are also often attributed to gallstones.

Small stones are more likely to cause complications than large ones. This is because they can move about in the liquid bile. They may irritate the wall of the gall bladder, causing it to become inflamed and infected. This can cause high fever with chills.
 

The stone can become dislodged from the gall bladder and get impacted in the bile or pancreatic ducts. This can cause jaundice, in addition to pain and fever.

An ultrasound of the abdomen can usually detect gallstones. Normally, this is the only test needed for diagnosis. Further evaluation with computed tomographic and magnetic resonance imaging can provide a three-dimensional image of the gall bladder and stones. Endoscopic procedures can detect stones in the duct and remove them at the same time. Blood tests are non-specific and usually only show elevated liver enzymes.

All gallstones do not require treatment. If the gallstones are discovered by chance during an ultrasound, and the patient is healthy and an asymptomatic adult, regular follow up is all that is needed. The same holds true of patients with diabetes. Although they are more prone to developing gallstones, the incidence of complications in them is no different from that in others.

Patients who have had attacks of pain, fever or jaundice require treatment and eventually surgery. The bacterium responsible for typhoid (Salmonellatyphi) is able to survive in the gall bladder despite antibiotic treatment. These individuals experience relapses of typhoid. They also excrete the bacteria in their stool, creating a reservoir of infection.
Such people need to undergo cholecystectomy .

The surgery is usually surgery is usually performed by laparoscopy. The muscles are not cut and only holes are punched in the abdomen. The patient needs to spend only two or three days in the hospital. Recovery is rapid and re turn to normal activities is possible within a week.

The idea of surgical intervention is scary to many, and they desperately look for alternatives. A chemical called ursodeoxycholic acid can be used. It is available as capsules and syrups. All the systems of medicine (includingallopathy) use this com pound and its derivatives to dissolve gallstones. The dosage required is high (8-10mg/kg).

 

People often do not take the medicine in adequate do sage as it can cause diarrhoea. Normally, only 30 per cent of the stones (if of the stones (if they're less than 5mm in size and without calcium deposits) respond to medication, and that too only after about two months. The treatment may take three to four years to show results. Even then, after five years, the stones reform in 50 per cent of the people. This is, therefore, not a viable option and eventually surgery is inevitable.

  

Dr Gita Mathai is a paediatrician with a family practice at Vellore.

Questions on health issues may be 

emailed to her at yourhealthgm@yahoo.co.in