Gallstones

As a specialist in keyhole gallbladder surgery, Mr Hopkins follows latest national and international guidelines (click here to find out more) in the investigation and management of patients with gallstones, utilising the most up-to-date surgical techniques, including laparoscopic common bile duct exploration and intra-operative ultrasound or cholangiogram scans.

What is the gallbladder?

‍The gallbladder is a small organ on the underside of the liver. It stores and then releases bile, a liquid to aid digestion, into the intestine after eating in order to aid the digestion of fat. Only about 20% of the total body’s bile is ever stored in the gallbladder, which is why the body can adapt to it being removed.

What are gallstones?

‍Gallstones develop when there is an imbalance in the make-up of the bile within the gallbladder, leading to tiny crystals which, over time, can grow into solid stones (pea size), sometimes very large stones like a pebble. They are usually made of cholesterol or bile pigments.

What symptoms do gallstones cause?

‍Most patients with gallstones will not have any symptoms. The most common symptom is abdominal pain called biliary colic. This is typically sudden, crampy abdominal pain that usually lasts 1 to 5 hours, although it can sometimes last just a few minutes. The pain can be felt in the centre of your abdomen or just under the ribs on your right-hand side—it may spread from here to your back or shoulder blade. It's sometimes triggered by eating certain foods, but may happen at any time of day and may wake you up during the night. Biliary colic is intermittent; after an episode of pain, it may be days, weeks, or months before you have another episode.

When gallstones cause episodes of biliary colic, it's known as uncomplicated gallstone disease. Other symptoms, that might be a more serious problem of gallstones, and could require emergency treatment, are in the problems of gallstones below.

How are gallstones diagnosed?

‍Mr Hopkins will listen to your symptoms carefully in the clinic, as the relevant symptoms really guide the diagnosis, as gallstones are commonly found on a scan. Gallstones are usually confirmed using an ultrasound scan, which is similar to the gel scan used during pregnancy. Sound waves are sent from the scanner, through your skin and into your body. They bounce back off the body tissues, forming an image on a monitor, which is painless and usually takes about 10 to 15 minutes to complete. If you have not had a scan previously, or it is felt you need a confirmatory scan by a specialist radiologist, Mr Hopkins will arrange an ultrasound scan from the clinic.

Gallstones in the bile duct are sometimes seen during a specialist ultrasound scan, but if not visible, but your blood tests suggest the bile duct may be affected, you may need an MRI scan. An MRI scan is usually carried out to look for gallstones in the bile ducts; occasionally it is performed to further look for gallstones not seen on an ultrasound scan. This type of scan uses strong magnetic fields and a narrow whole-body scanner, and radio waves to produce detailed images of the inside of the body.

A CT scan, or ERCP procedure, are usually carried out as an emergency to look for complications of gallstones, such as acute pancreatitis, or treat a stone obstruction. If you have had this type of scan or procedure in an urgent care hospital and are now coming to Mr Hopkins to seek an interval cholecystectomy, you should arrange for copies of these tests to be transferred for Mr Hopkins to review. Please talk to Kirsty when arranging your appointment.

What problems can gallstones cause?

‍There are uncomplicated gallstones and 4 surgical conditions relating to gallstone problems:

• Biliary colic: Gallstone moving around in the gallbladder can become temporarily stuck in the narrower parts, resulting in the gallbladder squeezing repeatedly to clear the blockage. The stone eventually moves back inside the gallbladder, clearing the block, and no long-term consequence occurs. Hence the description as uncomplicated.
• Cholecystitis: If the temporary gallstone blockage fails to clear, then inflammation, or even infection, can develop inside the gallbladder or its wall. Some patients can develop cholecystitis from other non-gallstone medical problems, which don’t usually need surgery. The inflammation will likely persist, even if infection is treated with antibiotics. Sometimes the infection can become severe, causing an abscess or even sepsis.
• Jaundice – Common bile duct blockage: If a small stone is cleared out of the gallbladder into the main bile duct between the liver and intestine (common bile duct), it can become stuck causing a blockage of bile, leading to jaundice. This needs to be treated, usually as an emergency, to remove the blockage.
• Pancreatitis – pancreatic duct blockage: If a small stone escapes from the gallbladder into the main bile duct, it can move down to where the pancreatic duct joins and temporarily block this duct to the gland. The pancreas gland, which usually produces enzymes to help break down food, can develop inflammation when a gallstone blocks the pancreatic duct—leading to damage of this gland, or even whole body inflammation. Some patients can develop pancreatitis from other causes, which doesn’t usually need gallbladder surgery, but if gallstones are found, usually a cholecystectomy is recommended urgently after initial recovery.
• Gallstone Ileus: This is a much rarer condition in which a large gallstone erodes through the wall of the gallbladder into the small intestine directly, and can subsequently cause a blockage of the bowel at a narrower downstream point, requiring emergency surgery.

Other conditions of the gallbladder

‍Cancers are very rare and it is important, if there is any worry about this, that you see your GP, or hospital doctors, for a referral to a specialist hepato-biliary service under a ‘2-week wait referral’, as this requires different and specialist treatment that I do not provide.

Gallbladder polyps are small swellings on the wall of the gallbladder, with or without gallstones (if you have stones we would treat you as for a patient with symptomatic stones). If a polyp is less than 10mm, it is usually followed up by further ultrasound scans. However, once this reaches 10mm in size or more, current guidelines are for the gallbladder to be removed due to the small chance for a polyp to change into a cancer. Large Polyps (>30mm) are treated like cancer.

Finally, biliary dyskinesia is an uncommon and hard to diagnose condition where the gallbladder is thought to not empty properly after a meal, resulting in similar pains to those with gallstones. Surgery can lead to an improvement of symptoms in some patients, but not all. If you are worried about this, you should discuss your own preference in detail in the clinic with Mr Hopkins.

What are the treatment options for gallstones?

• Watch and wait: Sometimes gallstones may be discovered during tests for a different condition, and don't cause any symptoms, so don’t need to be removed. Some patients are at higher risk for surgical procedures, so the problems should be more severe to justify surgery. As a general rule, the longer you go without a problem, the less likely it is that your condition will get worse, and will eventually resolve. Patient choice is very important as we all have different views on risks and benefits and you should discuss your own preference in detail in the clinic with Mr Hopkins. Some people may experience symptoms after eating fatty or spicy food. If certain foods trigger symptoms, you may wish to try avoiding them to prevent gallstone symptoms.
• Medication: There are no effective medicines for dissolving gallstones, and some out-dated drugs are only useful in those not fit for surgery with very small cholesterol stones—with a high chance of stones coming back.
• Surgery – Keyhole Cholecystectomy: If you have episodes of biliary colic or mild cholecystitis, treatment depends on how the pain affects your daily activities. If your symptoms are more severe and frequent, surgery to remove the gallbladder is usually recommended. Patients who have had a serious problem related to their gallstones (moderate or severe cholecystitis, obstructive jaundice, or pancreatitis) are highly recommended to have surgery if well enough. Post-ERCP (urgent telescope procedure to remove stones in the common bile duct) cholecystectomy is under research study. Patients with gallbladder stones who are at much higher risk for gallbladder surgery do not need an operation. Patients who could have an operation should fully recover from the emergency event and you should discuss your own preference in detail in the clinic with Mr Hopkins.

What does cholecystectomy surgery involve?
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Before surgery

‍Once we agree to go ahead with surgery, you will need to attend a pre-op assessment clinic, at which a number of routine checks and sometimes blood tests will be performed. You should do everything you can to maintain your health and fitness before an operation; we call this pre-habilitation. Smoking is strongly discouraged as it not only affects your breathing and the risk of anaesthetic problems, but can increase wound healing and infection problems. Improving your heart and lung fitness, with regular exercise, taking all your usual medications, and avoiding the risks of infections immediately before your operation is also advised. Regular vitamin and mineral supplements, especially if your diet can be variable, help make sure your body is ready for the healing after surgery. Some patients may be asked to complete a special liver-reducing diet in the two weeks before surgery.

The Keyhole Cholecystectomy

‍You will meet the anaesthetist beforehand and a full general anaesthetic is used, so you will be asleep during the operation. The abdomen is distended with special gas, and 4 small cuts (of 0.5 to 1.5cm) are made in the abdomen so that a camera (laparoscope) and instruments can be passed through the abdominal wall into the peritoneal cavity. The gallbladder is carefully removed from the main bile duct and then the surface of the liver. Occasionally, if there is a lot of inflammation in the area, a near-total cholecystectomy will be performed, for safety, leaving a 5% cuff of gallbladder behind to help prevent bile duct injury. In a small number of cases (<1%) where it is impossible to proceed, surgery will be abandoned early so that further clinic discussion can happen. You will routinely be issued anti-embolism stockings to wear during the surgery. The procedure normally takes around 45–60 minutes and all the keyholes are closed with dissolvable stitches.

If patients have previously had abnormal liver blood tests or a widening of the main bile duct on scans, a special scan (x-ray cholangiogram or ultrasound) can be performed during the operation to check if any gallstones are in the main bile duct. Sometimes these can be removed from the duct, if it is large enough, at the same time, but if small may be left to pass on their own with a follow-up MRI scan to check for clearance.

After surgery

‍Most patients can be discharged on the same day as the operation (daycase). You would be ready to be discharged around 3–6 hours following surgery if your pain is controlled with tablet painkillers, you can walk and you have eaten and passed urine. 10% of patients may not go home if they do not meet these criteria, or have an operation later in the day, or if you do not have someone to take you home and stay with you overnight. Occasionally an overnight stay is advised by the anaesthetist, or for complex gallbladder surgery you may be required to stay in hospital until I am happy your recovery is progressing.

All stitches are dissolvable. The glue or waterproof dressings used are suitable for the shower after 2 days and can be removed or cleared after 7 days, but you should not soak in a bath for 7 days.

Standard recovery takes 1–2 weeks after keyhole surgery, for driving and office work. Recovery after keyhole surgery for return to full activities including sport, exercise, gardening, or DIY and heavy lifting is up to 4 weeks. You should discuss your work/sporting activities with Mr Hopkins in the clinic.

What happens when I go home?

• Pain: Paracetamol and ibuprofen, with occasional codeine or tramadol, should give adequate pain relief at home. I advise taking some regularly (i.e., 4–6 hourly) for the first 48 hours following surgery, then continued as required. There may be some bruising at the operation site. This is entirely normal and will gradually go down. (If bleeding or swelling increases rapidly, within hours of surgery, you should seek medical attention.)
• Diet: You may eat and drink normally.
• Mobility: This is very important. Try to remain normally active. If you feel tired, you should sit down and put your feet up for short periods, but you should not go to bed during the day. This is to improve circulation in your legs, and reduce the risk of blood clots occurring.

What should I watch out for in the first week following surgery?

• Severe abdominal pain that does not go away with the painkillers prescribed
• Major loss of appetite, or vomiting after the anaesthetic has worn off
• Fever or flu-like symptoms associated with pain or vomiting
• Significant redness/swelling at the surgical site
• Calf pain or increasing breathlessness

If you experience any of these, it is important to seek medical attention as soon as possible, via the emergency department if needed, and it is important to tell everyone that you have had keyhole surgery.

What are the risks of surgery?

‍Gallbladder removal surgery is the most commonly performed keyhole operation and is considered to be a safe procedure, but, like any type of surgery, there are risks of surgery:

Short term

• Shoulder tip pain – This is common after keyhole surgery and is due to gas used to inflate the abdomen during surgery. It normally resolves within 24–48 hours, and is helped by walking around.
• Infection – If occurs, this usually affects the small wounds, with signs of swelling or redness. This can be treated with tablet antibiotics. More rarely, deeper internal infections can occur at the gallbladder site, and if you feel more unwell you should seek out urgent medical care.
• Bleeding – Can occur with any operation if the cautery is dislodged, and occasionally may require a blood transfusion (unless you express a wish not to). Very occasionally it requires another operation to stop the bleeding or remove the blood clot. It is more common in patients taking blood thinning medicines.
• Bile leakage – In 1% of cases, when the gallbladder is removed, bile fluid can leak out into the abdomen after the gallbladder is removed, from the surface of the liver or the gallbladder duct clips. Symptoms are abdominal pain or swelling, vomiting, and a fever. Usually an operation is required to drain the bile and wash out the inside.
• Bile duct stones – Sometimes a stone can move into the main bile duct before or during the operation. They usually pass through into the intestine, but if not will require a further telescope procedure to remove.
• Bile duct injury (or an intestine injury) – This is the serious risk of this operation. This can occur in 1 in 3–400 operations and if not repaired at the time is likely to require further intervention, including major surgery, to repair.
• Chest or breathing problems, cardiovascular problems if you have a history of this, or clots in the legs or lungs (DVT or PE), is a risk of any keyhole operation, and while we do all we can to reduce these risks, they are never zero.

Post-cholecystectomy syndrome

‍Some people experience symptoms similar to those caused by gallstones after surgery, including pain/indigestion, diarrhoea. This is known as post-cholecystectomy syndrome (PCS). It is not always clear what the cause is, but you should be checked for either a bile leak or bile duct stones. If these are not found, in most cases symptoms are mild and short-lived, but occasionally they can persist for many months. If you have persistent symptoms, you should contact Mr Hopkins via clinic or your GP for advice. If there are retained stones you would benefit from a telescope procedure to remove them, alternatively medication to relieve your symptoms will be suggested.