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Gallstones: Take Them Out or Leave Them Be?

Diabetes mellitus presents numerous challenges to patients and physicians constantly battling to stave off its deleterious effects on various organs in the body. While end-organ damage in diabetic patients targets vital organs like the kidney, heart, brain and lungs, a less known organ called the gallbladder likewise deserves attention.
The gallbladder is the organ in the body responsible for storing and concentrating bile. It is located on the under surface of the liver in the right lobe, in the upper right side of the abdomen. Bile is a digestive juice, known in the vernacular as “apdo”, essential for the digestion and absorption of fat-containing foods and vitamins. It is a golden liquid produced in the liver and carried down to the small intestines through small tubes the size of a straw called bile ducts. The bile ducts link the liver to the gallbladder as well through a short tube, the cystic duct. Some bile is stored in the gallbladder and pumped out when fat-containing food reaches the small intestines.

Although the gallbladder at first glance seems unimportant in terms of body functions, a diseased gallbladder may cause a lot of problems. The most common pathology involving the gallbladder is the development of cholelithiasis, more commonly known as gallstones. In fact, this is one of the most common gastrointestinal diseases seen in the Philippines, and gallstone removal is one of the most commonly performed elective surgical procedures in the country.

A gallstone develops when the body’s chemistry gets out of balance. The bile gets too thick in the gallbladder, and crystallizes into “stones”. These can be single or many, and can vary greatly in size. Gallstones generally can be classified into cholesterol stones, pigment stones or mixed.

Cholesterol stones are yellowish in color and are more associated with disorders in fat metabolism and high fat intake. Pigment stones and mixed stones are generally associated with liver dysfunction, hemolytic blood disorders or biliary infection.

It has been taught before that Westerners usually developed cholesterol stones, while Asians tended to have pigment or mixed stones. We have, however, seen in recent years the increasing incidence of cholesterol stones in the Philippines. Many theorize that with the adoption of Western dietary habits, cholesterol stones in Filipinos will be the norm rather than the exception. Whatever the type, size or origin of these stones, they can present with a variety of signs and symptoms.

Fortunately, a lot of people with gallstones (>50%) virtually have no symptoms and majority will require no intervention. Those who do have symptoms may notice gassiness or bloating, pain in the epigastrium (upper mid-abdomen) or the right upper quadrant of the abdomen. The pain may sometimes radiate to the right shoulder, the back or even to the left side in rare cases. Many patients develop pain 15 minutes to 2 hours after eating, with fatty foods being the most notorious triggers. This is explained by the fact that the gallbladder contracts to empty its contents in response to fatty food intake and this triggers entrapment of the stones in the neck or cystic duct causing pain. In more severe or complicated cases, other symptoms may arise including nausea or vomiting, fever, chills, a yellow tint to the whites of the eyes or dark-colored urine may be present. Complications include acute cholecystitis, perforation of the gallbladder or biliary obstruction, a condition which results from stones getting out of the gallbladder and being lodged in the bile ducts. These may become life-threatening if not treated and warrant immediate medical attention.

The most accurate, reliable and cost-effective way to detect gallstones is with an ultrasound exam. Other tests such as a CAT scan may detect gallstones, but are not as sensitive in picking up small stones and not as cost effective. Rarely, gallstones can be seen on an ordinary abdominal X-Ray.

Diabetics must take special interest in gallstones for several reasons. Disorders in metabolism may cause elevations in circulating fatty acids and triglycerides, increasing the risk for development of gallstones. It has likewise been shown that in some diabetics, gallstones causing cholecystitis rapidly progress to more severe forms like empyema (pus in the gallbladder) and even perforation. It is for this reason that in the past, even diabetics who have no symptoms were advised immediate surgery.

Currently, it is universally accepted that asymptomatic individuals with gallstones will require no further intervention beyond sound medical advice like abstaining from fatty foods and observing for symptoms. Such advice includes avoidance of food cooked in oil, food rich in cholesterol and dairy products. Even in diabetics without symptoms, watchful waiting does not increase morbidity and mortality in the long run. It is understood that patients must consult physicians to ascertain the presence or absence of symptoms and must be followed up regularly.

In contrast, those patients with symptomatic stones have a higher risk of future problems so treatment is warranted. The standard treatment is to remove the gallbladder along with the stones in surgery. In patients who’ are too old or sick to undergo surgery, an attempt at dissolving them with medications may be advised. However, the low rate of response and the high incidence of recurrent symptoms must be made clear.

Pulverizing gallstones with ultrasound waves (lithotripsy) has been proposed before as a treatment option. Aside from causing trauma to adjacent organs like the liver, fragments of the gallstones may get out of the gallbladder and make their way down the bile duct. As long as these stones do not get caught in the bile duct, this is not a problem since they may just pass down the intestines. If these stones do get caught in one of the bile ducts, this can cause a very severe infection (cholangitis) or severe inflammation of the pancreas (pancreatitis). Management of these life-threatening complications is much more complex and is better discussed in future articles.

There have been anecdotal reports of successful results with alternative treatment options like apple juice and similar “cleansing” diets. A close scrutiny of these reports however shows that majority of the cases presented are asymptomatic stones which would have been left alone by traditional treatment. Likewise, there is absence of evidence using randomized trials validating these options vis a vis conventional treatment. It is likewise important to emphasize that size of the stone alone is not predictive of response to treatment. Although big stones in theory may easily cause pain, smaller stones may easily escape the gallbladder and obstruct the bile ducts with dire consequences.

Surgical removal of the gallbladder along with the stones has been the standard of care for gallstones. The gallbladder is not a necessary organ and patients are not expected to incur permanent functional impairment after its removal. In the US and in most advanced centers elsewhere, laparoscopic cholecystectomy has become the gold standard. In the Philippines, the laparoscopic approach is slowly but surely replacing the open or conventional cholecystectomy as the procedure of choice.

An open cholecystectomy involves a single incision (6 – 15 inches) just under the rib cage on the right side. It is carried through the skin, fat and muscle layers so that the surgeon can place his hands or several fingers inside the body to remove the gallbladder. It is a time-tested procedure allowing the surgeons direct visualization, manual handling of tissues and may be done under regional anesthesia.

The laparoscopic approach was developed using the basic premise that the removal of a small body organ should not entail the creation of a large incision with associated extensive tissue damage. In laparoscopic surgery, several small incisions (1/4 -‘/z inch) are made through which a telescope connected to a TV camera and small instruments are placed to perform the surgery. The surgeon watches on a TV monitor while performing the procedure. The gallbladder is brought out through the incision below the navel where the scope has been inserted. Both procedures achieve the objective of taking out the gallbladder along with the stones and this fact should be emphasized to dispel conjectures that laparoscopic surgery may lead to inadequate clearance of stones (“baka may maiwan o hindi makuha lahat”).

The laparoscopic approach has been proven to be superior to conventional open cholecytectomy because of less pain, quicker recovery, fewer problems with incisions and better cosmetic appearance. It has even been proven to be safe for pregnant patients if certain precautions are taken. It must be emphasized that both laparoscopic and open cholecystectomy may have complications such as bile duct injury, bleeding, bile spillage, hernia, spillage of stones, missed bile duct stones and complications related to general anesthesia. The past decade has shown that the chances of incurring complications from laparoscopic cholecystectomy is much lower than 1% in the expert hands of properly trained surgeons using proper instrumentation.

For diabetics in whom the constant fear of poor healing dissuades patients from consenting to surgery, the proven advantages of laparoscopic cholecystectomy make it the procedure of choice. We must keep in mind that open cholecystectomy still plays a major role in some cases. In fact, in around 5% of cases, a procedure started laparoscopically is converted into open due to technical reasons or unexpected intraoperative findings. A surgeon may likewise advise outright cholecystectomy if he expects difficulty with the laparoscopy as in cases of multiple abdominal surgeries, extreme obesity and when general anesthesia is not advisable.

When one is diagnosed to have gallstones, the questions to ask include the IF -whether to undergo operation or not; the HOW- which type of surgery is appropriate; the WHEN -the timing of surgery; and of course, the WHO- properly trained surgeons. You and your doctor will ultimately decide, taking into consideration how severe your condition is, how healthy you are, and the individual skill and training of the doctors involved in your care. Rest assured that in this day and age, even for diabetics, the management of gallstones in the Philippines is at par with what the rest of the modern world has to offer.

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