Gall bladder disorders

There are various disorders that affect the gall bladder, and they usually involve gallstones.

A gallstone is a solid crystal deposit that forms in the gallbladder, which is a pear-shaped organ that stores bile salts until they are needed to help digest fatty foods. Gallstones can migrate to other parts of the digestive tract and cause severe pain with life-threatening complications.

Gallstones vary in size and chemical structure. A gallstone may be as tiny asa grain of sand or as large as a golf ball. 80 percent of gallstones are composed of cholesterol. They are formed when the liver produces more cholesterol than digestive juices can liquefy. The remaining 20% of gallstones are composed of calcium and an orange-yellow waste product called bilirubin. Bilirubin gives urine its characteristic color and sometimes causes jaundice.

Gallstones are the most common of all gallbladder problems. They are responsible for 90% of gallbladder and bile duct disease, and are the fifth most common reason for hospitalization of adults in the United States. Gallstones usually develop in adults between the ages of 20 and 50; about 20% of patients with gallstones are over 40. The risk of developing gallstones increases with age--at least 20% of people over 60 have a single large stone or as many as several thousand smaller ones. The gender ratio of gallstone patients changes with age. Young women are between two and six times more likely to develop gallstones than men in the same age group. In patients over 50, the condition affects men and women with equal frequency. Native Americans develop gallstonesmore often than any other segment of the population; Mexican-Americans havethe second-highest incidence of this disease.

Gallstones can cause several different disorders. Cholelithiasis is defined as the presence of gallstones within the gallbladder itself. Choledocholithiasis is the presence of gallstones within the common bile duct that leads intothe first portion of the small intestine (the duodenum). The stones in the duct may have been formed inside it or carried there from the gallbladder. These gallstones prevent bile from flowing into the duodenum. Ten percent of patients with gallstones have choledocholithiasis, which is sometimes called common-duct stones. Patients who don't develop infection usually recover completely from this disorder.

Cholecystitis is a disorder marked by inflammation of the gallbladder. It isusually caused by the passage of a stone from the gallbladder into the cysticduct, which is a tube that connects the gallbladder to the common bile duct.In 5-10% of cases, however, cholecystitis develops in the absence of gallstones. This form of the disorder is called acalculous cholecystitis. Cholecystitis causes painful enlargement of the gallbladder and is responsible for 10-25% of all gallbladder surgery. Chronic cholecystitis is most common in the elderly. The acute form is most likely to occur in middle-aged adults.

Cholesterolosis or cholesterol polyps is characterized by deposits of cholesterol crystals in the lining of the gallbladder. This condition may be causedby high levels of cholesterol or inadequate quantities of bile salts, and isusually treated by surgery.

Gallstone ileus, which results from a gallstone's blocking the entrance to the large intestine, is most common in elderly people. Surgery usually cures this condition.

Narrowing (stricture) of the common bile duct develops in as many as 5% of patients whose gallbladders have been surgically removed. This condition is characterized by inability to digest fatty foods and by abdominal pain, which sometimes occurs in spasms. Patients with stricture of the common bile duct arelikely to recover after appropriate surgical treatment.

Gallstones are caused by an alteration in the chemical composition of bile. Bile is a digestive fluid that helps the body absorb fat. Gallstones tend to run in families. In addition, high levels of estrogen, insulin, or cholesterolcan increase a person's risk of developing them.

Pregnancy or the use of birth control pills can slow down gallbladder activity and increase the risk of gallstones. So can diabetes, pancreatitis, and celiac disease. Other factors influencing gallstone formation are:

  • Infection
  • Obesity
  • Intestinal disorders
  • Coronary artery disease or other recent illness
  • Multiple pregnancies
  • A high-fat, low-fiber diet
  • Smoking
  • Heavy drinking
  • Rapid weight loss.

Gallbladder attacks usually follow a meal of rich, high-fat foods. The attacks often occur in the middle of the night, sometimes waking the patient with intense pain that ends in a visit to the emergency room. The pain of a gallbladder attack begins in the abdomen and may radiate to the chest, back, or thearea between the shoulders. Other symptoms of gallstones include:

  • Inability to digest fatty foods
  • Low-grade fever
  • Chills and sweating
  • Nausea and vomiting
  • Indigestion
  • Gas
  • Belching
  • Clay-colored bowel movements.

Gallstones may be diagnosed by a family doctor, a specialist in digestive problems (a gastroenterologist), or a specialist in internal medicine. The doctor will first examine the patient's skin for signs of jaundice and feel (palpate) the abdomen for soreness or swelling. After the basic physical examination, the doctor will order blood counts or blood chemistry tests to detect evidence of bile duct obstruction and to rule out other illnesses that cause fever and pain, including stomach ulcers, appendicitis, and heart attacks.

More sophisticated procedures used to diagnose gallstones include:

  • Ultrasound imaging. Ultrasound has an accuracy rate of 96%.
  • Cholecystography (cholecystogram, gallbladder series, gallbladder x ray). This type of study shows how the gallbladder contracts after the patient has eaten ahigh-fat meal.
  • Fluoroscopy. This imaging technique allows the doctorto distinguish between jaundice caused by pancreatic cancer and jaundice caused by gallbladder or bile duct disorders.
  • Endoscopy (ERCP). ERCP usesa special dye to outline the pancreatic and common bile ducts and locate theposition of the gallstones.
  • Radioisotopic scan. This technique reveals blockage of the cystic duct.

One-third of all patients with gallstones never experience a second attack. For this reason many doctors advise watchful waiting after the first episode.Reducing the amount of fat in the diet or following a sensible plan of gradual weight loss may be the only treatments required for occasional mild attacks. A patient diagnosed with gallstones may be able to manage more troublesomeepisodes by:

  • Applying heat to the affected area.
  • Resting and taking occasional sips of water.
  • Using non-prescription forms of acetaminophen (Tylenol or Anacin-3).

A doctor should be notified if pain intensifies or lasts for more than threehours; if the patient's fever rises above 101°F (38.3°C); or if the skin or whites of the eyes turn yellow.

Surgical removal of the gallbladder (cholecystectomy) is the most common conventional treatment for recurrent attacks. Laparoscopic surgery, the techniquemost widely used, is a safe, effective procedure that involves less pain anda shorter recovery period than traditional open surgery. In this technique,the doctor makes a small cut (incision) in the patient's abdomen and removesthe gallbladder through a long tube called a laparoscope.

If a stone is lodged in the bile ducts, additional surgery must be done to remove it. After surgery, the surgeon will ordinarily leave in a drain to collect bile until the system is healed. The drain can also be used to inject contrast material and take x rays during or after surgery.

A procedure called endoscopic retrograde cholangiopancreatoscopy (ERCP) allows the removal of some bile duct stones through the mouth, throat, esophagus,stomach, duodenum, and biliary system without the need for surgical incisions. ERCP can also be used to inject contrast agents into the biliary system, providing superbly detailed pictures.

Rare circumstances require different techniques. Patients too ill for a complete cholecystectomy (removal of the gallbladder), sometimes only the stones are removed, a procedure called cholelithotomy. But that does not cure the problem. The liver will go on making faulty bile, and stones will reform, unlessthe composition of the bile is altered.

For patients who cannot receive the laparoscopic procedure, there is also a nonsurgical treatment in which ursodeoxycholic acid is used to dissolve the gallstones. Extracorporeal shock-wave lithotripsy has also been successfully used to break up gallstones. During the procedure, high-amplitude sound waves target the stones, slowly breaking them up.

There are a number of imaging studies that identify gallbladder disease, butmost gallstones will not show up on conventional x rays. That requires contrast agents given by mouth that are excreted into the bile. Ultrasound is veryuseful and can be enhanced by doing it through an endoscope in the stomach. CT (computed tomography scans) and MRI (magnetic resonance imaging) scanning are not used routinely but are helpful in detecting common duct stones and complications.

Without a gallbladder, stones rarely reform. Patients who have continued symptoms after their gallbladder is removed may need an ERCP to detect residual stones or damage to the bile ducts caused by the stones before they were removed. Once in a while the Ampulla of Vater is too tight for bile to flow through and causes symptoms until it is opened up.

The best way to prevent gallstones is to minimize risk factors. In addition,a 1998 study suggests that vigorous exercise may lower a man's risk of developing gallstones by as much as 28%. The researchers have not yet determined whether physical activity benefits women to the same extent.

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