Diseases of the Gall Bladder

Diseases of the Gall Bladder

Where is the gallbladder located?

The gall bladder is an oval and hollow organ, 3 - 4 cm wide and 5 - 10 cm long, located at the lower edge of the liver. The bile duct system belongs to the liver, where the liver cells produce bile that flows into tiny bile ducts, which permeate the liver. These finally assemble at the lower edge of the liver to form two bigger ducts and leave the liver. After a short distance, the two unite to form the common bile duct, which in one place is connected to the gall bladder. After having passed the head of the pancreas, the common bile duct continues to the duodenum. There, it empties into the bowel together with the secretory duct of the pancreas. At this place of transition into the bowel, the papilla as the conclusion of the bile duct system is located and controls the flow of the bile.

In the gall bladder, there are muscle cells, which are able to involuntarily contract or slacken the gall bladder. This mechanism enables the gall bladder to take in bile while slackened and to squeeze out bile when contracting. The gall bladder only serves as a reservoir for the storage of bile. The liver cells daily produce about 800 - 1500 ml of bile, which partly flows directly into the duodenum via the common bile duct. Part of the bile remains stored in the gall bladder and is thickened.

How does the gall bladder function?

The bile plays a central role in digesting fats and in discharging the catabolic products of the liver metabolism. It consists of various substances, the main components being bile acid, cholesterol, lecithin, certain fats, and some enzymes. The demand of bile depends on the food consumed. Between the meals, only little bile is required in the small bowel, so that the greater part of the bile is stored in the gall bladder. During the passage of food through the stomach into the first part of the duodenum, various digestive mechanisms are activated and regulated by vegetative nerves and messenger substances (hormones). Among these mechanisms are the production of gastric juice and the release of bile. As the liver cannot increase the production of bile at short notice, the reserves of the gall bladder are mobilized if necessary. Digestive hormones from the stomach and nervous impulses from the vegetative nerve system cause the gall bladder to contract, so that the reserves of bile flow through the common bile duct into the duodenum and the small bowel. Thus, there is enough bile available to digest the consumed fats in the small bowel and to absorb them in the body.

Gallstones and acute inflammation as the most common diseases of the gall bladder

The most common diseases of the gall bladder and the bile ducts are caused by gallstones. The formation of gallstones is a highly complicated process, which may have different causes. If the composition of the bile changes or if the emptying mechanism of the gall bladder is faulty, stones may form in the gall bladder when the bile thickens in it.

Gallstones are quite different in size, form, and composition. Most frequent are cholesterol stones, but there are also pigment calculi and others. They may stay for years in the gall bladder without causing any complaints and are therefore called "dumb" gallstones. Most dangerous are the small ones as they may get into the bile ducts and impair the flow of the bile, for instance around the papilla.

The typical colicky complaints of a gall bladder colic are due to the passage of such a small stone. If a stone passes through a narrow duct, a colic will be the result, but if it gets stuck, the bile cannot drain any more and there is a congestion reaching as far back as into the liver. This congestion causes a yellow colouring of the eyes, and the urine turns dark. Yet, the stool takes on a light colour because the bile pigments do not completely reach the duodenum any more. Small stones,but also big ones, which cannot leave the gall bladder, cause an irritation of the mucous membrane of the gall bladder and thus an inflammation. It may occur quite acutely, but may also take a chronic course. This development may cover a span of weeks and months, sometimes of years.

How do I recognize gallstones and biliary colics?

The first indications of gallstones may be quite unspecific. Complaints in the upper abdomen like indisposition, flatulence, and minor indigestion, especially after rich and big meals, may have occurred for quite some time. But gallstones are often not noticed at all and are detected only by chance during a routine ultrasound examination. The typical complaints of a biliary colic are convulsive, burning or boring pains to the right and in the middle of the upper abdomen, which may last for some minutes, but also for several hours. Often, the pain radiates as far as the right shoulder and/or the back. Colics may be accompanied by nausea and a transient yellow colouring of the skin. Some patients suffer from diarrhoea. It is important to realize that these symptoms are not typical of biliary colics and may occur in connection with other diseases. If there is an inflammation of the gall bladder, the patient also suffers from a fever of 38 or 39 degrees in an acute phase that is sometimes accompanied by shivers. In general, patients feel indisposed or really sick and suffer from a lack of appetite. After these recurrent colics, many patients know exactly after what kind of food they occur and have abstained from it, sometimes for years. Food rich in fats like cheese, fried eggs or short-fried meals belong to this list.

How can a disease of the gall bladder be diagnostically confirmed?

Stones of the gall bladder may not cause any complaints for a long time. Often, the patients consult the doctor because of acute, colicky pains with or without fever, which they cannot control any more with their own pain killers. As with any other disease, the doctor must first carry out a thorough questioning of the patient. Some of the possible questions are about kind and duration of the pains, their characteristics and radiations, connection with food consumption, action of the bowels, and colour of urine and stool. A complete examination of the abdomen is necessary, and special blood tests are carried out to find indications for a possible inflammation, liver problems, or bile congestion.

One of the most important examinations today is the ultrasound one. It serves to detect with great precision whether there are stones in the gall bladder, whether the bile ducts are congested, or whether the wall of the gall bladder is swollen (indication of an inflammation). This examination is, however, a little less precise what concerns stones of the bile duct system. Other examinations, as for example an X-ray with the use of a contrast medium, CT, or MRI, are only necessary in cases when special questions arise.

How can a gall bladder disease be treated?

Existing colics are treated with pain killers and spasmolytic medicaments, and patients should only consume liquid or very light food. In the case of an acute inflammation of the gall bladder and fever, antibiotics must be applied. Normally, colics and inflammations can be well treated in this combined therapy. If the existence of gall stones is evident, there is great risk that colics reoccur or a pancreatitis develops. Therefore, an operation is indicated if there are the following pathological changes of the gall bladder to be observed:

Gall stones shown in the ultrasound after the patient suffered from a colic or an inflammation after healing of the complaints
(so-called operation a froid)
Acute inflammation of the gall bladder, which cannot be healed with antibiotics
Pancreatitis due to gall stones and already gone through
Proof of gall stones in the bile ducts

Concerning the available surgical techniques, a fundamental difference is made between the minimally invasive, laparascopic methods and the open, conventional removal of the gall bladder.

The laparascopic removal of the gall bladder

Today, the minimally invasive method is normal for the removal of the gall bladder. The intervention is known to the public through many TV-features, and, in the medical terminology, it is called laparascopic cholecystectomy. The laparascopic method has the advantage that access to the abdominal cavity can be achieved with very small incisions, having therefore smaller wounds as a consequence. So the cosmetic result is definitely better, there are less postoperative pains, and the patients can be released earlier.

During the laparascopic operation, the patient lies on his back on the operating table with his legs resting on supports. After a thorough disinfection of the area of operation and after covering it with sterile sheets, the surgeon opens the skin 1 - 2 cm to the right of the navel or in the navel. With a special blunt needle (Veress-needle), the abdominal wall is pierced. Through the injection of a little salt solution, the test is made whether a blood vessel was punctured and whether there is enough air in the abdominal cavity. Carbondioxide is now pumped into the abdominal cavity through the Veress-needle. With this, the abdominal wall is lifted from the inner organs, making sufficient room for the handling of the instruments. After this, a kind of shell is inserted into the abdominal cavity through the incision at the navel. Through it, a tiny camera equipped with a lamp is pushed into the abdominal cavity. Three further small incisions of 5 - 10 mm are used to insert three more shells under camera-monitoring. Through these three additional accesses, instruments like forceps and electric hooks can be introduced.

Now, the assistant seizes the blind end of the gall bladder and pulls it up. The surgeon grasps the gall bladder near the outlet of the bile duct and opens the peritoneum around the gall bladder with an electrical hook. By careful dissection, the cystic duct and the artery of the gall bladder become visible.

After the anatomical details have been clearly verified, the duct and the artery are clamped off with two metal clips. These two clips will stay in the abdominal cavity for good and may be seen in later X-rays.

The next step is to peel the gall bladder from its hepatic bed with an electro coagulation hook.

This leads to minor bleedings in the hepatic bed of the gall bladder, which are electrically scabbed.

The camera must now be transferred to another shell so that the gall bladder can be pulled out from the abdominal cavity. The shell near the navel is now replaced by a larger one (20 mm diameter). Through it, a forceps is introduced, which seizes the gall bladder at the outlet of the bile duct and pulls it to the outside through the shell.

The camera is then used to make sure that there are no bleedings in the hepatic bed. Finally, all the shells are removed, and the incisions are closed with one or two stitches.

There are certain cases, in which the laparascopic method cannot be used or where, after a laparascopic beginning, the surgeon has to switch to open surgery. This is for instance the case if the patient has adhesions in the upper abdomen from prior surgery. And, sometimes, the gall bladder is so strongly fixed to its surrounding by an acute or chronic inflammation that a laparascopic operation would risk injury of a bile duct or of a blood vessel because there is not sufficient visibility. This is why every patient must be informed before an intended laparascopic intervention that a switch-over to open surgery might be necessary.

Open surgery of the gall bladder

The difference to the minimally invasive method is fundamentally only how the access is made. Otherwise the technique is the same. Until a few years ago, open surgery was the standard intervention for the gall bladder. In this operation, access to the abdominal cavity is made by an incision of 6 - 10 cm below the right costal arch. The gall bladder at the lower edge of the liver is exposed with retractors, the small arteria for the gall bladder and the duct between the gall and the gall bladder are dissected and severed. Subsequently, the abdominal wall is closed layer by layer.

Whether a laparascopic or open operation of the gall bladder is carried out, depends on a number of factors and the question can only be answered individually. Normally, the laparascopic method is first choice, and only if this is not possible, the open method will be used. If there are cicatrisations in the upper abdomen due to prior surgery (stomach or bowel operations), often the open method is only possible. However, this becomes evident only during the operation. If patients suffer from a serious heart disease, a laparascopic operation might not be possible because the pressure in the abdominal cavity is increased by the gas pumped in. The pressure is passed on to the diaphragms and in this way, it may impede the action of the heart.

How happens after the treatment?

For both the laparoscopic and the open operation general anaesthesia is necessary. There is usually little postoperative pain, which can be treated very well with the usual pain killers. The gastric tube can be removed right after the operation. On the day of the operation, the patients are already allowed to drink again and should get up from bed, and on the following day, light meals may be again taken. As a rule, the patients are allowed to leave the hospital after 3 - 5 days. The sutures are removed after about 8 days. Increased physical activity may be taken up again after a week, but the fitness for work depends on the individual workload. There are rarely problems in connection with gall bladder operations. Occasionally, bleedings from a vessel or a leakage from a bile duct may occur if a clip was not properly placed. Fortunately, these dangers of gall bladder operations are very rare and stem from the anatomical variations found in man, which may lead in both operations by mistake to injury of the main bile duct, to a blocking by a clip, or to its partial or total transection. There are innumerable variants and many malicious developments, which ask a lot even from very experienced surgeons.

What has to be paid attention to in future everyday life?

After the wound has healed, the patient can take up his normal life again. It is extremely rare that new gallstones form in the common bile duct after the removal of the gall bladder. This is only known to occur more often with patients of Asiatic origin. The majority of patients never again have problems after a gall bladder operation. But as the great reservoir of bile for the digestion of fats is now missing, the patients are principally advised to be cautious and not to eat great quantities of fat in the future.

History

Bile as a liquid of the body has been known since antiquity. It was part of the ancient doctrine of the four juices, which mirrored the notion of that time how diseases developed. Until then, scientists and physicians had the opinion that man and matter consisted of only one element. But in the ancient doctrine of the four juices, the physician Empedocles of Akragas assigned the four elements of air, water, fire, and earth, which he had defined himself, to the four juices of the body: blood, mucus, yellow and black bile. It was thought that an unbalanced mixture of these juices of the body did not only evoke diseases, but they also determined characters. Thus, the yellow colour belonged to the fire and at the same time described the character of the choleric type who exclaims: "My bile overflows". Today, it is known that the formation of gallstones in fact goes along with a changed composition of the bile. Many descriptions prove that mankind has been plagued by gallstones for centuries, but also that there were only non-operative therapies to alleviate the pains. Surgeons only intervened if abscesses caused by gallstones broke through to the outside. When with the introduction of antisepsis and general anaesthesia in the 19th century the preconditions for abdominal surgery had been established, there was a rapid growth of knowledge as to the surgical therapy of stones of the gall bladder and of the bile ducts. There were also new diagnostic methods. Hence, by trying to visualize the biliary system through the application of contrast material, it became possible to localize stones. In 1882, Karl Langenbach succeeded in removing the first gall bladder, and in 1890, Ludwig Courvoisier was the first surgeon who dared to open the common bile duct in order to remove a stone and to re-establish the flow of the bile. The special difficulty to achieve a tight suture of the bile duct kept many surgeons of that time away from a surgical therapy because they knew that a leak of bile caused grave complications. The idea of how to guarantee the drain of the bile came from Hans Kehr in 1895, who invented the T-drainage, which is still in use today: a very thin plastic pipe is inserted in the main bile duct that then passes through the abdominal wall to the outside, so that the bile can drain unimpeded. After the wound around the bile duct has healed, the drain can be removed without complication. In the following decades, there were several surgical and diagnostic improvements, but the fundamental surgical therapy did not change. The development of the ERCP-examination by Ludwig Demling in 1974 was pioneering. It is a special contrast radiography of the bile ducts, which at the same time offers therapeutic possibilities. It was also the development of the minimally invasive surgery since 1985, which revolutionized the surgical interventions of the gall bladder and the bile ducts, offering to the patients a more comfortable surgical therapy.