Don’t give up your gall bladder too easily

Don’t give up your gall bladder too easily

Apologies to my medical readers, if any. This is all rather basic, but there is something to chew on towards the end.

Surgical removal of the gall bladder is one of the commonest operations performed nowadays. Close to a million people undergo “cholecystectomy” every year in USA. There are several good indications for surgery, but also some controversial situations, and perhaps alternative approaches.

            First a little refresher. The liver produces bile, which passes down a tube (the bile duct) into the upper intestine (duodenum) through a valve called the sphincter of Oddi, in the papilla of Vater. The gall bladder is a reservoir in which bile is stored between meals, connected to the bile duct by another tube (the cystic duct). Crystals can form in the gall bladder when the bile gets concentrated, and they coalesce into stones.

Gall bladder stones are really very common. In western countries, some 20% of women and 10% of men have stones in the gall bladder by the age of 60. Most of them sit quietly but a few cause attacks of pain and other mischief, especially when they migrate into the bile duct and cause obstruction.

We will consider three scenarios. Patients may present with

  • Stones with symptoms
  • Stones without symptoms, but also
  • Symptoms without stones

Stones with symptoms

Gall bladder stones (cholelithiasis) can cause nasty attacks of pain (in the right upper quadrant of the belly) when they block the cystic duct, which can lead to infection (cholecystitis). The common and correct treatment for these problems is to remove the gall bladder with the offending stones. Nowadays this is a relatively simple operation, done through small incisions with a laparoscope, often without the need to stay in hospital overnight.  It is not entirely without risk, the most problematic being when the bile duct gets damaged in the process. This occurs in less than 1% of cholecystectomies, but it can be tricky to repair.

Why give up your gall bladder? Can you not just remove the stones and leave it in place? Yes indeed, several non-surgical methods have been used. An interventional radiologist can poke a tube through the skin, access the gall bladder, drain any infection and remove the stones. A gastroenterologist can prescribe pills that dissolve stones (the common types anyway) and a urologist can smash the stones with a shock-wave lithotripter machine. The problem with these and other fancy approaches is that the stones form again rather quickly.

Stones sometimes pass from the gall bladder though the cystic duct into the bile duct, where they can grow quite large. Serious infection (cholangitis), jaundice and pancreatitis can occur when stones block the exit of bile duct at the papilla of Vater. That situation is usually treated rather urgently by a gastroenterologist with an ERCP procedure, passing an endoscope through the mouth down to the exit of the bile duct in the duodenum, opening it up with cautery and using devices to extract the stones. And the gall bladder needs to be removed also to prevent a recurrence.

So, cholecystectomy is almost always the appropriate treatment when stones cause trouble. The situation is less clear in our two other contexts

Stones without symptoms

It is worth emphasizing that gall bladder stones are really very common, and that most are asymptomatic. Nowadays they are often discovered “by mistake”, when an ultrasound or CT scan is done for another reason, in patients with no “biliary-type” symptoms. The obvious question then naturally arises. Should we go ahead and recommend removing the gall bladder in case it misbehaves sometime later? What to do depends mainly on the likelihood of trouble occurring in the future. Several research studies have shown that the risk is only 1-2% per year, so “prophylactic” cholecystectomy is not generally recommended. However, there are some exceptions. The most important is when scans show that the gall bladder wall is diseased, with a polyp or calcification (harbingers of possible tumor development later). Other examples are patients with sickle cell disease, those with immune deficiencies, and people who plan to be away from medical care for long periods, like in outer space or the Antarctic.

That reminds me that I read somewhere years ago that astronauts had their appendices removed before blastoff for the same reason. The appendix has long been seen as a vestigial organ that you don’t need, but there is now some evidence that it has some function in our immune system and looks after good gut bacteria. Whoda thunk!

Symptoms without stones

            This is the most tricky one. Many patients have attacks of pain that sound “biliary”, but the ultrasound scans show no stones. This raises the concept of “gall bladder dysfunction” or “dyskinesia”, recently renamed “Functional Gall Bladder Disorder” (FGBD) by the Rome Foundation. The concept is that the gall bladder does not contract smoothly, resulting in increased pressure and pain.  This idea is commonly tested with a “HIDA” or “CCK-CS” (Cholecystokinin-Cholescintigraphy) scan. This records how much the gall bladder contracts after a stimulant injection. An “ejection fraction” of less than 35% is usually accepted as abnormal. However, the value of that finding is disputed and has not been studied stringently. Surgeons vary in how much they rely on it when deciding whether to recommend surgery. The bottom line is that many patients in USA do undergo cholecystectomy for these symptoms (with or without an abnormal ejection fraction). Remarkably, the proportion of these surgeries being done for patients without stones is around 20 % in adults and up to 50% in children. Even more striking is the fact that FGBD is rarely diagnosed outside USA.

Whilst many papers claim surgical success in most patients, the quality of the research and data are poor. For years I have been trying to get funding from NIH to do a definitive trial, ideally a sham-controlled randomized study.

What other treatments are available? Firstly, it is important to remember that these symptoms are not life-threatening and often lessen or stop over time. So, there is no urgency, and time to try some simpler methods like avoiding stimulating foods and taking an anti-spasm pill when needed or every day for a while. Specialists in this field will often recommend “behavioral therapy” (learning about your symptoms and how to better deal with them) and/or prescribe a “neuromodulator” medication, that can cool the disturbed gut-brain axis. This is a context where it may be wise to seek more than one opinion.

Do you need the gall bladder anyway? Will you miss it?

The fact that there are many thousands of satisfied surgical customers shows that most patients do well without a gall bladder. However, some patients have digestive upsets, and some have impressive diarrhea, because the bile is dripping continuously into the intestines instead of waiting in the gall bladder until summoned by food.

More important, there are many patients whose pains continue or recur after surgery. Some say: “my gall bladder came back”!

These “post-cholecystectomy pains” are often blamed on dysfunction of the “sphincter of Oddi”, another can of worms that I wrote about last year. The sphincter is the valve that controls the flow of bile into the duodenum through the papilla of Vater. If it misbehaves, and stays shut when bile needs to flow, the pressure rises in the bile duct and causes pain. Diagnosis and treatment of “sphincter of Oddi dysfunction” is controversial. Check out https://drpetercotton.com/episod-revisited-and-validated-thank-you-zach/

Bottom line. Don’t give up your gall bladder too easily.

Anyone wishing to get into the weeds on all this can review the comprehensive summary document from the prestigious Rome Foundation … Cotton PB, Elta GH, Carter CR, Pasricha PJ, Corazziari ES. Rome IV. Gallbladder and Sphincter of Oddi Disorders. Gastroenterology. 2016 Feb 19:S0016-5085(16)00224-9. doi: 10.1053/j.gastro.2016.02.033. PMID: 27144629.

All part of life’s rich tapestry