In this episode of PodMD, experienced General Surgeon Dr Edward Tong will be discussing the topic of gallstones, including what gallstones are, the risks of gallstones, the treatment options available, the operation to remove the gallbladder, when a GP should refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMD studio Dr Edward Tong
Dr Edward Tong is an experienced General Surgeon providing care in Campbelltown and the surrounding areas. Dr Tong completed his Bachelor of Medicine at the University of Newcastle and his Master of Surgery at Sydney University. Following this, Dr Tong completed his General Surgical Training at Southern Health Victoria in 2013 and then completed an ASU fellowship and a UGI fellowship in the Gosford Public Hospital.
Dr Tong’s special interests include Bariatric Surgery, Gallbladder Surgery, Hernia Surgery and Skin Lesions.
Today, we’ll be discussing the topic of gallstones.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Edward, thanks for talking with us on PodMD today.
Edward : Thank you for having me.
The topic of today’s discussion is gallstones. Edward, can you describe for our listeners what gallstones are?
Edward: So gallstones are precipitations of sediment within the bile that commonly sits within the gallbladder. There are essentially three types of gallstones, namely cholesterol stones, pigment stones, or mix. In other words, that contain components of both. Cholesterol stones commonly consist of precipitations of cholesterol whilst pigment stones consists of precipitates of bilirubin, which is a substance that’s excreted by the liver. The stones can also be mixed.
The Physiology causing these stones, the type of stones are different and they are to deal with the balance of factors that lead to crystallisation of these substances and those that inhibit, for example, cholesterol stones, the concentration of cholesterol is one factor, but also the presence of something called phospholipids actually inhibit the formation of these sediments and therefore it’s the balance of these factors that leads to whether you know these goal zones would actually develop.
So cholesterol stones are the most common and they represent about 80% of all gallstones. The rest include pigment, pigment, stones and or mix. The risk factors that lead to a patient having gallstones include weights. So the heavier you are, the more likely that you are that you will develop gallstones. Age, if you’re older, then you’re more likely to develop gallstones. It’s also more a bit more common in female if you lead a sedentary, sedentary lifestyle. In other words, if you’re not very active or pregnancy is also a risk factor as well.
How would a patient with gallstones typically present?
Edward: They usually present with abdominal pain. That’s typically in the right upper quadrants of the abdomen and can radiate to the back and it’s classically worse with meals. It comes and goes to what we call biliary colic, but so the usual pattern is that you patients will either a really fatty meal and then between 30 minutes to an hour later, don’t get this pain in that right upper quadrant. That can sometimes radiate to the back, and then it sort of comes and goes. And that and. That’s why it’s actually called biliary colic. If the pain becomes constant, then that is a sign that the gallbladder could become infected. In other words, developing Cholecystitis. So usually it’s abdominal pain.
What are the risks of the condition?
Edward: The risks of having gallstones are several. First of all, the gallstone can go from the gallbladder into the common bile duct and into the pancreatic duct, causing a degree of obstruction that leads to the development of pancreatitis. So there are different levels of severity, with pancreatitis. First of all, the pancreas is an organ behind the stomach, that’s that’s responsible for the excretion of enzymes and involved in digestion as well as this excretion of several hormonal factors. So we’re fairly aware pancreatitis is a fairly common disorder and the most common cause of pancreatitis is gallstones. Now pancreatitis, can actually be fairly mild, but it also can also lead to a whole range of complications that could that could potentially be life threatening.
The more common risk with this condition is that you could develop Cholecystitis. In other words, an infection of the gallbladder, the Physiology of that is, the stone actually becomes impacted in the opening, where it joins the main ducts. So the obstruction causes edema of the wall of the gallbladder and that secondarily becomes super infected with bacteria and therefore that leads to an acute infection of the gallbladder. That can again be life threatening through several mechanisms.
Cholecystitis can, in severe cases can perforate, in which case the patient will come into the emergency department very, very sick, very unwell. It also can, you know, the severity of the infection can be such that the gallbladder can become necrotic or dead. In other words, again, the patient would come in with severe abdominal pain, sparking temperatures very low blood pressure. This sort of septic picture, which can also be life threatening also. Cholangitis is another risk that can come that can arise from gallstones. So cholangitis essentially is when there’s an there’s a blockage of the main ducts and it becomes super secondarily infected with with bacteria. More commonly, E coli, Klebsiella, [inaudible] these sort of organisms. It also has this potential to become life threatening by becoming causing the patient to become septic, affecting their blood pressure. And you know, these are all potentially fairly dangerous conditions that happens not too uncommonly with the presence of gallstones.
What are the treatment options?
Edward: The treatment options with gallstones is, first of all, it requires an assessment of the patient. Not everybody who has gallstones require an operation. And one of the indications of the of the patient needing an operation needing to have their gallbladder removed is that if they have classic billary pain, pain coming from gallstones and you know they’re fit enough for an operation. So it’s important to have a thorough surgical assessment to see whether the patient warrants and operation to remove their gallbladder.
Now, if they fulfil those criteria and if they’re fit enough for surgery, the gold standard at this stage is, you know, a keyhole operation to remove the gall bladder. In other words, a laparoscopic cholecystectomy. So again, there are other options if the patient is not fit enough. For example, you can basically watch the patient over a serial fit clinical assessments, you can, you know, in severe cases, if they do develop Cholecystitis or an infection of the gallbladder, sometimes putting in the drain. Or a cholecystostomy tube to address the problem of sepsis is an option, but nevertheless you know if the patient is fit enough. If they have biliary type pain, the gold standard of treatment is to perform a laparoscopic cholecystectomy.
Dr Tong, could you explain the operation to remove the gallbladder?
Edward: So the operation to remove the gallbladder, or in other words, the laparoscopic cholecystectomy is a is a very commonly performed operation with very well defined risk profile and also outcome measures. So to give I’ll break up the answer to this question in three parts. I’ll describe briefly what the operation involves. Following that, I will talk a little bit about the potential complications that can arise. And thirdly, I’ll discuss also the likely recovery and the things that we should look out for our GP colleagues.
First of all, the what the operation involves. Firstly, the patient will be asleep. They’ll come in on the day of the operation. And you know the patient will be given a full general anaesthetic. They’ll be they’ll be 4 cuts, one cut over the belly button, one cut just in the epigastrium and two cuts, two 5 millimetre cuts in the right subcostal area. We do this operation keyhole. So what that means is that we put a camera into the tummy, blow up the tummy with gas. What we call a Pneumoperitoneum. We put in some long instruments and then we remove your the gallbladder. At the time of the operation, we will also routinely perform a X-ray in a intraoperative cholangiogram, and that does tells us two things. It tells us whether we’re in the right position and that we are, in fact in the at the level of the cystic duct and not have caused a common bowel duct injury. It also tells us whether there are any stones in the common bile duct which may need subsequent treatment to remove.
So once so once we remove the gallbladder, we’ll close and the patient may go home on the same day or actually they may, you know, stay in overnights and go home the following day. They sometimes if the operation is difficult, we may leave a drain and sometimes the drain can be quite sore as well. It can lead to a degree of right upper quadrant pain also. So immediately after the operation the patient may feel some pain, certainly around the wounds, but they also feel a bit of shoulder tip pain. And that’s because of the fact that we’ve caused that pneumoperitoneum. Or gas in the tummy and the stretching of the of the abdomen can lead to referred pain in the shoulder tip.
So the complications that we often tell will tell patients about will include, you know, potential injury to small bowel, large bowel bleeding, anaesthetic complications such as on table heart attack or stroke. These risks are very, very low, it’s less than .2%. The issue with the common laparoscopic cholecystectomy we also tell them that there’s a there’s a risk of injury to th common bowel ducts and the risk of that is less than .2 to .5%. But if it happens, the passion will need additional procedures to address this issue. The recovery of the patient depending on how the patient recovers the patient may go home the day after. Or several days after, depending on you know how sore they are or how difficult the operation was. And they usually will feel a bit of pain for the first two to four weeks after the operation around the wounds and around the shoulder tip.
We usually advise patients not to do any heavy lifting for the first six weeks. After the operation. We we will routinely follow up on these patients two to three weeks after the operation just to tell them about the pathology we send the gallbladder off for pathological assessments. And you know, we’ll have a discussion with the patient, what it shows and also just inspect the wounds and make sure everything’s OK. So in summary, that’s the process. If patients do come in for the laparoscopic cholecystectomy and that’s something that you guys can as GP colleagues can tell the patients before they come and see us as in terms of what to expect.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Edward: I think the laparoscopic cholecystectomy is a very good option, a surgical option to, you know, to remove the gallbladder. It’s, you know, it’s tried and tested, it’s very reproducible with, you know, general surgeons with a range of different technical ability. So currently the gold standard for the treatment of this condition is to perform a laparoscopic cholecystectomy in, you know, in the right clinical context. However, there has been a number of trials and developments to try and make that even less invasive than what it is. For example, there’s something called a single incision laparoscopic surgery, SILS, in other words, with a with a keyhole, laparoscopic cholecystectomy, they still need to be at least four different port sites in order to facilitate the operation. With SILS or a single incision, they aim to put all the ports in the one incision and that’s through the belly button.
It’s a lot more technically difficult. The pain recovery and the benefit of utilising this procedure is not shown to be of strong enough benefit to be a strong advocate to take over the role of laparoscopic cholecystectomy and therefore what you have found that while some surgeons do offer SILS, it’s not really a widely performed procedure. There has been the other area of development has been the use of what we call ICJ in order to help identify the common bile ducts. One of the main risk of laparoscopic cholecystectomy, in particular in the in the more difficult cases is potential injury to the common bowel ducts. So the use of the ICG. So ICG is a is a medication that is injected to given to the patients like roughly about one to two hours prior to the procedure. And then the idea is that the ICG will be taken up by the biliary tree and that’s and that you know, it highlights the biliary structures more clearly to so to help the surgeon identify the structures and prevent injury to the to the main common bowel dicts.
This has been shown to be useful in select cases where it is very technically difficult. Where you know it’s either certain anatomical considerations include, for example, if they have a very short cystic duct, or you have to have a [inaudible] you know where or where you know you expect the technical difficulty of the laparoscopic cholecystectomy is difficult. There are select cases where the use of ICG has been shown to be of benefit. Again, this still is an evolving area and you know it’s not all surgeons at this point would use that even in their more difficult cases also.
Are there any warning signs a GP or their patient can look out for?
Edward: I think if a patient presents with constant pain in the right upper quadrant, that’s a concern and probably either, depending on how sick the patient is, whether it’s appropriate to either get an early referral to see a surgeon, or whether they should send the patient to the emergency department if they look sick, if they have spiking temperatures. Very high temperatures up to 39 or if they have also have a high bilirubin. These are all signs in which you know you would be concerned and you would seriously consider whether you would send the patient to the emergency department.
What is the likelihood of recurrence of the condition?
Edward: Recurrent it depends on the clinical context. First of all, if a successful complete laparoscopic cholecystectomy is completed, then it is very unlikely to have recurrence of gallstones like very low like you know less than 5%. However, sometimes you can get a recurrence of this biliary pain. If it tends to be a bit more frequent, if there’s a partial cholecystectomy has been done, we do do partial subtotal cholecystectomies in cases where it’s very technically difficult and it’s not safe to dissect too close to the common bile ducts, and in this case you know the recurrence of biliary pain can be up to 20 to 40%.
Sometimes, even after a laparoscopic cholecystectomy, it is possible to get a primary stone in the common bile duct. It is possible but it is very unlikely, and in literature quote quoted as between 1 to 5%. Sometimes as well, it is also possible to get a post cholecystectomy syndrome and that this can be up to 20 to 30% of patients after the gallbladder operation and that occurs when in two different situations when the pain is actually that was initially assessed is actually not really billary pain. The gallbladder is removed, but yet the patient still has ongoing symptoms, mainly because the original pathology of the pain is not really addressed. In other words, the pain was not caused by gallstones.
The other issue with the other pathophysiology with this post Cholecystectomy syndrome is that you can get a Sphincter of Oddi dysfunction. So there is this sphincter that is just at the level of the cystic ducts and following a cholecystectomy, the contraction of this sphincter can start to be a bit different to what it normally is, and that sometimes can contribute to the recurrence of this abdominal pain. And this is actually a pain that’s not due to the presence of gallstones as such, or the recurrence of gall stones. But it’s just due to altered Physiology in in the way that this sphincter contracts and dilates so.
The other, of course you know, following a cholecystectomy i a patient has pain, the other very significant consideration is whether the patient has developed a complication from the operation, and one of the most feared complications following a laparoscopic cholecystectomy is a bile leak. So if the patient develop signs that would be that you would start to consider whether the patient has a bile leak. These include sparking temperatures, worsening abdominal pain, sometimes the bilirubin can also be elevated, and if this is suspected it is very important that the surgeon who did the original operation is contacted as quickly as possible.
So again it is there’s a whole range of different scenarios that can arise. With pain coming arising following after the gallbladder or the laparoscopic cholecystectomy operation, it may or may not not due to be due to be recurrence of gallstones, but again it requires a thorough clinical assessment to see what the cause of that pain is.
When should a GP refer?
Edward: First of all, I think the classic textbook answer to that is, you know, anybody who’s got gallstones and got biliary type pain, as we’ve discussed, which is consistent with gallstones, then they should, they’re likely to have require an operation. And therefore, you know, those patients definitely should, should be referred to a general surgeon. If the patient has got gallstones but they have, they have atypical pain I think it is still appropriate to for a referral to see the general surgeon to see whether a lab [inaudible] is warranted in this case. We may not offer a lab [inaudible] we may offer in further investigations they include potentially a gastroscopy to see whether the pain is actually arising due to gastritis or potentially offering a higher scan to seek whether there’s further confirmation that the pain is in fact coming from the biliary tree.
So again, depending on our assessment, again, we may or may not offer a laparoscopic cholecystectomy even though the patient has got gallstones. Or alternatively, you know if our GP colleagues are concerned, you know where you know whether this is potentially billiary pain or not, then we’re more than happy to accept the referral and to perform a work up from our end to see whether further surgical investigations or operation is warranted in this case.
What role does the GP play in the treatment of the condition?
Edward: I think that our GP colleagues play a very important role in the treatment of this condition, as we recall, like we discussed, some of the risk factors that may contribute to the presentation of gallstones and our GP colleagues have a very important role to, you know, encourage a less sedentary lifestyle. Encourage weight loss. And, you know, certain modifiable risk factors which are lifestyle related that our GP colleagues can encourage their patients to undergo.
Secondly, also, it’s our GP colleagues playing an extremely important role in in screening for this condition because in identifying patients who’ve got this type of abdominal pain, who may warrant investigations such as an abdominal ultrasound, and that is where we actually pick up the these patients to avoid them from, you know, going into the path where they come into hospital, very sick. They may need to have a very difficult operation and there’s a high more and the more difficult the operation, the more you know mobility and mortality risk that’s associated with the operation as well. So early pickup of this condition where it is indicated to do an easy laparoscopic cholecystectomy for these patients is very, very helpful. And our GP colleagues play a very important role in this.
The other important crucial role our GP colleagues play is also helping out, helping the surgeons follow up on these patients that we’ve operated on, we always will see our patients immediately after the operation, however you know the these complications or these abdominal pain following the college statement may happen before or after the date of our follow up and because our GP colleagues have a much more see the these patients on a much more regular basis and they’re not more likely to pick up issues and in which case it would be very appropriate for our colleagues to refer these patients to us for further management and decision making. So I just wanted to highlight our GB colleagues play an extremely important role in helping us manage this condition.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on gallstones?
Edward: I think the key take home messages are firstly, our GP colleagues play a very important role in this in the management of this condition and that. Is in both in the area of pick up early assessment and follow up.
The second take home message is that not all gallstones or patients who’ve on ultrasound have been diagnosed with gallstones, require an operation and it is important for a thorough clinical assessment to decide whether they need an operation or not.
So and thirdly, I think the third thing that I wanted to highlight is that. Early pickup of this condition prevents patients you know who are very, very sick with this condition coming into the hospital and undergo and often undergoing dangerous, you know, not dangerous. But you know, like difficult technically challenging operations and a far better approach will be, you know, to identify these patients who need an operation early and to operate on these patients early. So and that would lead to less morbidity and better outcomes for patients also.
Thanks for your time and the insights you’ve provided.
Edward: Thank you