In this episode of PodMD, Upper GI, Bariatric and General Surgeon Dr Patwinder Gill will be discussing the topic of gallstones and gallbladder pathology. We discuss common gallbladder pathology GPs are likely to encounter, differences in presentations between younger and older patients, gallstones in pregnant women, and more.
- Transcript
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*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 Patwinder Gill, better known a Winnie Gill.
Dr Gill is an Australian-trained General Surgeon based in Melbourne. She has special interests in bariatric, benign upper GI and hernia surgeries, as well as general surgical conditions.
You can read more about Dr Gill on her profile page on our PodMD website.
*Please listen to our disclosure at the end of this podcast
Today, we’ll be discussing the topic of Gallstones and Gallbladder Pathology. Winnie, thanks for talking with us on PodMD today.
Patwinder: Thank you for having me.
Could you give us a brief overview of gallstones and common gallbladder pathology that GPs are likely to encounter in everyday practice?
Patwinder: So the commonest things I think GPs are most familiar with are gallstones, because they occur in about 20% of the general population and is quite a common presenting complaint, in particular surgical presenting complaint for GPs.
Other gallbladder problems that GPs may encounter are gallbladder polyps that can usually be found sort of more incidentally while investigating causes of upper abdominal pain and other gallbladder pathologies.
The more common is adenomyomatosis of the gallbladder and much less commonly something called choledocholithiasis, where there’s gallstones that are in the common bile duct. Very rarely would any investigation also find some gallbladder cancers, but they do occur. But, you know, commonly gallstones are the most common finding that GPs deal with.
What are some of the key risk factors for gallstone formation and how do these usually differ between younger and older patients?
Patwinder: Yep. So younger female patients are more likely to develop gallstones compared to male patients of similar age. However, this discrepancy does seem to plateau out as the patient’s ages changes and as they age. So I’ve also noticed that there are some genetic susceptibility to gallstone formation. There are a lot of patients that come to us and say, oh my, parent or aunt or, you know, a relative does tend to present or have had gallbladder stones and have had their gallbladders out in the past. And we’ve now found a particular gene called the ABCG8 gene that causes a genetic risk of increased susceptibility of developing gallstones. Now, most patients who have first-degree relative who’ve had gallstones have about a 15% chance higher of developing gallstones in the presence of this gene.
We also know that pregnancy can also cause some changes in the composition of bile and delayed gallbladder empty with increasing frequency and number of pregnancies. So this can also increase the risk of the patient developing gallstones. Patients with diabetes also have an increased risk, although the mechanism of which is not really quite understood. Some have proposed that the hepatic insulin resistance plays an important role in development of gallstones, and also maybe the setting of hypertriglyceridemia and autonomic neuropathy in these patients also lead to the biliary stasis that then lead to the gallstone formation.
We’ve also known that patients with obesity, where there’s enhanced cholesterol synthesis and secretion, again noted notably more in females and class 3 obesity are more likely to be symptomatic from their gallstones as compared to non-obese patients. Patients with rapid weight loss, in particular on those with very low calorie diets or after bariatric surgery, also have a higher propensity of developing gallstones. So this is sort of proposed in the sense that there’s increased bile mucin concentration and bile calcium concentration, and which then promotes cholesterol nucleation and stone formation. And these patients are also more likely to be more symptomatic compared to their counterparts.
There are a few medications that can increase the risk of gallstone formation. So patients who’ve been on fibrates, ceftriaxone for a prolonged period of time, patients who are on somatostatin analogues like octreotide, postmenopausal patients who are on estrogen therapy, and more commonly nowadays, patients who are on GLP-1 receptor agonists like Ozempix, Xcender, Wegovy, are also at an increased risk of developing gallstone.
I’m guessing that they wouldn’t know until, they’re diagnosed with it because it is quite asymptomatic sometimes, isn’t it?
Patwinder: Yeah, majority of the patients who have gallstones are asymptomatic and majority of the time it’s found when they are being investigated for other causes or other symptoms, sorry. But as we discussed, there’s certain patients that are more likely to be symptomatic from their gallstones.
Can you talk us through how gallstone disease presents differently in younger patients compared to older patients and whether this changes management or even urgency of referral?
Patwinder: So younger patients tend to present more with the classic symptoms of biliary colic, so pain in the epigastrium, radiating to the right upper quadrant or around to the back, usually occurring post-meals and in a more colicky nature. The younger patients are also more likely to be able to relate their pain to having actually had a meal and can correlate their symptoms to activities that they’ve done or meals that they’ve had. They’re also more likely to present earlier, I think, with their symptoms, which is better in the sense that it allows us to, you know, aim for an elective management rather than an emergent management.
Older patients, however, tend to present with either episodes of acute cholecystitis on a background of chronic cholecystitis, and they usually don’t tend to note their symptoms unless they’ve been symptomatic quite some time. More often than not, they tend to put their symptoms down to other problems. They’ve dealt with reflux for a prolonged period of time, and they’ve put it down to indigestion most commonly, and haven’t really noted the differences in their symptoms. So they’re more likely to present actually with acute on chronic cholecystitis, with fevers, changing their appetite, nausea, vomiting, and chills. And more often than not, it’s a diagnosis that we find on a CT scan and then pinpointing it to the gallbladder just due to the fact that it’s more vague in their presentation.
It’s more important, however, older patients are referred to the emergency or to the general surgeon for earlier management, just because they also have additional comorbidity that may impact their ability to tolerate cholecystitis.
Yeah, absolutely. And possibly, you know, there would need to be a little bit more investigation to sort of get to the bottom of it as well.
Patwinder: Yeah, that’s right.
So when a GP does see a patient with suspected biliary colic, what are the essential elements of assessment and initial investigation in primary care?
Patwinder: So, as we discussed before, the presentations can be classic for biliary colic, but a higher index of suspicion is needed for older patients with more vague symptoms. Obviously, the first step is to confirm the diagnosis, and a simple thing is to do an ultrasound of the abdomen. A blood test that looks at the liver function test is also quite helpful. Elevated ALP and GGT in particular, in comparison to ALT and AST changes, suggest more biliary pathology as compared to a hepatic picture.
Patients with Adenomyomatosis of the gallbladder who don’t have gallstones may not be symptomatic at all, and more often they won’t have any changes to their liver function. So if they don’t have any gallstones associated with Adenomyomatosis, we’re moving away from encouraging these patients to have the gallbladders out. Although there is a very small chance of previously assumed gallbladder cancer. We’re not really seeing that nowadays.
So the other thing to think about is whether the symptoms actually correlate to the investigation findings. So we prefer to use ultrasounds over CTs, mostly because gallbladder stones don’t tend to be radiopaque. A few of them are, but the vast majority of them are not. So ultrasounds are more accurate. Ultrasounds can be quite tricky in larger patients. just due to their body habitus and the location of their liver in comparison to their size, allowing for a good view of the gallbladder. Other things that we did talk about before was gallbladder polyps and, you know, the risk of these causing problems, but I think you’ve addressed that gallbladder polyps in a separate podcast as well.
Are there any red flag symptoms that we should be aware of when we’re sort of diagnosing these symptoms?
Patwinder: Yeah, so I mean, the commonnest complaint, obviously, with biliary colic is the frequency of their symptoms. So if patients are getting very rare symptoms and are able to manage the symptoms with dietary modification and lifestyle modification, The urgency for an operation is less so as compared to someone who is troubled by it multiple times a day or on a daily basis. Patients whose symptoms don’t actually resolve, so they’re persisting with the abdominal pain, although still colicky in nature, probably should have their surgery offered to them earlier or sooner rather than later, because these are the patients that are more likely to develop cholecystitis.
Now, if the patients have classic red flag symptoms or constitutional symptoms, where they’re losing weight, they’re having fevers, chills, they’re developing abdominal pain that’s a little bit different from the classic biliary colic. And one does need to think about complications like choledocholithiasis or pancreatitis, or even the, you know, dreaded cancer that we talked about.
Now, there are situations where patients have markedly thick gallbladders on their ultrasound. Again, they should be referred sooner rather than later. And if there’s any presence of pericholecystic fluid on the ultrasound, probe tenderness, dilated common bile duct, or a porcelain gallbladder, they need an intervention sooner rather than waiting for an elective approach.
In terms of management, are there any or what are the conservative measures that GPs can safely initiate And at what point should they consider a surgical referral?
Patwinder: I think the frequency of patient symptoms is the most important. So in patients where it’s a completely incidental finding of gallstones and they’ve not been symptomatic of biliary colic ever, we can just manage that with dietary modification. So this is done with a low-fat diet, cessation of contributing medications, for example, GLP-1 receptor agonist, estrogen therapy if possible, or prolonged use of particular antibiotics.
Now, if we can’t do these lifestyle modifications, then we should be considering a cholecystectomy. If the patients have complications from their gallbladder or gallstones, then I think an early surgical intervention is definitely something that we should consider.
How should GPs approach gallstones in women, especially young women, planning for pregnancy?
Patwinder: I have a personal interest in this as I’ve seen quite enough patients who are pregnant with gallstones and pregnancy in itself is a risk factor for developing gallstones. I find that patients need to have an understanding of the fact that the gallstones can cause trouble during pregnancy. Now, it may worsen their biliary colic, but it may also contribute to episodes of cholecystitis or polydocolithiasis and then obstructive jaundice during their pregnancy, which can in itself impact the pregnancy and cause complications to the pregnancy itself.
So, I mean, other than the standard investigations of our ultrasound liver function tests that we talked about, we should be catering their symptomology to the trimester in which they’re in. So, if this is if the patient has biliary colic, or episodes of cholecystitis in the early stages of the pregnancy, so in the first trimester. We usually try and manage this with symptomatic management and dietary modifications. We should also be referring them to the surgical team. Now, whether it’s a general surgeon or the emergency department will depend on how symptomatic the patient is. But we can then plan for an elective laparoscopic cholecystectomy in the second trimester with the patients.
Now, the reason we chose, or we’ve sort of chosen the arbitrary second trimester is because we’ve noted that this is probably the safest time to intervene. The gallbladder is going to continue to be a problem during the pregnancy, but the uterus is low enough that there’s still enough space for us to approach this laparoscopically, and the uterus is also more stable. So you’re less likely to cause irritation of the uterus, which then can lead to early miscarriage or early delivery. So we usually do try and cater for this procedure to be done in the second trimester.
Now the patient is quite symptomatic during the third trimester and predominantly with biliary colic. We do tend to bring them into hospital and manage their pain at this time, but we try to avoid doing a laparoscopic cholecystectomy then. Mostly, as you can imagine, if the uterus is sitting right under the diaphragm, there’s barely any space for us to get to the gallbladder laparoscopically, and in a big open operation in the third trimester will definitely guarantee a C-section for the patient in a much longer recovery. And imagining doing an operation with very little space can increase the complications to the patient. So we try and avoid this. And if we can get them through that final trimester and the early postpartum period, we usually would plan for an elective cholecystectomy in the first six weeks to three months postpartum to address this.
We know for a fact that patients who have had biliary colic with their first pregnancy will have definite trouble with their second one or further pregnancies. So we do have a discussion with them and encourage them to have a cholecystectomy prior to the next pregnancy.
For older patients or those with significant comorbidities, how does the risk-benefit balance of surgery change?
Patwinder: So we do have to be mindful of the fact that when you’re older, you have multiple comorbidities that can affect your ability to tolerate illnesses, in particular episodes of cholecystitis, but also your ability to actually manage the load of a general anaesthetic that’s placed on your heart and your lungs during the procedure. Now, even if it is a straightforward procedure, I normally do tell my patients having a general anaesthetic is like running a marathon for your heart. And if their heart can’t really tolerate that, we do need to do certain steps or put in certain steps in order to improve their ability to tolerate a general anaesthetic.
Now, with these patients, we do generally have a longer chat with them about their risk benefit from having surgery. So if they are barely symptomatic, we can talk about lifestyle modifications, but if they’re quite symptomatic, we can involve the perioperative medical team and the anaesthetic team early. And we can do something called prehabilitation to get patients to improve their cardiac and respiratory function before surgery so that we can go ahead and do surgery with the appropriate backup so we can liaise with the ICU team and the medical team so that these teams are readily involved immediately after the procedure to try and optimize the patient recovery.
Now in patients who have quite significant symptoms, but are also significantly comorbid. There are other things that we can do, such as doing a definitive ERCP, for example, to allow any stones to just pass through without causing jaundice or pancreatitis, or even put drains in such as percutaneous cholecystostomies. But again, we usually try and optimize patients to get them to be able to have a cholecystectomy, because that gives them a longer term better outcome than having these other sort of temporizing measures.
In terms of triaging referrals, what practical advice would you give GPs to streamline referrals? For example, what information or investigations are most helpful to you as a specialist?
Patwinder: That is a very good question. We do like more information rather than less information on the referral letters. So an early referral with patients who are symptomatic with clear timelines of how long they’ve been symptomatic for any associated complications such as derangement in their LFTs, any changes or red flag symptoms that they’re experiencing, such as weight loss, nausea, vomiting, persistent pain would expedite their triaging in the hospital system and even in the rooms privately.
The biggest thing would be attaching the ultrasound report because sometimes we don’t have access to those particular reports and most patients don’t usually remember where they have the ultrasounds done and you end up spending quite a bit of time Googling various radiology centers to try and locate the one that they’ve went to. So having that report is very helpful for us. It’s also really important that if you are concerned and haven’t heard back about a referral, the patient hasn’t heard back about it, that in particular in the public system, that you send a follow up referral, because sometimes the first one doesn’t get through. And the second one needs to be placed.
Could you please identify the three key take home messages from the podcast and from our discussion?
Patwinder: So a patient’s age, as we talked about before, is very important. So younger patients are more likely to be symptomatic, and women of childbearing age should be referred early for cholecystectomy. A higher index of suspicion of biliary disease needs to be had for older patients. And again, their referral to a surgeon should be in relation to their comorbidities as well. Now, there are patients with gallstone disease, adenomyomatosis, and polyps who’ve ever had pancreatitis should also be referred for cholecystectomy as these can be complicated down the track. So the third thing is simple interventions that can be placed while the patient is waiting for their surgical review is a simple lifestyle modification such as a low-fat diet and a healthier lifestyle like exercising and maintaining a healthy weight. Cessation of contributing medications, in particular GLP-1 receptor agonists, is helpful in taking or reducing the risk of patients developing complications while waiting for their surgical consultation.
Winnie, thanks very much for your time today and the insights you’ve provided. It’s been great.
Patwinder: Thank you, Rowena. Thank you for having me.
*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.
