What is cholelithiasis and how is it treated?

What is cholelithiasis?

Cholelithiasis is the presence of stones within the gallbladder. The production of bile by the liver is necessary for the digestion of fats, but since we are not eating continuously, the bile has to be “stored” somewhere. This place is the gallbladder, which is connected to the duct that carries bile from the liver to the intestine (duodenum). This duct that connects the gallbladder with the main duct or common bile duct is called the cystic duct. During a meal, the gallbladder contracts and releases the bile contained inside it.

Why and how do stones (gallstones) form inside the gallbladder?

This viscera has a lining that can become inflamed. And there can be obstructions in the cystic, which produce slowing in the emptying of the gallbladder. In the interior of the gallbladder, due to inflammation, solid detritus are deposited which can increase in size, giving rise to different types of stones (cholesterol stones, bilirubin stones,…) and to different sizes of stones. The stone is, in conclusion, the result of the lack of proper functioning of the gallbladder.

Now, inflammation and slowing or bile stasis causes infection by proliferation of germs inside the gallbladder, which will lead to gallbladder inflammation called cholecystitis, which can be acute or chronic. This is the same thing that happens in stagnant water, which favors the multiplication of bacteria.

The manifestation of cholelithiasis is pain, with moments of more intensity followed by other moments of more calm. This is the colicky type of pain. If vesicular inflammation is added to these symptoms, fever and chills may appear.

Small stones originating in the gallbladder can migrate towards the main duct or common bile duct and can obstruct it. The bile will not pass into the duodenum, it will pass into the blood and the patient will have yellow skin (jaundice), indicating biliary obstruction and requiring urgent or preferential treatment.

As the pancreatic duct opens into the common bile duct, these stones can also obstruct the outflow of pancreatic fluid and cause pancreatitis, a very serious disease.

Large stones, larger than 3 centimeters in diameter, have been associated with gallbladder cancer, due to the continuous and chronic damage caused by the stone or stones on the gallbladder wall. Gallbladder polyps are also associated with gallbladder cancer, as well as the so-called porcelain gallbladder or calcification of the gallbladder wall.

In summary, the presence of stones in the gallbladder, with clinical manifestation of pain, is an indication for surgery; that is, surgical removal of the gallbladder, since otherwise the complications are cholecystitis, obstructive jaundice, pancreatitis and gallbladder cancer, just to name the most frequent complications.

What is the treatment for cholelithiasis?

The treatment is surgery: removal of the gallbladder. Until thirty years ago, the only treatment was to “open” the abdomen, the so-called laparotomy. At the end of the 1980s, laparoscopy, a procedure in which, through an incision near the navel, the abdomen is filled with carbon dioxide gas that separates the abdominal wall from the abdominal viscera, became more and more common. This allows two or three more small incisions to be made in the abdomen. A camera is introduced and with the help of appropriate instruments the gallbladder is removed.

Laparoscopic cholecystectomy, as the procedure is called, manages to reduce postoperative pain and postoperative stay, compared to laparotomy, and the operation can be performed in the morning and the patient can go home in the afternoon.

In a small percentage of cases this operation cannot be performed because the state of the gallbladder or the viscera surrounding the gallbladder prevent us from performing the technique safely. In these cases, a laparotomy is performed and the cholecystectomy is performed. Conversion from laparoscopy to laparotomy is less than 5% of cases. But one concept must be made clear: the important thing is to remove the gallbladder, laparoscopy being an access route, but laparoscopy should not be magnified, so that it seems that if the gallbladder has to be removed by laparotomy it is a failure. The failure is that the patient does not want to undergo surgery, because of the risk involved in cholelithiasis, which manifests itself with symptoms.

The indications must be very clear:

1. Single or repeated biliary colic (pain).
2. Cholecystitis, with the manifestation of fever or jaundice.
3. Pancreatitis, as a single or repeated episode.
4. The cases referred to above: porcelain gallbladder, biliary polyps and suspected gallbladder cancer.

There are more indications but these are the most important ones that should not be forgotten.

Is there any risk for the patient?

At the outset I state that the risk is not to have surgery, because the risks of not having surgery far outweigh the risks of the intervention.

The risks are based on the condition of the patient and the condition of the gallbladder. On the patient’s side, cirrhosis, heart failure, chronic obstructive pulmonary disease, etc., are diseases that may contraindicate surgery. These are diseases that can contraindicate the operation, or contraindicate the technique, so that laparotomy would be indicated instead of laparoscopy.

The risks linked to the state of the gallbladder go hand in hand with the evolution of the symptoms. For this reason, the intervention should not be delayed. Repeated biliary colic makes access to the gallbladder more difficult, and the risk of injury to the bile ducts easier. These risks are minimal in experienced hands.

How do you live without a gallbladder?

The human body is nature’s most perfect machine. When the gallbladder is removed, the common bile duct, which has a cylindrical structure, increases in diameter and takes over the function of the gallbladder. All cholecystectomized patients have a larger diameter of the common bile duct, which has the vicarious function of “replacing” the gallbladder, in addition to performing its own function, which is the transport of bile from the liver to the duodenum. Furthermore, cholelithiasis indicates that the gallbladder does not function and, therefore, its presence is not necessary.

Generally speaking, carnivorous animals have a gallbladder, because we have to digest fats, but herbivorous animals, such as the horse, do not have a gallbladder because their diet, based on vegetables, does not need the receptacle provided by the gallbladder.

What are the main benefits?

It is clear that the benefits are multiple for the patient, as he/she is freed from a disease that, due to infection or complications, even cancer, can lead to death.

What should the patient do before and after the operation?

Before the operation, the patient must undergo a preoperative examination that includes complementary tests such as analysis, electrocardiogram, chest X-ray (which may not be done) and anesthetic evaluation. On the day of the operation you must fast for a minimum of 6 hours. In men, shaving of the abdomen.

At the end of the operation and after 4 to 6 hours, an oral diet is started, with liquids, then purees and then a soft diet. The pain can be prevented with common analgesics, such as paracetamol or metamizol, and it is advisable not to make important efforts for a month, to avoid a hernia in the umbilical area, and it is also advisable not to eat fats, fried foods, or large meals for three months.

Are there alternatives to surgical treatment?

Clearly, no. There are medications aimed at dissolving the stones, but they have not been as successful as expected and, in a diseased gallbladder, it does not guarantee that there will be no complications, nor does it prevent the greatest of them, gallbladder cancer or carcinoma.