Gallbladder Disease

The gallbladder is a 4-inch sac with a muscular wall located underneath your liver.

The gallbladder serves as a reservoir until bile is needed in the small intestine to digest fats. This need is signaled by a hormone called cholecystokinin, which is released when food enters the small intestine.

Cholecystokinin [ cho·le·cys·to·ki·nin] causes the gallbladder to contract and deliver bile into the intestine. The force of the contraction propels the bile down the common bile duct and into the small intestine, where it emulsifies (breaks down) fatty molecules.

This part of the digestive process enables the emulsified fat, along with important fat-absorbable nutrients (such as vitamins A, D, E, and K), to pass through the intestinal lining and enter the bloodstream.

 

Overview of Gallbladder Disease

The term “gallbladder disease” is used for several types of conditions that can affect your gallbladder.

The majority of gallbladder diseases are caused by inflammation due to irritation of the gallbladder wall, which is known as cholecystitis (ko-luh-sis-TIE-tis). This inflammation is often due to gallstones blocking the ducts leading to the small intestine and causing bile to build up. It may eventually lead to necrosis (tissue destruction) or gangrene. Other diseases of the gallbladder include gallbladder polyps, gallbladder cancer. And a non-functioning gallbladder.

Gallstones

Gallstones develop when substances in the bile (such as cholesterol, bile salts, and calcium) form hard particles that block the passageway to the gallbladder.

Gallstones also tend to form when the gallbladder doesn’t empty completely or often enough. They can be as small as a grain of sand or as large as a golf ball.

Numerous factors contribute to your risk of gallstones. These include:

• being overweight or obese
• eating a high-fat or high-cholesterol diet
• eating a low-fiber diet
• having diabetes
• being age 40 or older
• taking medications that contain estrogen
• having a family history of gallstones
• being female
• Being a Native American
• Being a Mexican-American
• Being sedentary
• Being pregnant
• Losing weight very quickly
• Having liver disease

Cholecystitis [cho·le·cys·ti·tis]

Cholecystitis is the most common type of gallbladder disease. It presents itself as either an acute or chronic inflammation of the gallbladder.

Acute Cholecystitis

Acute cholecystitis is generally caused by gallstones, but it may also be the result of tumors or various other illnesses. It may present with pain in the upper right side or upper middle part of the abdomen. The pain tends to occur right after a meal and ranges from sharp pangs to dull aches that can radiate to your right shoulder. Acute cholecystitis can also cause:

• fever
• nausea
• vomiting
• jaundice
• different colored stools

Chronic Cholecystitis

After several attacks of acute cholecystitis, the gallbladder will shrink and lose its ability to store and release bile. Abdominal pain, nausea, and vomiting may occur.

Choledocholithiasis [ cho·led·o·cho·li·thi·a·sis]

Gallstones may become lodged in the neck of the gallbladder or in the bile ducts. When the gallbladder is plugged in this way, bile can’t exit. This may lead to the gallbladder becoming inflamed or distended. The plugged bile ducts will further prevent bile from traveling from the liver to the intestines. Choledocholithiasis can cause:

• extreme pain in the middle of your upper abdomen
• fever
• chills
• nausea
• vomiting

Acalculous Gallbladder Disease

Acalculous gallbladder disease, or biliary dyskinesia [dis-kə-ˈnē-zh(ē-)ə], occurs without the presence of gallstones. It can be chronic or acute and may result from the gallbladder muscles or valve not working properly. The symptoms can include abdominal pain on the right side of your body that radiates to your shoulder. Eating foods high in fat often triggers this. Related symptoms may include:

• nausea
• vomiting
• bloating
• loose stools

Sclerosing Cholangitis

Inflammation, scarring, and damage to the bile ducts is referred to as sclerosing cholangitis. It’s unknown what causes the disease. People with sclerosing cholangitis may have an enlarged liver or spleen along with a decrease in appetite and weight loss.

Gallbladder Cancer

Cancer of the gallbladder is a relatively rare disease. If it’s not treated, however, it can spread from the inner walls of the gallbladder to the outer layers and then to the other organs and ducts. The symptoms of gallbladder cancer may be similar to those of acute cholecystitis.

Gallbladder Polyps

Gallbladder polyps are lesions or growths that occur on the gallbladder. They’re usually benign and have no symptoms.

Gangrene of the Gallbladder

Gangrene develops when the gallbladder stops functioning due to inadequate blood flow. This may occur due to:

• infections
• injury
• diabetes
• surgery
• diseases related to blood circulation

The symptoms of gallbladder gangrene can include:

• pain in the gallbladder region
• fever
• nausea or vomiting
• gas
• disorientation
• low blood pressure

Abscess of the Gallbladder

Abscess of the gallbladder results when an area of the body becomes inflamed with pus. Pus is the accumulation of white blood cells, dead tissue, and bacteria. It may present with upper right-sided pain in the abdomen.

Prevention

Diet may play a role in gallstones. Specific dietary factors may include:

Fats. Although fats (particularly saturated fats found in meats, butter, and other animal products) have been associated with gallstone attacks, some studies have found a lower risk for gallstones in people who consume foods containing monounsaturated fats (found in olive and canola oils) or omega-3 fatty acids (found in canola, flaxseed, and fish oil). Fish oil may be particularly beneficial in patients with high triglyceride levels, because it improves the emptying actions of the gallbladder.

Fiber. High intake of fiber has been associated with a lower risk for gallstones.

Nuts. Studies suggest that people may be able to reduce their risk of gallstones by eating more nuts (peanuts and tree nuts, such as walnuts and almonds).

Fruits and Vegetables. People who eat a lot of fruits and vegetables may have a lower risk of developing symptomatic gallstones that require gallbladder removal.

Sugar. High intake of sugar has been associated with an increased risk for gallstones. Diets that are high in carbohydrates (such as pasta and bread) can also increase risk, because carbohydrates are converted to sugar in the body.

Alcohol. A few studies have reported a lower risk for gallstones with alcohol consumption. Even small amounts (1 ounce per day) have been found to reduce the risk of gallstones in women by 20%. Moderate intake (defined as 1 – 2 drinks a day) also appears to protect the heart. It should be noted, however, that even moderate alcohol intake increases the risk for breast cancer in women. Pregnant women, people who are unable to drink in moderation, and those with liver disease should not drink at all.

Coffee. Research suggests that drinking coffee every day can lower the risk of gallstones. The caffeine in coffee is thought to stimulate gallbladder contractions and lower the cholesterol concentrations in bile. However drinking other caffeinated beverages, such as soda and tea, does not seem to have the same benefit.

Imaging and Diagnostic Techniques

Ultrasound of the Abdomen (Ultrasonography). Ultrasound is a simple, rapid, and noninvasive imaging technique. It is the diagnostic method most frequently used to detect gallstones and is the method of choice for detecting acute cholecystitis. If possible, the patient should not eat for 6 or more hours before the test, which takes only about 15 minutes. During the procedure, the doctor can check the liver, bile ducts, and pancreas, and quickly scan the gallbladder wall for thickening (characteristic of cholecystitis).

How well ultrasound can help in the diagnosis varies based on the patient’s situation:

• Ultrasound accurately detects gallstones as small as 2 mm in diameter. Some experts recommend that the test be repeated if an ultrasound does not detect stones, but the health care provider still strongly suspects gallstones.
• Air in the gallbladder wall may indicate gangrene.
• Ultrasound does not appear to be very useful for identifying cholecystitis in patients who have symptoms but do not have gallstones.
• Ultrasound is also not as accurate for identifying common bile duct stones or imaging the cystic duct. Stones or a dilated bile duct may only be detected during ultrasound less than 50% of the time. Nevertheless, normal ultrasound results, along with normal bilirubin and liver enzyme tests are very accurate indications that there are no stones in the common bile duct.

Endoscopic Ultrasound. In an ultrasound variation called endoscopic ultrasound (EUS), the physician places an endoscope (a thin, flexible plastic tube containing a tiny camera) into the patient’s mouth and down the esophagus, stomach, and then the first part of the small intestine. The tip of the endoscope contains a small ultrasound transducer, which provides “close-up” ultrasound images of the anatomy in the area. EUS is useful and quite accurate when the health care provider suspects common bile duct stones, but they are not seen on a regular ultrasound and the patient is not clearly ill. However, if common duct stones are detected, they cannot be removed using this method.

Computed Tomography. Computed tomography (CT) scans may be helpful if the doctor suspects complications, such as perforation, common duct stones, or other problems such as cancer in the pancreas or gallbladder. Helical (spiral) CT scanning is an advanced technique that is faster and obtains clearer images. With this process, the patient lies on a table while a donut-like, low-radiation x-ray tube rotates around the patient.

Magnetic Resonance Cholangiography (MRCI), or Magnetic Resonance Cholangiopancreatography (MRCP). A dye is injected into the patient’s veins that helps visualize the biliary tract. It is most likely to be useful in a small group of patients who have symptoms that suggest gallbladder or biliary tract problems, but whose ultrasound and other routine tests have been negative. For these patients, performing a MRCP can eliminate the need for ERCP and its side effects. MRCP is extremely sensitive in detecting biliary tract cancer.

Advances in technology have made ultrasonography, CT, and MRI the primary imaging tests for suspected gallbladder disease.

X-Rays. Standard x-rays of the abdomen may detect calcified gallstones and gas. Variations include oral cholecystography or cholangiography.

• In oral cholecystography, the patient takes a tablet containing a dye the night before the test. The dye fills the gallbladder, and x-ray images are taken the next day. The test has largely been replaced by ultrasound; however, it may be useful in some cases for determining the structural and functional status of the gallbladder, often before nonsurgical procedures.
• In cholangiography, a dye is injected into the bile duct and x-rays are used to view the duct. It is typically used during operations to provide a clear image of the biliary tract.

Cholescintigraphy (Also Called Gallbladder Radionuclide Scan or HIDA scan). Cholescintigraphy, a nuclear imaging technique, is more sensitive than ultrasound for diagnosing acute cholecystitis. It is noninvasive but can take 1 – 2 hours or longer. The procedure involves the following steps:

• A tiny amount of a radioactive dye is injected intravenously. This material is excreted into bile.
• The patient lies on a table under a scanning camera, which detects gamma (radioactive) rays emitted by the dye as it passes from the liver into the gallbladder.
• The test can take up to 2 hours, because each image takes about a minute, and images are taken every 5 – 15 minutes.

If the dye does not enter the gallbladder, the cystic duct is obstructed, indicating acute cholecystitis. The scan cannot identify individual gallstones or chronic cholecystitis.

Occasionally, the scan gives false positive results (detecting acute cholecystitis in people who do not have the condition). Such results are most common in alcoholic patients with liver disease or patients who are fasting or receiving all their nutrition intravenously.

Endoscopic Retrograde Cholangiopancreatography (ERCP). Endoscopic retrograde cholangiopancreatography (ERCP) was once the gold standard for detecting common bile duct stones, particularly because stones can be removed during the procedure. (See “Surgery” section below for a description of the procedure.)

However, this technique is invasive and carries a risk for complications, including pancreatitis. With the technological advancement of noninvasive imaging techniques, ERCP is now generally limited to patients who have severe cholangitis and a high likelihood of common bile ducts stones, which would need to be removed. It may also be used to diagnose biliary dyskinesia.

Virtual Endoscopy. Virtual endoscopy is an experimental technique that uses data from CT and MRI scans to generate a three-dimensional view of various body structures. The images resemble those used in endoscopy (an invasive procedure), but the procedure is noninvasive. Virtual endoscopy may be able to detect smaller stones in the common bile duct than MRI.

Treatment

Acute pain from gallstones and gallbladder disease is usually treated in the hospital, where diagnostic procedures are performed to rule out other conditions and complications. There are three approaches to gallstone treatment:

• Expectant management (“wait and see”)
• Nonsurgical removal of the stones
• Surgical removal of the gallbladder
• Because cholecystitis frequently recurs, most people with the condition eventually require gallbladder removal surgery (cholecystectomy). The timing of surgery will depend on the severity of your symptoms and your overall risk of problems during and after surgery. If you’re at low surgical risk, you may have surgery within 48 hours or during your hospital stay.
• Cholecystectomy is most commonly performed using a tiny video camera mounted at the end of a flexible tube. This allows your surgeon to see inside your abdomen and to use special surgical tools to remove the gallbladder (laparoscopic cholecystectomy). The tools and camera are inserted through four incisions in your abdomen, and the surgeon watches a monitor during surgery to guide the tools. An open procedure, in which a long incision is made in your abdomen, is rarely required.

  A less invasive way to remove gallbladders is under study. Known as natural orifice transluminal endoscopic surgery (NOTES), the procedure is intended to lessen scarring and discomfort. While laparaoscopic cholecystectomy remains the standard of care for gallbladder removal, NOTES is being performed in a few centers worldwide and may eventually be an important alternative.

  Once your gallbladder is removed, bile flows directly from your liver into your small intestine, rather than being stored in your gallbladder. You don’t need your gallbladder to live normally.

 

References:
https://medlineplus.gov/gallbladderdiseases.html
http://www.mayoclinic.org/diseases-conditions/gallstones/symptoms-causes/dxc-20231395
http://www.mayoclinic.org/diseases-conditions/cholecystitis/basics/definition/con-20034277
http://umm.edu/health/medical/reports/articles/gallstones-and-gallbladder-disease