Thank you for asking this question. I am an internal medicine
physician and do not have any surgical experience, but I can answer
your questions.
The most common cause of blocked bile ducts are from gallstones.
Stones can form in the gallbladder if there is a change or imbalance
in the composition of bile, such as too much cholesterol, increased
amounts of pigment material, and/or reduced levels of bile acids which
are "detergent-like" substances that help keep the cholesterol in
solution form. Evidence suggests that gallstone development may also
result from an impairment of gallbladder contraction, which would lead
to incomplete emptying of the gallbladder in response to a fatty meal.
How do gallstones cause pain?
From Harrison’s Principles of Internal Medicine:
“Gallstones usually produce symptoms by causing inflammation or
obstruction following their migration into the cystic duct or common
bile duct. The most specific and characteristic symptom of gallstone
disease is biliary colic (gallstone or biliary pain). Obstruction of
the cystic duct or CBD by a stone produces increased intraluminal
pressure and distention of the viscus that cannot be relieved by
repetitive biliary contractions. The resultant visceral pain is
characteristically a severe, steady ache or pressure in the
epigastrium or right upper quadrant (RUQ) of the abdomen with frequent
radiation to the interscapular area, right scapula, or shoulder.
Biliary colic begins quite suddenly and may persist with severe
intensity for 30 min to 5 h, subsiding gradually or rapidly. An
episode of biliary pain is sometimes followed by a residual mild ache
or soreness in the RUQ, which may persist for 24 h or so. Nausea and
vomiting frequently accompany episodes of biliary colic. Fever or
chills (rigors) with biliary colic usually imply a complication, i.e.,
cholecystitis, pancreatitis, or cholangitis. Complaints of vague
epigastric fullness, dyspepsia, or flatulence, especially following a
fatty meal, should not be confused with biliary colic. Such symptoms
are frequently elicited from patients with gallstone disease but are
not specific for biliary calculi. Biliary colic may be precipitated by
eating a fatty meal, by consumption of a large meal following a period
of prolonged fasting, or by eating a normal meal.” (1)
What is the difference between biliary colic and the pain from
cholecystitis?
As mentioned above, the pain of biliary colic typically reaches a
crescendo, and then resolves completely. Pain resolution occurs when
the gallbladder relaxes, permitting stones to fall back from the
cystic duct. An episode of right upper quadrant pain lasting for more
than four to six hours should raise suspicion for acute cholecystitis.
Patients with constitutional symptoms such as malaise or fever are
more likely to have acute cholecystitis.
What other conditions can cause biliary pain?
A variety of other conditions can give rise to symptoms in the upper
abdomen, which may be confused with biliary colic or acute
cholecystitis. These include:
Acute pancreatitis
Appendicitis
Acute hepatitis
Peptic ulcer disease
Diseases of the right kidney
Right-sided pneumonia
Fitz-Hugh-Curtis syndrome (perihepatitis caused by gonococcal
infection)
Subhepatic or intraabdominal abscess
Perforated viscus
Cardiac ischemia
These conditions can usually be differentiated by the clinical setting
in which they occur and by obtaining the appropriate diagnostic
studies. (3)
How are gallstones treated?
As gallstones are the most common cause of biliary blockage, I will
focus on these. There are three general options for people with
gallstones; the best option depends upon the clinical setting:
1) Expectant management: Do nothing, wait and watch.
2) Surgical therapy: Removal of the gallbladder with its stones.
3) Non-surgical therapy: Elimination of the stones while preserving
the gallbladder
People with asymptomatic gallstones:
People with gallstones who are asymptomatic usually require no
specific intervention. Experts feel that the risk from surgical
removal of the gallbladder is greater than the risk from not treating
silent stones. Thus, preventive gallbladder removal in asymptomatic
gallstones is not recommended since many such individuals will remain
asymptomatic for a very long time, possibly even for the rest of their
lives. Individuals with silent gallstones must be educated as to the
initial symptoms of gallstone disease because treatment should be
sought once the first symptoms occur since the chance of recurrent and
more severe symptoms becomes very high.
Surgical options:
The gallbladder is an important organ, but is not essential for life.
Therefore, the standard treatment for symptomatic patients who suffer
from gallstones has been to have the gallbladder removed surgically
along with its contained stones. Removing the gallbladder may have
little or no effect on digestion. Loose stools, gas, and bloating may
develop in about half the patients, but in most they are mild,
requiring no dietary restrictions after the gallbladder is removed.
Open cholecystectomy: Cholecystectomy, surgical removal of the
gallbladder, is one of the most commonly performed surgical
procedures; more than 700,000 are performed in the United States each
year. There are two versions of this operation. The first is the
classic open cholecystectomy which leaves a 4- to 6-inch scar and
usually requires three to five days of hospitalization and several
weeks of recuperation. The operation is extremely safe (complications
occurring in only 6 percent of patients but major complications are
very rare). However, the risk increases with age and in patients with
other medical problems.
Laparoscopic cholecystectomy: The second and newer surgical technique
is laparoscopic cholecystectomy. Under general anesthesia, a
video-endoscope and instruments are introduced into the abdomen
through four or five very small non-muscle cutting incisions and used
to visualize and remove the gallbladder. The patient is typically
hospitalized for one to two days and requires a recovery time of one
to two weeks. Over the past few years laparoscopic cholecystectomy
quickly became the standard operation for removing the gallbladder.
Experience with this technique has shown this operation to be safe and
well tolerated by the patient but the chance of complications relating
to common bile duct injury is somewhat higher than that of the other
procedure.
Non-surgical options:
Nonsurgical approaches are available for the treatment of gallstones.
These require no surgical incision or general anesthesia and eliminate
the stones while preserving the gallbladder. Four non-surgical
approaches are currently available for the treatment of gallstones.
Oral bile acid pill: An oral bile acid pill (ursodeoxycholic acid or
ursodiol) is a medication approved by the Food and Drug Administration
of the United States for the treatment of gallstones. It contains a
natural bile acid that slowly dissolves predominantly cholesterol
gallstones over a period of one to three years. However, about
two-thirds of patients become symptom free about two to three months
after the bile acid pill is started and remain as such even though it
may take several years for the stones to actually disappear.
Nevertheless, because of its slow action its use is not practical in
patients with recurrent or acute symptoms. It is very safe and well
tolerated, but mild transient diarrhea may occur in a minority of
patients. Its use is limited to small cholesterol stones, it requires
a functioning gallbladder, and is typically effective in only 50
percent of patients who are qualified to take it.
Topical gallstone dissolution: The second non-surgical approach is
topical gallstone dissolution, which is not approved and still in the
investigational stages in the United States. It involves dissolving
the stones by bathing them with a gallstone dissolving solution
(solvent)..
Percutaneous endoscopic laser or electrohydraulic lithotripsy: The
third non-surgical approach is percutaneous endoscopic laser or
electrohydraulic lithotripsy. In this procedure, a catheter is
inserted into the gallbladder under local anesthesia and remains in
place for two weeks. The patient would then return when the catheter
track is slightly enlarged to the size of a small straw. A laser probe
is then used to apply short bursts of laser energy to fracture the
stones into small pieces that are then washed out of the gallbladder.
The devices for this procedure are currently approved and available in
the United States and it is the only non-surgical approach that is
effective for all types of stones. Thus, it is useful for
non-cholesterol pigment stones. The main disadvantage is that it is a
prolonged procedure requiring three to four outpatient visits over
several weeks for completion. It is also labor intensive and,
therefore, rarely done only on patients at high-risk who have
non-cholestesterol stones.
Extracorporeal shock wave lithotripsy: The fourth approach is
extracorporeal shock wave lithotripsy (ESWL). Shock waves generated
outside the body are focused on the gallstones to fracture them into
smaller fragments and "sand," which can then be dissolved more
efficiently by the oral bile acid pill. ESWL has been approved and
used extensively in the treatment of kidney stones. It was recently
approved for the treatment of gallstones as well. Since it relies on
bile acid therapy to clear the fractured stones and residue, it can
only treat cholesterol stones. It is not effective for more than three
stones or large stones and a functioning gallbladder is required.
Studies to date show that its success rate is not very high and may be
painful, necessitating sedation. It may also cause attacks of biliary
pain as fragments pass through the bile duct into the intestine. The
shock waves may cause some internal organ damage, which usually is not
significant. (2)
Please use the answer clarification to ask any questions before rating
this answer. I will be happy to explain any issue.
Thanks,
Kevin, M.D.
Search strategy:
No internet search engine was used in this answer. All sources are
from objective, physician-written, peer-reviewed resources.
Links (Search strategy “gallstones patient information” using Google):
Jefferson Digestive Disease Institute
http://jeffline.tju.edu/CWIS/DEPT/GI/patient_info/disease7.html
Praxis.md
http://praxis.md/bhg/bhg.asp?page=BHG01GA24
http://praxis.md/bhg/bhg.asp?page=BHG01GA24
Bibliography:
1) Greenberger et al. Gallstones from Harrison’s Principles of
Internal Medicine v1-2. New York: McGraw-Hill, 2001.
2) Zakko. Patient information: Overview of gallstones. UptoDate,
2002.
3) Zakko. Clinical features and diagnosis of acute cholecystitis.
UptoDate, 2002. |
