The gall-bladder rests on the underside of the LIVER and joins the common hepatic duct via the cystic duct to form the common BILE DUCT. It acts as a reservoir and concentrator of BILE, alterations in the composition of which may result in the formation of gall-stones, the most common disease of the gall-bladder.
affect 22 per cent of women and 11 per cent of men. The incidence increases with age, but only about 30 per cent of those with gallstones undergo treatment, as the majority of people with them have no symptoms. There are three types of stone: cholesterol, pigment and mixed, depending upon their composition; stones are usually mixed and may contain calcium deposits. The cause of most cases is not clear, but sometimes gall-stones will form around a ‘foreign body’ within the bile ducts or gall-bladder, such as suture material following surgery in the area.
Muscle fibres in the biliary system contract around a stone in the cystic duct or common bile duct in an attempt to expel it. This causes pain in the right upper quarter of the abdomen, with nausea and occasionally vomiting.
Gall-stones small enough to enter the common bile duct may block the flow of bile and cause jaundice.
Blockage of the cystic duct may lead to this condition. The gall-bladder wall becomes inflamed, resulting in pain in the right upper quarter of the abdomen, nausea, vomiting and fever. There is characteristically tenderness over the tip of the right ninth rib on deep inhalation (Murphy's sign). Infection of the gall-bladder may accompany the acute inflammation and occasionally an EMPYEMA of the gall-bladder may result.
A more insidious form of gall-bladder inflammation, producing prolonged low-level or intermittent abdominal pain, nausea and flatulence which may be worse after a fatty meal.
Stones are usually diagnosed when someone complains of the symptoms described above, although symptomless gall-stones can be found by chance when investigating another complaint. Confirmatory investigations include abdominal RADIOGRAPHY - although many gall-stones are not calcified so do not show up on these images; ULTRASOUND scanning; oral CHOLECYSTOGRAPHY - which entails a patient's swallowing a substance opaque to X-rays which is concentrated in the gall-bladder; and ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) - a technique in which an ENDOSCOPE is passed into the duodenum and a contrast medium injected into the biliary duct.
Biliary colic is treated with rest and injection of morphine-like analgesics. Once the pain has subsided, the patient may then be referred for further treatment as outlined below. Acute cholecystitis is treated by surgical removal of the gall-bladder. There are two techniques available for this procedure: firstly, conventional cholecystectomy, in which the abdomen is opened and the gall-bladder cut out; and, secondly, laparoscopic cholecystectomy, in which fibreoptic instruments called endoscopes (see FIBREOPTIC ENDOSCOPY) are introduced into the abdominal cavity via several small incisions (see MINIMALLY INVASIVE SURGERY). Laparoscopic surgery has the advantage of reducing the time it takes for the patient to recover, so shortening their stay in hospital. Gall-stones may be removed during ERCP; they can sometimes be dissolved using ultrasound waves (lithotripsy) or tablet therapy (dissolution chemotherapy). Pigment stones, calcified stones or stones larger than 15 mm in diameter are not suitable for this treatment, which is also less likely to succeed in the overweight patient. Drug treatment is prolonged but stones can disappear completely after two years. Stones may re-form on stopping therapy. The drugs used are derivatives of bile salts, particularly chenodeoxycholic acid; side-effects include diarrhoea and liver damage.
These are rare.
may form and, if symptomatic, should be removed.
of the gall-bladder is a disease of the elderly and is almost exclusively associated with gall-stones. By the time such a cancer has produced symptoms, the prognosis is bleak, but if the tumour is discovered early, 60 per cent of patients will survive five years.
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