Gallstones: Does Everybody Need Surgery?

What are the causes of gallstones? 

It is difficult to tell what causes gallstones as there are so many associated risks. It is more in females compared to men (3:1). Incidence increases with age. The occurrence is more in overweight/obese patients. It can also be familial. It is also more in people who starve for a long time or have drastic weight loss. It is commonly associated with people who eat lot of oily food. As you can understand, there is no specific reason.

What is the incidence of gallstones in India?

Incidence of gallstones varies in different parts of the world. In India, there is huge variations in different parts of the country. North East and Bengal has the highest incidence (10 percent) and South India has the lowest (2–3 percent). In North East India and Bengal, gallstones can be detected at a very early age compared to South India.

Are there any medicines for gallstones?

The main question that worries the patients is what to do when diagnosed with gallstones. It is more confusing as they get different answers from different doctors.

If one tells them they can be dissolved, then the patients should be very careful. If there was ever a medicine to dissolve gallstones permanently, then the person who discovered it would probably get a Nobel Prize and can be the richest man as western counties spend billions on surgery. In short, there is no medicine to dissolve them permanently.

What are the complications of gallstones?

Before answering the question whether one needs surgery or not, we need to understand the risks of gallstones and surgery.  They are as follows:

Pain (biliary colic): Normally, pain comes after food, especially fatty foods, across upper abdomen and can radiate to the back. It can last up to a few hours. If any one experiences these symptoms repeatedly and is found to have gallstones, then it is symptomatic gallstones. Patients are strongly advised to have surgery (laparoscopic cholecystectomy: key hole procedure to remove gall bladder with stones) before having any of the other complications listed below.

Infection (cholecystitis): This infection of gall bladder usually happens when gallstone blocks the cystic duct (see picture). This would need admission and prompt treatment with intravenous antibiotics at least for 48 hours and surgery (laparoscopic cholecystectomy: key hole procedure to remove gall bladder with stones) on same admission.

Infection cholangitis: This happens when there is infection  with blocked bile duct caused by the stone in the bile duct. This is a very serious condition as the infection can spread to the blood in a very short time and cause serious organ damage (renal failure / cardiac failure / liver failure). This is associated with high risks, so patients would be in ICU. Patients will need ERCP ( camera procedure to remove stone in bile duct). Once recovered from the infection, patients will need surgery (laparoscopic cholecystectomy: key hole procedure to remove gall bladder with stones) on the same admission.

Jaundice: This can happen when gallstone slips from the gallbladder to the common bile duct and causes obstruction to flow of bile (see picture). Patients will need ERCP (camera procedure to remove stone in bile duct). Sometimes, the stone can pass on its own. This will be determined by serial blood tests. Once recovered from the infection, patients will need surgery (laparoscopic cholecystectomy: key hole procedure to remove gall bladder with stones) on the same admission.

Pancreatitis: This is the most serious complication of gallstones with serious threat to life depending on the severity of pancreatitis. Most patients will need ERCP (camera procedure to remove stone in bile duct). Vary rarely can the stone pass on its own. Once recovered from pancreatitis, patients will need surgery (laparoscopic cholecystectomy: key hole procedure to remove gall bladder with stones) on the same admission.

What is the function of the gallbladder?

Its main function is to store bile and release it when needed (usually after food). Losing it will not interfere with digestion. After surgery, the main bile duct takes over the function of the gall bladder.

Contrary to belief, there is restriction of food after surgery to remove gall bladder (laparoscopic complications).

What are the complications of gallbladder surgery / laparoscopic cholecystectomy and what percentage have complications?

Complications happen in 0.2 percent of the cases, that is, 1 in 500 cases of laparoscopic cholecystectomy worldwide. Complications include bleeding, bowel injury and bile duct injury. The complication risks are higher in people who have had one of the above discussed complications from gall stones.

Who needs gallbladder surgery / laparoscopic cholecystectomy?

You can make an informed decision to have a laparoscopic cholecystectomy based on the following information:

If the gallstones are symptomatic or you had any one of above complications, then there is an absolute indication for surgery on the same admission or as soon as possible before you have other complications.

If gallstones are incidental (this is the controversial part where the patient needs to make a decision) and found on scan for some other reason and are not causing any complications, then you have to decide whether to have the surgery or not. The above article will help you make that decision. If someone is diagnosed with gallstones, then they have 2–5 percent risk of the above complications every year versus 0.2 percent risk of complication from surgery to remove gallbladder. If a patient has a complication, then he/she would need at least 3–5 days admission, more time to recover and the cost of treatment also increases with each complication.  It is the patient’s decision whether to risk complications and then face a complicated surgery with a higher risk of complications and prolonged recovery with added extra expenditure or have an elective surgery where you can go home the same day or the next day.

If one does not live in select few cosmopolitan cities with access to all the healthcare facilities, then it does not make sense to wait until the complication occurs as it will be difficult to deal with them in small cities with limited resources and facilities. One’s life is put to serious risk in such cases.

Are there any food restrictions after surgery?

 Absolutely none. One can start having food few hours after surgery and can eat anything he/she wishes without any restriction and malabsorption.