Dr Stephen Chang, general surgeon at Mount Elizabeth Hospital specialising in liver, pancreas, gall bladder and bile duct surgery, explains gallstone disease and its treatment options.

In clinical practice, very often we find people with symptoms which have been mistaken for ‘gastric’ pain – often a sensation of pain or discomfort in the upper abdomen either around the midline or to the right.

Many of them may have been given a trial of medication for gastritis with no improvement and may have even subjected themselves to endoscopic examination which did not reveal any significant gastric problem. 

A substantial number of them were actually suffering from gallstone disease!

The confusion arises because the nerve supply to the stomach and the gall bladder share the same origin in the vagus nerve.

What are the symptoms of gallstones?

Thankfully, 60 – 80% of gallstones are asymptomatic and do not pose a health risk. 

Among those with symptoms, some are recurrent and chronic, while some are acute with severe symptoms or complications arising from the gallstones. Symptoms of these complications include:

• Biliary colics – moderate to severe, colicky pain in upper middle & right abdomen, which may go to back or shoulder tip
• Fatty food dyspepsia – feeling of indigestion, belching, bloating, flatulence, ‘acidity’
• Acute cholecystitis – acute inflammation of the gall bladder, presenting with a more severe continuous pain in the upper middle & right abdomen which may be accompanied by fever
• Liver duct stone – due to ‘dropping’ of gallstones from the gall bladder into the liver duct (bile duct) causing yellowing of eyes and skin (jaundice), tea coloured urine and pain in the upper abdomen
• Inflammation of pancreas (pancreatitis) – due to obstruction of the pancreas duct as the ‘dropped stone’ passes down the liver duct causing severe upper abdominal pain 

How are gallstones formed?

Gallstones are formed in the gall bladder or bile duct when bile in there hardens. Obesity, use of contraceptives, a high cholesterol diet, alcohol and some blood destruction disorders may lead to an increased risk of developing gallstones.

How are gallstones diagnosed?

The most common and accurate way to diagnose gallstones is through an abdominal ultrasound which will show the stones in the gall bladder. It may also show other signs for gallstones that have turned complicated.

How are gallstones treated?

Gallstones without symptoms or complications are generally left alone. Gallstones that cause symptoms or lead to complications are best treated with surgical removal together with the gall bladder.

Although the stones in the gall bladder may theoretically be broken down with shock waves or chemical treatment, they often recur and the complications from such treatments outweigh the risk for gall bladder removal surgery in established surgical practice. 

Benefits of single incision laparoscopic surgery (SILS)

In the conventional laparoscopic (keyhole) surgery, 4 incisions are made through the abdominal wall leaving behind 4 scars with at least 3 scars in the upper abdomen being visible. With single incision laparoscopic surgery (SILS), a single incision is made through the umbilicus which is our body’s ‘natural’ scar, and thus no new scars are created. 

Not only is there benefit in terms of cosmetic value, there is also some evidence of reduced pain experience among patients who had this form of surgery. This has been proven in scientific trials¹. Through improvement in technique, the cost of this surgery is now comparable to the conventional 4-incision technique.

Summary

Symptoms of gall bladder stones are very often mistaken to be ‘gastric’ in nature. Symptomatic gallstones are best treated with surgical removal of the stone and the gall bladder. Advances in surgical technique and instrumentation allow the procedure to be done expeditiously and safely with minimal discomfort and disruption to daily life.

References

1. Chang SK, Wang YL, et al. A Randomized Controlled Trial Comparing Post-operative Pain in Single-Incision Laparoscopic Cholecystectomy Versus Conventional Laparoscopic Cholecystectomy. World J Surg. 2014 Dec 2.