Gallstones, Cholecystitis, Inflammation of the Gallbladder
Gallstones develop in the gallbladder when either the amount of cholesterol secreted into the gallbladder by the liver is too high, or the amount of other substances in the bile is too low to prevent the cholesterol from remaining in solution. In either condition, the cholesterol precipitates out as small crystals which eventually form larger stones. Many people have gallstones for years without any symptoms whatsoever. Symptoms from gallbladder disease usually consist of upper right quadrant abdominal pain especially after ingestion of heavy meals which contain rich foods. The pain may radiate around to the back and up under the shoulder blade. Sometimes nausea and vomiting occur. If severe inflammation of the gallbladder occurs, it is called cholecystitis, and the patient may develop severe abdominal pain and fever. The most common treatment for patients with symptomatic gallstone disease is cholecystectomy (removal of the gallbladder surgically). This can be done by a surgeon using the standard technique (an incision made in the upper right quadrant of the abdomen) or the newer technique of laparoscopic removal of the gallbladder. This newer technique is performed with an instrument called a laparoscope which is inserted into the abdomen through a small incision made around the navel. In some patients who are not surgical candidates, stones may be dissolved by medicine or broken up by ultrasound or shockwave techniques (lithotripsy). The reoccurrence of stones once medicine is stopped can occur. Whether these techniques will avoid the need for surgery in all patients is unknown.
Image of Outside of GallBladder and Interior of the Gallbladder
Gallstones may be painful and cause fever.
Sometimes stones from the gallbladder may become lodged in the duct that allows flow of bile from the gallbladder to exit into the duodenum. When this happens, these lodged stones may cause pain, fever and elevation of one’s liver function tests. Your Borland-Groover physician may perform an ERCP in order to evaluate if this is the problem, and if stones are found within the ducts, he can remove them during ERCP. A new approach to imaging of the bile duct which is less invasive and with less complication than ERCP is called MRCP. MRCP is a technique in which a special MRI unit with special software produces pictures that resemble those obtained with ERCP. The downside, if anything is found such as a stone or mass or leak of the bile duct, then ERCP may be required to fix the problem. At present the role of MRCP is still being defined.
In a small group of patients who have had their gallbladder removed, they may have recurrent pain similar to the pain that they had prior to its removal. At times this pain may be severe and in a few cases have significant impact in ones quality of life. Such patients may have a clinical condition known as post-cholecystectomy pain syndrome which may be caused by sphincter of Oddi dysfunction. The sphincter of Oddi is a small muscle which is at the bottom of the common bile duct and it controls the flow of bile into the duodenum. In such patients with pain, there may be an associated elevation of their liver function tests, or they may have demonstrated dilatation of their common bile duct on ERCP. In such patients, often times a small cut done during ERCP of the sphincter of Oddi will make this pain go away.
A more difficult group of patients are those that have had their gallbladders removed and who have recurrent pain which is severe and there is no elevation of their liver tests in association with the pain, and neither is there dilatation of their bile ducts at the time of ERCP assessment. In such patients a technique called sphincter of Oddi manometry may be used. In this technique an ERCP scope is passed to the level of the sphincter of Oddi (The Ampulla), and through the ERCP scope, a special catheter is placed into the muscle to measure pressures and the frequency of contraction. If elevated, the endoscopist may elect at that time to make a small cut, known as a sphincterotomy. This difficult group of patients may see a 50% chance of improvement. The downside: in this special group of patients, the risk of pancreatitis post ERCP with manometry may be as high as 25%. One way to hopefully minimize this risk is to use a technique at the time of manometry known as aspiration manometry which was first reported by Dr. Sherman’s group at the University of Indiana. We have been using this technique ourselves, and we too believe, as he first reported, that it decreases the incidence of pancreatitis considerably. The bottom line, if you are considering to have manometry done during ERCP, be sure it is being done by someone who knows what they are doing.