The Furry Monkey

GALLBLADDERS

So why is there a section on gallbladders and their associated problems in a mainly Non-Hodgkin's Lymphoma related website you ask?

Well the reason is, my furry friends, that I finished my radiotherapy and within a week I was in bed dosed up on morphine in extreme pain. It was the start of my gallstone/gallbladder experience. The pain is excrutiating and there is absolutely NOTHING that you can do to ease it. I was vomiting all the time and even my favourite painkiller, morphine didn't work. In the end I was having pethadine injections each time just to keep the pain at bay. You will find more details of what I went through by checking out my diary.

I've heard of other NHL patients suffering with gallbladder problems after having radiotherapy/
chemotherapy. Maybe it is related, who knows? No one knows for certain. So to help you with information on the old gallbladder, I've created a new section all about it.

All I can say is, a BIG thank you Dr Bearn for doing my laparoscopic cholecystectomy!!! You made my year!

ERCP

GALLBLADDER

 

ERCP

ERCP stands for endoscopic retrograde cholangiopancreatography. As hard as this is to say, the actual exam is fairly simple.

Endoscopic refers to the use of an instrument called an endoscope - a thin, flexible tube with a tiny video camera and light on the end. The endoscope is used by a highly trained subspecialist, the gastroenterologist, to diagnose and treat various problems of the GI tract. The GI tract includes the stomach, intestine, and other parts of the body that are connected to the intestine, such as the liver, pancreas, and gallbladder.

Retrograde refers to the direction in which the endoscope is used to inject a liquid enabling X-rays to be taken of the parts of the GI tract called the bile duct system and pancreas. The process of taking these X-rays is known as cholangiopancreatography.

Cholangio refers to the bile duct system, pancrea to the pancreas. ERCP may be useful in diagnosing and treating problems causing jaundice (a yellowing of the whites of the eyes) or pain in the abdomen. To understand how ERCP can help, it's important to know more about the pancreas and the bile duct system.

The liver produces bile. Bile is a substance made by the liver that is important in the digestion and absorption of fats. Bile is carried from the liver by a system of tubes known as bile ducts. One of these, the cystic duct, connects the gallbladder to the main bile duct. The gallbladder stores the bile between meals and empties back into the bile duct when food is consumed. The common bile duct then empties into a part of the small intestine called the duodenum. The common bile duct enters the duodenum through a nipple-like structure called the papilla. Joining the common bile duct to pass through the papilla is the main duct from the pancreas. This pathway allows digestive juices from the pancreas to mix with food in the intestine. The pancreas, which is six to eight inches long, sits behind the stomach. This organ secretes digestive enzymes that flow into the intestine through the same opening as the bile. Both bile and enzymes are needed to digest food. Problems that affect the pancreas and bile duct system can, in many cases, be diagnosed and corrected with ERCP.

Equipment

The flexible endoscope is a remarkable piece of equipment that can be directed and moved around the many bends in the upper gastrointestinal tract. The newer video endoscopes have a tiny, optically sensitive computer chip at the end. Electronic signals are then transmitted up the scope to the computer which then displays the image on a large video screen. An open channel in the scope allows other instruments to be passed through it to perform biopsies, inject solutions, or place stents.

Reasons for the Exam

Due to factors related to diet, environment and heredity, the bile ducts, gallbladder and pancreas are the seat of numerous disorders. These can develop into a variety of diseases and/or symptoms. ERCP helps in diagnosing and often in treating the condition. Apart from its diagnostic uses, ERCP can also be used to relieve jaundice by removing gallstones from the bile ducts or by placing a plastic tube (stent) across a narrowing in the lower bile duct.

ERCP is used for:

Preparation

The only preparation needed before an ERCP is to not eat or drink for eight hours prior to the procedure. You may be asked to stop certain medications such as aspirin before the procedure. Check with your Doctor. Also inform the Doctor of any allergies or any reactions you have had to drugs, particularly antibiotics or pain medications. ALWAYS follow all of your doctor's instructions regarding preparation for the procedure.

The Procedure

An ERCP uses x-ray films and is performed in an x-ray room. The throat is anesthetized with a spray or solution, and the patient is usually mildly sedated. The endoscope is then gently inserted into the upper esophagus. The patient breathes easily throughout the exam, with gagging rarely occurring. A thin tube is inserted through the endoscope to the main bile duct entering the duodenum. Dye is then injected into this bile duct and/or the pancreatic duct and x-ray films are taken. The patient lies on his or her left side and then turns onto the stomach to allow complete visualization of the ducts. If a gallstone is found, steps may be taken to remove it. If the duct has become narrowed, an incision can be made using electrocautery (electrical heat) to relieve the blockage. Additionally, it is possible to widen narrowed ducts and to place small tubing, called stents, in these areas to keep them open. The exam takes from 20 to 40 minutes, after which the patient is taken to the recovery area.

Results

After the exam, the Doctor explains the results. If the effects of the sedatives are prolonged, the Doctor may suggest an appointment for a later date when the patient can fully understand the results.

Benefits

An ERCP is performed primarily to identify and/or correct a problem in the bile ducts or pancreas. This means the test enables a diagnosis to be made upon which specific treatment can be given. If a gallstone is found during the exam, it can often be removed, eliminating the need for major surgery. If a blockage in the bile duct causes yellow jaundice or pain, it can be relieved.

Alternative Testing

Alternative tests to ERCP include certain types of x-rays (CAT scan, CT) and sonography (ultrasound) to visualize the pancreas and bile ducts. In addition, dye can be injected into the bile ducts by placing a needle through the skin and into the liver. Small tubing can then be threaded into the bile ducts. Study of the blood also can provide some indirect information about the ducts and pancreas.

Side Effects and Risks

A temporary, mild sore throat sometimes occurs after the exam. Serious risks with ERCP, however, are uncommon. One such risk is excessive bleeding (this happened to me - internal bleeding is not fun!), especially when electrocautery is used to open a blocked duct. In rare instances, a perforation or tear in the intestinal wall can occur. Inflammation of the pancreas also can develop. These complications may require hospitalization and, rarely, surgery.

GALLBLADDER

So where is the gallbladder in your body? It's here.... just underneath your liver that's where.....LOL!

The Gallbladder

The gallbladder is a small pear-shaped bag located beneath the liver on the right side of the abdomen. The gallbladder stores bile, and concentrates it holding ready for digestion. The gallbladder can store up to one cup of concentrated bile. Shortly after eating a meal, the gallbladder squeezes and its bile is released back into the bile duct, and then into the gut. Bile helps fat digestion, and some bile is reabsorbed, returning to the liver, whilst the waste materials within it are eliminated from the body in the stools - which is why they are usually coloured brown.

Gallstones

1 in 10 people over 50 in the UK have gallstones. Gallstones are solid pieces of material that form in the gallbladder, and are usually a little softer than stones. Around one in ten people have gallstones, most commonly as they get into mid-life. Women develop gallstones more commonly than men and at a younger age. Gallstones vary in size and may be as small as sand grains or as large as a plum. The gallbladder may develop a single, often large, stone or many smaller ones, even several thousand.

As the gallbladder concentrates bile, it can cause cholesterol and/or bile pigments to crystallise, eventually growing large enough to form gallstones. This can be encouraged by a combination of factors, including inherited body chemistry, body weight, sluggish gallbladder movement, and perhaps diet. Some proteins in bile can promote or inhibit cholesterol crystallisation. Obesity is a major risk factor for gallstones, with a large clinical study showing that even being moderately overweight increases the risk of developing gallstones, probably because it causes excess cholesterol in bile, low bile salts, and decreased gallbladder emptying.

Curiously, very low calorie, rapid weight-loss diets, and prolonged fasting, seem to also cause gallstone formation. Increased levels of the female hormone oestrogen, from pregnancy, hormone therapy, or contraceptive pills may increase bile cholesterol levels and decrease gallbladder emptying. Low-fibre (roughage), high-cholesterol diets, and diets high in starchy foods have been suggested as contributing to gallstone formation.

Cholesterol stones are white or yellow and make up about 80% of gallstones, but most are mixed and contain some pigment. They develop when bile contains an imbalance, with too much cholesterol and not enough bile salts. Pure pigment stones are small, dark and made of bilirubin, accounting for the other 20%, and may result from cirrhosis, biliary tract infections, and hereditary blood cell disorders, such as sickle cell anaemia or spherocytosis.

What diseases can gallstones cause?

Most people with gallstones do not know they have them, as they do not experience any trouble from them. However, gallstones can lead to gallbladder pain, or leave the gallbladder and enter the bile duct, also causing blockage leading to (yellow) jaundice, inflammation with rigors (shivering), or acute pancreatitis.

Gallbladder pain can be caused by muscular spasm when the gallbladder attempts to expel the stones (biliary colic), or more seriously, irritation or inflammation due to infection (acute cholecystitis). The pain varies from a brief feeling of indigestion after eating, to severe attacks of up to several hours duration, with nausea, vomiting or belching, and sometimes bloating.

Pain is usually felt in the middle or right side of the upper abdomen, and sometimes, due to the way the gallbladder develops in early life, pain can be 'referred' around the right rib margin pain to the back and around the shoulder or shoulder blade.

In jaundice bile cannot flow into the gut and spills into the blood, causing a yellow skin and eye colour. Digestion is also impaired causing bloating, the stools turn a putty colour, and due to the overspill into blood, some, urine becomes dark. Bile infection can occur in this situation causing 'rigors' or severe shivering attacks.

How are gallstones diagnosed?

The Doctor will suspect gallstones from listening to your history, examining you, and perhaps also blood and urine tests. However, to prove gallstones requires imaging (scanning)

Ultrasound: More properly called ultrasonographic scanning (USS), this is the same scanning technique used to observe the unborn baby in the womb. It uses sound waves and is totally safe and painless. Sound waves bounce off gallstones and the reflections show on a video screen.

X-rays: Gallstones only show up on 'plain' X-rays 10% of the time, but by taking a dye by mouth which concentrates in the bile, gallstones can be demonstrated. This is called an oral cholecystogram (OCG). CAT or CT scanning is better than 'plain' X-rays, but can miss stones, especially if they are small and do not contain much calcium (chalk).

Cholangiography: Depending on the complications which gallstones cause, it may be necessary to look for gallstones in the bile duct as well as the gallbladder. This can be done in a variety of ways. The simplest way is to inject dye into the bile duct during a gallbladder operation, 'intra-operative cholangiography', but it is not necessary to have an operation to do this.

Endoscopic Retrograde Cholangio-Pancreatography (ERCP), dye can be injected through a swallowed telescope (endoscope) backwards up into the bile and pancreatic ducts. Bile duct gallstones can be removed through the telescope, but not those in the gallbladder.

Because there are some slight risks of ERCP, and because it is not always possible to inject dye into the bile duct, a new scanning technique called Magnetic Resonance Cholangio-Pancreatography (MRCP) has been developed, but this requires very up to date equipment, only provides pictures, and is not yet universally available.

Another way is to inject dye through the skin into the liver, called Percutaneous Transhepatic Cholangiography (PTC), and this can also allow stone removal, but it also carries some risks and so is usually used if ERCP fails for some reason.

What treatments are possible?

People can live without a gallbladder (over 50,000 operations are carried out in the UK alone every year), and the most common treatment for gallstone problems is surgical removal of the gallbladder, known as cholecystectomy (pronounced co-lee-sist-ect-omy).

There are several surgical options:

Laparoscopic cholecystectomy (keyhole gallbladder removal). This is the most common treatment. After a general anaesthetic, a number of tiny cuts, usually four, are made in the abdomen, through which surgical instruments and a miniature video camera are inserted. Most surgeons now perform cholecystectomy using a video camera mounted on a telescope (laparoscope) passed through the umbilicus (tummy button) and several other small 'keyhole' incisions, avoiding a big, painful scar. The camera sends a magnified image to a video monitor, giving the surgeon a close-up view. The operation is performed by manipulating the surgical instruments through the three other 'keyholes', usually three. The gallbladder is identified and carefully separated from the liver and other structures. Finally, the gallbladder is disconnected from the bile duct and removed through one of the small incisions. It usually means a day or two in hospital at the most and a further two weeks' convalescence. It results in less pain, quicker healing, improved cosmetic results, and fewer complications. The gallbladder is removed without cutting through any abdominal muscles, and if necessary, ERCP (see above) can be used to locate and remove stones in the bile duct.

One serious complication which can occur, however the gallbladder is removed, is injury to the bile duct, which connects the gallbladder and liver. This may cause a painful and potentially dangerous infection and may require corrective surgery, but this is rare. Meticulous surgical skill and training help to prevent, as may the performance of cholangiography prior to disconnecting the gallbladder from the bile duct. Sometimes complications such as adhesions, severe inflammation or bleeding occur, forcing the surgeon to switch to the 'open' cholecystectomy using a standard incision for safety. This now happens in less than 5% of cases, and in expert centres, less than 1%. A longer convalescence will be required.

Open surgery. Sometimes, keyhole surgery is not possible and an "open" cholecystectomy is necessary. This involves the removal of the gallbladder under general anaesthetic through a larger cut in the abdomen. These operations are generally safe, and for most people the benefits are greater than the disadvantages. However, all surgery does carry some risk. The most common complication in gallbladder surgery is damage to the bile ducts, which may require additional surgery.

Diet: A diet high in fibre (roughage - fruit and vegetables) and low in fat may help by reducing gallbladder stimulation, but this is usually a holding measure for most patients.

Drugs etc:

Drug treatments are designed to dissolve gallstones, but few people respond to this and it may take months or years to work, whilst the gallstones still symptoms. Mild diarrhoea is common. They may reform after dissolution. Gallstones in the bile duct can be treated by ERCP as outlined above. As this does not remove the diseased gallbladder, an operation may still be required. Shock-wave or 'ultrasound' lithotripsy can be used to shatter stones in the bile duct and gallbladder, but can result in some complications and is still under evaluation.

Other treatment options

In special situations (for example, if a patient cannot be given an anaesthetic), non-surgical treatment of stones may be necessary. One approach is to use medicines to dissolve the stones, but this treatment is not suitable for everyone and may take a very long time.

Another approach, extracorporeal shock wave lithotripsy (ESWL), uses shock waves to break up the stones into tiny pieces that can then pass easily out of the system. However, attacks of intense colic pain are common after ESWL and the success rate is not consistently high.