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Tummy troubles: gall stones and gall bladder disease TUMMY TROUBLES: GALL STONES AND GALL BLADDER DISEASE
Q. We often hear of persons with gall stones and disorders of their gall bladder. What is this all about?
A. The gall bladder is a small sac which is located close to the liver. It is found just under the lower margin of the rib cage on the right hand side. If very swollen, as sometimes occurs in disease, it may be felt here.
Products which help the body digest fats are manufactured by the liver. These are stored in the gall bladder. After a meal containing fat, the sac contracts and this fluid is pumped into the bowel by a narrow duct. Here it mixes with the food. The gall bladder is very susceptible to disease. Infections during life (most notoriously hepatitis) can leave myriads of dead germs in the gall bag. These are often subsequently the starting point for stone formation.
Q. If a person has gall stones, is he usually aware of the condition?
A. This is a very common problem, affecting many people. Many are quite unaware of their condition and it is often discovered by chance during x-ray of the abdomen for something else.
It has been found that 32 per cent of women and 16 per cent of men over the age of 40 have gall stones. About the age of 40, the occurrence of stones rises abruptly. In recent studies, the gall stone age group seems to be reducing. Now it is very common in women in their twenties and thirties. Pregnancy and obesity seem to be predisposing factors.
In about 70 per cent of cases, gall stones do not produce symptoms. Many surgeons believe that a person with stones should have them removed for statistics indicate about fifty per cent of these people will subsequently develop symptoms needing surgery.
The chance of developing cancer of the gall bladder in the presence of stones is very low and has been assessed at less than one per cent, although recent American reports say it is much more common than once believed. The larger the stones the higher the cancer risk, the reports claim.
Q. What happens in a gall attack?
A. If the gall bladder ducts become blocked by the stones, swelling of the sac occurs. Under these circumstances, germs attack the walls of the sac and this produces added risks. Ninety per cent of acute gall bladders are due to stones. These may suddenly block the cystic duct, the narrow canal that leads from the sac.
The gall bag quickly becomes swollen, tense and inflamed and infection can quickly supervene. Often there have been past vague, ill-defined symptoms of chronic gall bladder disease. Suddenly these become acute. A sudden pain develops over the gall bladder, just below the right lower rib margin. It can be agonising and may be one of the most severe pains a person can develop.
It is often preceded by a heavy meal, which may have been either rich in fats or rich foods such as onions, coarse vegetables, etc. The pain is agonisingly severe and can produce prostration, sweating and vomiting. Often it penetrates to a position just below the right shoulder blade. This radiation is typical and there may be a mild accompanying fever.
Sometimes if the duct is blocked with stones, a yellow discolouration of the eyes and later skin may occur. This is called jaundice.
The upper right abdominal wall becomes extremely tender to touch. It may be firm and sometimes the doctor can actually feel the distended organ.
Q. How is an attack of gall stones usually treated?
A. This is usually an emergency and prompt medical assistance is needed. Most patients are aware that something sinister is occurring and the need for attention is usually quite apparent. Acute attacks usually subside on conservative treatment. Severe cases are treated in hospital where they are under expert observation but mild cases may be treated at home. Bed rest, fluids by mouth (or intravenously if there is vomiting), antibiotics to check infections, sedatives and pain relieving preparations (often given by injection) form the basis of treatment.
When the acute stage settles down, as it often does, surgery is frequently carried out several weeks or months later. But if the acute attacks do not subside it may be essential to embark on immediate emergency surgery.
Most patients make a successful recovery following surgery but commonsense and care are advisable for several months. Being careful in the intake of fatty, fried, coarse foods is advisable for some time. Otherwise there can often be local discomfort and a sensation of dyspepsia and flatulence.
The regular use of fibre in the form of unprocessed bran is often recommended after surgery to ensure bowel regularity and to remove excessive amounts of bile salts from the bowel. This is also claimed to reduce the subsequent risk of large bowel cancer.
Q. We hear people continually complain about their gall stones. It seems to go on and on causing general ill health but they do not necessarily have the terrible type of pain you have been talking about. What is their problem?
A. These people probably have chronic gall bladder disease. The organ may be diseased and there are probably stones present, giving general abdominal discomfort, usually in the upper right side, often with nausea, flatulence, dyspepsia and other symptoms of indigestion. Heavy meals, fatty foods, condiments, salads, onions and similar foods may aggravate symptoms.
Sometimes if a small stone becomes temporarily caught in the duct severe pain occurs but this may subside as it passes. This is called biliary colic. Often the pain will shoot into the back between the shoulder blades.
Q. Is treatment necessary?
A. Diagnosis is usually made by x-rays and, if stones are suspected, ultrasound is now often used, for some stones do not show up in the usual x-ray examinations. If stones are present, or the organ not working normally and symptoms becoming worse, surgical removal is often recommended. Endoscopic removal is often attempted, this being a smaller operation for stones in the canal. Also, a new instrument is used to "shatter" the stones by the use of high frequency sound waves. Certainly a lot of self-help ideas may reduce symptoms, such as being sensible in the food that is eaten, avoiding foods that are known to cause distress, particularly those high in fat, certain well known vegetables, such as salads, leafy greens, onions and fried foods, full cream milk and butter.
Q. What about drug medication?
A. In recent years a great deal has been written about dissolving gall stones and the drugs cheno de-oxycholic acid and urso-de-oxycholic acid have been used with some success. But these are usually now reserved for older patients who might not be good surgical risks. In the younger persons they are not recommended, especially if there has been a history of jaundice. Also only cholesterol stones will dissolve. It is an ongoing treatment, for once therapy stops the stones will often recur. Many doctors are unwilling to subject a person to lifelong medication when a complete cure may occur with surgery.
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