Gallstones. Exceptional healthcare, personally delivered

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1 Exceptional healthcare, personally delivered

2 Introduction are small stones that form in your gallbladder. This is a small pear-shaped pouch that is attached to your liver and stores bile that helps your body break down food. are very common (affecting about 5.5 million people in the UK). By the age of 75, about 1 in 3 women and 1 in 5 men have them. Usually, they cause no trouble in which case they do not need to be treated, but sometimes they can be painful and can cause inflammation of the gallbladder, jaundice or pancreatitis. If your gallstones do cause problems, the most likely symptom is pain in your abdomen and some patients require surgery. The gall bladder and biliary system 2

3 What does the gall bladder do? Your gallbladder is part of your digestive system. Bile is a yellow-green digestive juice that is produced by the liver and it is stored and concentrated in the gallbladder. When you eat or drink, your gallbladder squeezes bile out into a tube called the bile duct and from there it flows into the bowel where it helps break down fat in the food that you eat. When your liver makes bile that is not needed straight away, the bile flows into your gallbladder for storage. Normally your gallbladder holds about six teaspoons of bile at any one time. Why do we form gallstones? Cholesterol stones are the most common type in the UK. Bile contains cholesterol and sometimes an imbalance in the components of bile can lead to a high concentration of cholesterol. This can then form crystals which given time can grow into gallstones. can be as small as a grain of sand or as big as a golf ball. You may have just one big gallstone or many small ones. Other causes of gallstones are blood disorders (some types of anaemia), liver disease (cirrhosis) and infection in the bile. Why me? We are not always sure why gallstones form but there are groups of patients that are more likely to get them. You are more likely to get gallstones if you are: n Over 40 years old n Female n Obese n Pregnant n Have lost a lot of weight quickly n Eat a lot of fatty food n Have cystic fibrosis, diabetes, Crohn s disease or injury to your spinal cord n On oral contraception 3

4 What symptoms can I get from gallstones? n Most people don t get any symptoms from their gallstones and these are often discovered incidentally on scans performed for other reasons. Generally, these do not need to be treated. n Pain: The most common symptom is pain in your tummy that can be quite severe and can last from a few minutes to some hours before settling down. This is known as Biliary Colic. n Cholecystitis: The gall bladder can become infected and inflamed and this causes pain that lasts longer and is associated with a fever. This will need to be treated with antibiotics generally in hospital. n Jaundice: If a stone escapes into the bile duct and blocks the flow of bile, this can cause your skin and eyes to go yellow. This is often accompanied by itching and in severe cases this can cause a fever and shivering. Jaundice is frequently associated with dark urine and pale coloured stool. n Pancreatitis: This is an inflammation of the pancreas caused by a stone escaping from the gall bladder and blocking off the flow of digestive juices from the pancreas. It manifests as severe pain in your upper abdomen, often requiring hospitalisation. This can be a serious condition. What can I do to avoid the symptoms? Staying on a low fat diet while you are waiting for treatment for your gallstones can help minimise episodes of pain. 4

5 How are gallstones diagnosed? X-Rays are not usually seen on standard X-rays of the tummy and so these are not routinely done. Ultrasound scan The best test for gallstones is an ultrasound scan on the right side of your tummy. This is a very safe test that does not involve radiation and is accurate at diagnosing gallstones. Blood tests These tests don t directly tell if you have gallstones but they can pick up some of the problems that gallstones can cause such as infection, jaundice and pancreatitis. MRCP This is an MRI scan of your gall bladder and bile duct, which is more sensitive than ultrasound in picking up stones in the bile duct. This can be performed instead of or as well as an ultrasound scan if more information is needed. ERCP (Endoscopic retrograde cholangiopancreatography) This is an endoscopic test that involves passing a camera through the mouth and into your small intestine to check if the bile duct contains stones. It has the added benefit of being able to remove these stones at the same time. Sometimes a small cut is made in the muscle of the bile duct to allow the stones to pass, or a plastic tube (stent) is left in place to allow the bile to flow freely CT scan This is less commonly done for gallstones and is only performed if you have a complication of gallstones such as pancreatitis or cholecystitis (inflammation of the gall bladder). 5

6 What are my treatment options? If you have silent gallstones that don t cause any symptoms, no treatment is necessary. If your gallstones cause pain or inflammation, the usual treatment is an operation to take out your gallbladder (cholecystectomy). This is done to prevent further attacks of pain and also to prevent the complications of gallstones mentioned above. Laparoscopic (keyhole) surgery this is now one of the most commonly performed operations in the UK. It involves making between 1 and 4 small cuts on your tummy wall, each up to 3cm in length. These are used to insert a telescope and instruments into your abdomen to allow the surgeon to perform the operation. After the gall bladder is released, the whole gall bladder (along with the stones within) is removed through one of these incisions. You will be given a general anaesthetic for the procedure, which means that you will be completely asleep throughout the operation. Occasionally a small soft plastic tube (drain) is left in after the operation to drain out any unwanted fluid. This is usually removed the following day. Open surgery In up to 5% of patients, it is not possible to complete the operation laparoscopically. This can be due to scarring from previous surgery, severe inflammation of the gall bladder, difficulty in seeing vital structures clearly or due to unexpected complications. In these cases, we resort to the traditional approach of removing the gall bladder by means of a longer incision measuring about 15-20cm under the ribs on the right hand side. You will need to stay in hospital for a few more days after this surgery and need a longer period of convalescence. Bile Duct Exploration If stones are stuck within the bile duct they can be removed at the time of cholecystectomy in some patients. This involves making a cut in the duct and taking out 6

7 the stones. It is a more complicated operation that can take longer although can still be performed via keyhole. A drain is usually left in and the hospital stay is one or two nights. What are the advantages of laparoscopic surgery? The advantages include less pain, smaller scars, quicker discharge from hospital and an easier return to work. What are the possible complications? Laparoscopic surgery is safe but as with any operation complications are possible. These include: n Anaesthetic complications (especially if you have other serious medical problems) n Blood clots in the legs (Deep vein thrombosis) that may then move and get lodged in your lungs (Pulmonary embolism) we give you a blood-thinning drug and compression stockings to minimise this risk. n Shoulder tip pain this is very common and transient (usually lasting less than 24 hours). It occurs due to the gas used to inflate the abdomen during the operation. n Bleeding (during or after the operation) n Infection (in particular of the wound near your tummy button) n Bile leak (1 in 100) this can occur either from the bile duct or tiny ducts in the liver. If this does happen, it frequently settles down spontaneously. If it doesn t, another procedure may be necessary (such as ERCP). n Injury to the bile duct (3 in 1000) this is potentially a serious complication and can require further surgery. n Injury to the bowel (1 in 1000) n Retained stones before or during the operation, a stone can escape from the gall bladder and move into the bile duct. Most of these stones pass into the bowel but if they 7

8 don t, an ERCP may be necessary. n Diarrhoea - occasionally patients notice diarrhoea after the operation. This usually settles without any further treatment after a few months but can sometimes last longer and needs to be treated. n Hernias A small hernia can form at the site of the incisions made on your tummy wall for the operation. Will I be in much pain after the operation? At the end of your operation, local anaesthetic will be injected around your incisions to give you pain relief. You will also be given painkillers in the form of tablets or injections. On discharge you will be given tablet painkillers to take home. You should expect to have some soreness around the wounds which will disappear in a few days. Do I have to have surgery at all? Are there any alternatives? There are no good, safe, viable alternatives to surgery that are widely accepted. Other methods such as dissolution of the gallstones and using shock waves to break them down have been tried in the past but have been given up due to high failure rates. Watchful expectancy: You do have the option of choosing not to have treatment for the gallstones if the symptoms are minor and you do not want to have surgery. However, this comes with the risk of developing the complications of gallstones listed above and would be needed to be discussed with your GP or surgeon. Can I manage without my gall bladder? You can live a healthy life without your gallbladder. After it is taken out your liver will carry on making bile. Instead of being stored in the gallbladder, the bile flows straight into your bowel to help digest your food. 8

9 Does my diet have to change now that my gall bladder has been removed? A low fat diet is only necessary until you have had your operation. Once your gall bladder has been removed, you can go back on to a normal diet, although it is advisable to keep on eating healthy low fat foods in the long term. How long will I need to stay in hospital? In most cases, you come in on the morning of the operation and go home the same day (day case surgery). This is not the case for everyone though and depends on other factors such as your age, weight, other medical conditions, previous operations that you have had and drugs that you are taking. This can usually be determined at the time of your pre-assessment visit. If your operation is more difficult than anticipated or if there are any unexpected complications, you will need to stay in hospital until you are well enough to go home. Do I need to change my dressings or get any sutures removed? Any sutures used will dissolve and do not need to be removed. The dressings on your wounds are shower proof and you can shower with them on. In about 5 days after your operation, you can soak yourself in a bath and the dressings should peel away easily. You can then leave the incisions uncovered but do keep them dry. Will I be seen in hospital again after my operation? Not routinely unless your surgeon specifically wants to follow you up for some reason. If you have any problems after the operation, see your own GP and he/she will be able to advise you or arrange for you to be seen at the hospital. 9

10 Wound infections These are measures that you can take to try and reduce the chance of developing a wound infection after surgery. Most infections occur around the tummy button n Shower on the morning of surgery with soap and pay particular attention to washing your tummy button. Clean it as well as you can n For men, don t shave the hair from your tummy. n After surgery leave the dressings on for 5 days undisturbed if possible n Once the dressings are removed, keep the wounds clean and pat dry them (not rub) Some clear or bloody discharge from the wounds or bruising is common and does not always mean an infection that needs antibiotics. If you have any concerns then a visit to your GP or practice nurse for a wound check is often reassuring. What do I need to be aware of at home? Most patients recover quickly but some people do get some problems after surgery. Things to look out for at home are: n Worsening tummy pain n High temperatures or fever n You start looking yellow (jaundiced) with orange urine or pale stools Should any of these develop then either visit your GP for referral back to us, contact the department via the numbers above or visit the Emergency Department at Frenchay Hospital for assessment. You may need some blood tests and another ultrasound scan. 10

11 When can I get back to normal activities? What about work? This varies from individual to individual and depends on how rigorous your job is. Take it easy for the first 2-3 days after the operation. After this, you can ease yourself back into light household duties and go back to work in days after the operation. When can I start driving? When you are pain free and can comfortably perform an emergency stop without any discomfort. Also do check with your insurance company to see if they have any specific requirements regarding driving after surgery, to ensure that you are adequately covered. Useful Information ngallstone Information introduction.aspx ngallstone Treatment Treatment.aspx NHS Constitution. Information on your rights and responsibilities. Available at [Last Accessed November 2012] 11

12 How to contact us: Frenchay hospital switchboard Southmead hospital switchboard Frenchay Day Case Unit Ward / Ward / Southmead Day Case Unit Ward L J ward U ward Woodland Unit If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice. North Bristol NHS Trust. First Published January Review due January NBT002730