Could That Pain Be Your Gallbladder?

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You sit down to another episode of your current favourite box set after dinner and halfway through you feel a sharp pain under your ribcage on the right. You grit your teeth, knowing you just have to wait it out. It has become an almost nightly ritual, but one that’s seen you taking more Panadol and Nurofen when the pain’s especially bad. What on earth is going on?

 

What is ‘biliary colic’?

Biliary colic is the name of the type of pain caused by episodes of distension of the gallbladder wall due to gallstones.

The gallbladder is a small organ, no larger than the pad of your thumb, tucked under your liver. It stores bile for the digestion of fats you eat. Most people release about 750ml of bile into their gut every day. Some individuals, however, are prone to developing gallstones, which can make their way into the neck of the gallbladder and cause obstruction of the only bile outlet from the organ. This causes swelling of the gallbladder and as a result, a dull constant pain called ‘biliary colic’.

Biliary colic pain can come on following large, fatty meals due to the increased need of bile release for the breakdown of these complex compounds for digestion. It usually subsides over half an hour to an hour and can be associated with sweating, nausea, sometimes vomiting and occasionally radiation of pain to the shoulder blade on the same side. The pain however, can come on at other times at rest and the increased frequency is often a cause of distress for sufferers of biliary colic.

 

What are gallstones and how did I get them?

A large proportion of the Australian and New Zealand community have gallstones, nearly a quarter of the population over the age of 50. However not all of these people are symptomatic. It is only when a stone periodically lodges in the neck of the gallbladder (the outlet) that pain is experienced.

 

There are a number of different types of gallstones:

Cholesterol stones – more than 80% of gallstones in Western countries are cholesterol based. An abnormally high level of cholesterol secreted by liver cells relative to the other compounds (lethicin and bile salts) that normally go into bile will lead to the formation of these stones.

Pigment stones – these stones are a variety of colours but are normally darker green or brown or sometimes jet black. These can be formed if an individual suffered from high turnover of red blood cells in conditions such as; haemolytic anaemia or cirrhosis.

Mixed stones – sometimes stones can be colonised by bacteria in the gallbladder and alter the composition of bile leading to the accumulation of different compounds on the pre-formed cholesterol stones. These are known as ‘mixed’ stones of cholesterol and pigment.

 

Those at risk of gallstone formation are:

• Females
• Of increasing age (older)
• Those with family history of gallbladder disease
• Rapid changes in weight
• Of ethnic (particularly Asian) origin

 

How serious can this get?

Although the majority of individuals with gallstones don’t experience symptoms, those who do are at greater risk of cholecystitis. Cholecystitis is a disease where a stone has become lodged in the neck of the gallbladder for a long period of time, leading to reduced outflow of bile, bacterial overgrowth and mucosal inflammation. The gallbladder is then at risk of causing inflammation to other surrounding structures or bursting, releasing bile and pus into the abdomen, both of which are serious complications requiring hospitalisation.

If you believe you are starting to experience cholecystitis (persistent, prolonged pain under your ribs on the right hand side and/or pain in your right shoulder or shoulder blade with a fever) it is advisable to present to the emergency department of your hospital.

Another complication is the passage of gallstones into the common bile duct (which normally drains the gallbladder and the liver). This can cause bacterial overgrowth within this common bile duct, leading to excruciating pain, jaundice (yellowing of the skin) and fever - something called 'acute cholangitis'. This can also be a serious complication and will require hospitalisation, antibiotics and surgery.

 

What should I do next?

If you think you are experiencing biliary colic, it is important to seek advice from your GP. The key test for confirming presence of gallstones, an ultrasound of your upper abdomen, may be arranged by your GP. If gallstones are visualised, you will likely be sent to an outpatient appointment with a general surgeon at a hospital.

The definitive management of biliary colic is resection of the gallbladder, ‘cholecystectomy’. Most of these operations are done ‘laparoscopically’ (keyhole surgery) and on an elective basis within three to six months. Patients are often able to go home within the first couple of days of the procedure, if not in the first 24 hours post-operatively.

There are rarely serious complications from this procedure, and your surgeon will be sure to go through a list of potential adverse effects however the main ones are:

• Bile leak: in 1-2% of keyhole gallbladder removals, puncture of one of the adjacent structures to the gallbladder leading to leakage of bile into the abdomen occurs. Pain typically worsens in the first week after the procedure.
• Bile duct injury: conversion to open cholecystectomy: your surgeon may deem the operation unsafe to perform through keyhole surgery before the procedure or during it. This may be due to complicated anatomy or anticipated complications. In this case, the surgeon may decide to make a wider incision just under the ribs over the gallbladder to better visualise and remove it.
• Reaction to anaesthetic: a risk as with any operation, and an anaesthetist will assess your risk before the operation.

You may continue to feel slightly unwell for a few weeks after the operation. Symptoms may include feeling gassy, loose bowel motions and mild indigestion. These should resolve completely. If more serious pain or profound diarrhoea or fever should occur, you should return directly to the emergency department for assessment.

 

Before it happens

As is the age-old dictum, prevention is the best cure, and there are a number of things you may do to reduce your risk of developing gallstones, including weight reduction and reduced intake of cholesterol or fat-rich foods. Monitoring your lipid (blood fat) levels at your GP regularly may assist you in knowing when there's a problem and when to take some steps to prevent not only gallbladder disease, but improve your overall health.

 

References

- Afdhal, N., Chopra, S. and Grover, S. (2018). Approach to the patient with incidental gallstones. [online] UpToDate. Available at: https://www-uptodate-com.proxy.library.adelaide.edu.au/contents/approach-to-the-patient-with-incidental-gallstones?search=gallstones&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1161025 [Accessed 27 Mar. 2018].

- Crawford, M. (2013). Biliary pain. Australian Family Physician, 42(7), pp.458-461.

- Heuman, D., Mihas, A. and Allen, J. (2018). Gallstones (Cholelithiasis): Practice Essentials Background, Pathophysiology. [online] Emedicine.medscape.com. Available at: https://emedicine.medscape.com/article/175667-overview#a3 [Accessed 27 Mar. 2018].