The Symptoms, Diagnosis, and Care of Gallbladder Attacks
Biliary colic, also termed ‘gallbladder attacks,‘ refers to the pain that one experiences when a gallstone temporarily obstructs the gallbladder. Gallstones are the result of an accumulation of cholesterol, calcium, bilirubin, and typically manifest sporadically (appearing without warning).
The normal function of the gallbladder involves the storage of bile, a dark green fluid produced by the liver. Upon the consumption of food, chemical signals from the stomach and intestines are released and stimulate the gallbladder to empty bile through a duct system into the intestines. Bile assists with the digestion of fats present in the recent meal.
If a gallstone lodges in the duct system that bile travels through, bile would be unable to reach the intestines to carry out its normal function. Instead, there is congestion within the duct system and backflow of bile back to the gallbladder. This backflow of bile activates nociceptors (pain receptors) on the gallbladder, causing the characteristically sharp, right upper abdominal pain, associated with gallbladder attacks. Since bile is usually released by the gallbladder when food is in the intestines, the onset of pain is typically an hour or two following the consumption of a heavy meal.
The preliminary diagnosis of gallbladder attacks is typically made by a family physician who recognizes the characteristic right upper abdominal pain pattern while examining a patient. The physician would likely order digital imaging of the right upper abdomen through ultrasonography. This enables visualization of potential gallstones, which if present, leads to a definitive diagnosis of a gallbladder attack.
Regarding the management of gallbladder attacks, there are symptomatic relief options and curative options available. Symptomatic relief involves the use of anti-inflammatory agents, such as NSAIDs, to alleviate some of the pain. If the pain is severe, opioids (strong pain-killers) such as morphine may be dispensed. While some of the pain may be alleviated through these options, the root cause of the gallbladder attacks (gallstones obstructing the duct system), remains unaddressed. To remove the gallstones, one must undergo surgical removal of the gallbladder, known as cholecystectomy, which cures the gallbladder attacks. This procedure is performed on an elective basis, meaning that the patient decides whether they wish to undergo surgery.
Numerous studies have been performed to determine whether early cholecystectomy is superior to delayed cholecystectomy for patient prognosis. A 2013 Cochrane review tentatively suggested that early removal of the gallbladder is associated with more favorable mortality and morbidity rates for the patient. However, this is still subject to debate due to the lack of larger reviews.
Ultimately, gallbladder attacks necessitate eventual surgical intervention for curing the disease and avoiding complications in the long-term. The decision to delay undergoing surgery, for whatever reason, should be based on a thorough and informed discussion between a patient and their surgeon. While cholecystectomy involves undergoing general anesthesia, the surgery is not considered “high risk,” in that most patients subjected to the surgery recover well within weeks, without major complications.
Conventional Advice on Cholecystectomy
The general approach to the treatment of gallstones that has existed for more than half a century is that of prophylactic surgery, in which biliary tract system obstruction is prevented prior to excessive stone formation and stone formation is prevented while the stone passage is delayed. It is based on the idea that bile that is trapped in the gallbladder prevents the bile from passing out of the biliary system (especially into the intestines) where it can contribute to the formation of stones.
Because stone formation is triggered by a protein called cholecystokinin that is released by stone-forming gallbladders, prophylactic surgery provides the greatest chance of preventing gallstone formation in the first place. The two most common methods of prophylactic surgery are gallbladder removal and laparoscopic cholecystectomy. Laparoscopic cholecystectomy is a minimally invasive surgery that enables surgeons to remove the gallbladder via a small incision in the abdomen. Surgeons perform laparoscopic cholecystectomy, with an average of 1/4 to 1/2 of the liver removed, and more than 99% of patients undergoing cholecystectomy report minimal to no pain during the surgery and in most cases, are discharged from the hospital shortly thereafter, with the ability to go about their daily activities without restrictions. This recovery can last up to six weeks, but many patients report no residual pain.
The two most common alternatives to biliary tract obstruction that lead to gallstone formation are dehydration and food allergies. Steroid-sparing prophylaxis is an option whereby patients are offered prophylactic steroids to prevent the occurrence of stone formation and subsequent gallbladder surgery. Clinical evidence supports that prophylactic steroids decrease the risk of gallstone formation in patients with severe diabetes and obesity. The long-term benefit of steroid prophylaxis is unclear.
Prophylactic Surgery vs. Surgical Intervention
The decision to undergo surgery for acute cholecystitis of gallstones is not one that should be made lightly. Gallbladder removal with laparoscopic surgery is considered very safe for most patients. Failure rates of both biliary tract obstruction and cholecystectomy are low and well below one percent.
In very severe cases of gallbladder inflammation and inflammation of the gallbladder wall that is likely to cause gallbladder failure, surgery may be required to alleviate any associated complications. If a patient is unable to undergo the necessary pre-operative examination or elects not to undergo any medical intervention, the remaining cholecyst artery remains open, but the gallbladder is at risk for chronic obstruction.
Cholecystectomy is usually reserved for cases of extremely severe gallbladder inflammation and an inability to undergo prophylactic surgery for any reason. Prophylactic surgery should only be considered as a “last resort” option in these instances, particularly when patient symptoms do not allow for any reasonable management.
The Symptoms, Diagnosis, and Care of Gallbladder Attacks The Symptoms, Diagnosis, and Care of Gallbladder Attacks
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