GALL BLADDER STONE – WHEN TO CONSULT A DOCTOR!

Each patient with gall stone will have different symptoms of gall stone disease. The symptoms vary from mild abdominal discomfort after food to severe abdominal pain with vomiting, sometime fever, jaundice and not uncommonly with life threatening complications of gall stone disease like pancreatitis, peritonitis etc. The common clinical presentations are as follows:

1. DYSPEPSIA

     This is a nonspecific indicator of gall stone disease. Some individuals with gall stone may have fullness after food and delayed digestion. Some feel bloat after food and vomiting sensation. If this happens in obese person of middle age group, suspect gall stone disease and investigation for gall stone disease is justified.

2. BILIARY COLIC

    Biliary colic is the most common clinical presentation of gall stone disease. Here there is acute onset of pain over the upper abdomen or at the back usually associated with vomiting. Usually, this pain starts after food especially after fatty food and the pain is intermittent in nature. The cause of pain is either due to impaction of gall stone at cystic duct (gall bladder outlet) or at lower common bile duct. If the pain is persisting more than six hours, it may end up with the development of infection and leads to acute calculus cholecystitis (Inflammation of the gallbladder)

    Transient blockage of gall bladder mouth will prevent the emptying of bile from the gall bladder and leads to increase in the intra luminal pressure within the gall bladder which ends up with severe pain. Pain is intermittent in nature, because the gall bladder contracts intermittently.

3. ACUTE CALCULUS CHOLECYSTITIS

    Cholecystitis is primarily caused by obstruction of the biliary tract due to the presence of gallstones. Typically, this obstruction causes distention gall bladder, bile stasis (lack of bile flow to and from the gall bladder), inflammation and infection of the gall bladder. Acute inflammation of the gallbladder is known as acute cholecystitis and the most common cause is gall stone disease. A gallstone that becomes lodged into the neck of the gallbladder can cause infection and inflammation of the gallbladder (Acute calculus cholecystitis). Usually, it takes six hours to develop the infection with obstructed stone at the cystic duct. At this time there will be persistent pain with or without vomiting and sometime associated with fever also. There is a classical presentation that each meal can cause pain especially after fatty foods. If the stone is impacted in the cystic duct, it leads to gall bladder inflammation.

    After this pain, sometime the impacted stone may come back to gall bladder and pain will go off. But at the same time the stone may slip down in to the bile duct and cause blockage of bile duct at any part of the bile duct.

    At this stage most of the patients come to the hospital for consultation. Clinically these patients present with severe upper abdominal pain, colicky (Intermittent) in nature followed by vomiting and sometime with fever. Usually, the fatty food aggravates the pain. Pain usually starts at middle of upper abdomen and then radiate to right upper quadrant, back and shoulder. Depending on the infection sometimes fever can be there and may persist for longer duration if not treated with antibiotics.

4. CHRONIC CALCULUS CHOLECYSTITIS

    A recurrent attack of pain abdomen associated with fatty food is suggestive of chronic calculus cholecystitis. Sometime this may be associated with bile duct stone also. Usually, will have pain related to specific type of food and may be associated with or without vomiting and with or without fever. This is due to the recurrent blockage of cystic duct by the gall stone following each meal and associated ongoing infection of the gall bladder.

5. EMPYEMA OF GALL BLADDER.

    This is an extension of acute calculus cholecystitis. Here, after acute calculus cholecystitis, if not treated with antibiotics or even after treatment with antibiotics, there will be pus formation within the gall bladder. This pus formation may end up with high fever with persistent pain abdomen. In case of diabetic patients’ intensity of pain will be less because of autonomic neuropathy and fever may be less because of weak immune mechanism.

6. GANGRENOUS CHOLECYSTITIS

    Again, this is also an extension of acute calculus cholecystitis. This happens usually in patients with any atherosclerotic lesion involving the cystic arteries. More commonly this condition is noted in patients with long duration diabetes, hypertension and coronary artery disease. Here the gall bladder loses its blood supply and it becomes nearly dead. Again, this complication may predispose to more systemic infection and systemic infection related complications.

7. GALL BLADDER PERFORATION.

    This complication also follows acute cholecystitis. Here the gall bladder bursts due to the following reasons. First is due to decreased blood supply to the gall bladder especially in patients with diabetes or other systemic disease.

    Next reason is stone impaction at the cystic duct and because of weak gall bladder wall and increase in gallbladder luminal pressure the gall bladder perforates.

    Also, impaction of gall stone at Hartman’s pouch for long duration may leads to erosion of gall bladder wall by the gall stone and come out of the gall bladder.

   Once gall bladder bursts it leads to a condition known as peritonitis. In this condition there will be diffuse intense pain all over the abdomen and slight move of the patient body may increases the pain. On palpation of the abdomen there will be diffuse pain and there may be a palpable mass over the right side of the upper abdomen. The presence of signs of peritonitis is a bad prognostic sign especially in older age group.

8. LIVER ABSCESS

    Liver abscess is an extension of gall bladder perforation into the gall bladder bed.  After the perforation of the gall bladder, the contents from the gall bladder form a collection within the liver and end up with liver abscess formation. Again, these patients present with pain abdomen along with high grade fever and sometime features of severe infection.

9. FISTULAS.

    This happens when the gall stone erodes the nearby organ and develops abnormal communication between two organs. The common communications are with common bile duct, duodenum and large intestine. When there is a communication there will be features suggestive of any infection like pain abdomen, fever or jaundice. These fistulas are usually confirmed with a special test called MRCP (Magnetic Resonance Cholangio Pancreatography).

    The important point to be noted is that it is very important to understand that the individual patients cannot identify these conditions by themselves. Even the doctor can suspect the possible diagnosis and confirmation is with routine investigations like ultrasonography of abdomen or special investigations like MRCP.