JEDDAH, 20 April — The respectable associate of Amon in old Egypt died 3,000 years ago. Two thousand years later his mummy sailed to England to be presented to the British museum. Ironically, his remains survived the trial of three millennia only to be devastated by Adolf Hitler’s bombs. His mummified remains were almost completely destroyed. In an attempt to learn something from the remains, an autopsy was carried out and revealed that he originally died of gallstones.
Many types of sand and stones are made in the human body. They vary in size, structure and location. Stones might be found in the lachrymal (tears) pathway, in the salivary (saliva) glands and ducts, in the kidney and urinary system, in the intestine and in the biliary system.
Many of my patients ask, “Why do I have stones in my gall bladder?” To answer this question we have to differentiate between two types of gallstones: Cholesterol and pigmented stones. The biologic changes necessary to cause the two types of stones are different and not fully understood. We know that cholesterol is kept soluble in the bile under the influence of two factors, the bile salts and phospholipids — chemicals present in the bile. If the concentration of cholesterol rises in the bile, cholesterol crystals precipitate. Special proteins in the bile can favor or prevent the process of nucleation of the crystals in small stones. When these crystals are nucleated in the gall bladder, tiny stones appear and it is a matter of time before they grow to form bigger stones. Cholesterol stones are the most common stones. They occur in about 70 percent of cases. The less common 30 percent pigmented stones are divided according to their color in brown and black stones. The brown stones are caused usually by infection in the biliary system. The bacteria responsible for this infection secrete enzymes that favor the formation of the brown stones. The black stones occur usually in people having hemolytic disorders (blood clotting diseases) and patients with cirrhosis of the liver.
Many factors are favoring stones formation in the gallbladder. Women are affected more than men. The stones can occur at any age, but they are more common in middle age. They are seen more in Western nationalities. Some races have a very high rate of gallstones like the Pima Indians in the United States; 70 percent of their women have gallstones. Obesity and parity are factors, which increase the risk of building gallstones. Contraceptive pills and hormonal replacement therapy also seem to have a similar effect. Rapid weight loss, long-term fasting and some lipid (blood fats) lowering agents can also favor the production of gallstones. Some intestinal diseases such as Crohn’s disease and blood hemolytic disorders (clotting diseases) can increase the rate of gallstones formation in the gallbladder.
Bile, which is secreted in the liver, passes through canals (biliary system) to be stored in the gallbladder. The gallbladder is a pear shaped vesicle situated at the lower surface of the liver. Its function is to store and concentrate the bile solution in the gallbladder. The bile is concentrated by absorption of water through the wall of this organ. The passage of the food from the stomach to the duodenum (the first part of the small intestine) leads to contractions of the muscles in the wall of the gallbladder and evacuation of the bile through the biliary system into the intestine. The bile is then mixed with the food and begins to act as a digestive solution. Stones in the gallbladder or in the biliary system can close this pathway and prevent the bile from reaching the biliary ducts and even the small intestine. This usually leads to severe symptoms like pain, fever, colic, jaundice, or inflammation of the pancreas.
Untreated gallstones can lead to complications with the gallbladder itself, the biliary system, the pancreas or the intestines. Some of these complications can be severe and even fatal. The duct connecting the bladder with the biliary duct system is called the cystic duct. When stones close this duct, mucus collection in the gallbladder occurs. This results in a painful mass in the right upper abdomen. Infection in the gall bladder cavity can lead to abscess formation, a condition called “empyema.” The gallbladder can perforate into the intestine, creating inflammation and adhesions. Evacuation of gallstones occurs inside the intestine. This leads in the majority of cases to closure of the intestinal lumen, a clinical condition called intestinal obstruction. Jaundice — yellow coloration in the eye and skin due to raised blood bile — can occur secondary to obstruction of the common bile duct — the duct connecting the liver, gallbladder and intestine — by migrating stones from the gallbladder. Pancreas inflammation due to irritation of the pancreatic tissue from the bile can develop. It is very serious and can be fatal.
The diagnosis of gallstones is easy and done by ultrasound examination of the abdomen.
The treatment of gallstones is mainly surgical. The strategy is to remove the sick gallbladder with the stones within it. Recent advances in the surgical approach to many abdominal diseases achieved in the last decade allow us to perform this surgery with the laparoscope. Laparoscopic surgery is a minimal invasive surgery. This means fewer invasions in the human body and harm during and after surgery. The gallbladder is removed through small openings without the need for a big incision. The patient experiences much less discomfort and pain after surgery. The hospital stay is limited to one day in the majority of cases and patients can go back to their normal activities and work usually within one week after surgery. There is no wound scar and therefore a better cosmetic appearance.
Trials to treat gallstones by dissolving them with medication or fragmenting them with electric or ultrasound shock waves have not been successful. The results of these methods were disappointing as the gallstones recurred in the majority of cases and the complication rates were high.
Three thousand years have passed since the death of the associate of Amon. During that time great advance in treating gallstones have been made. The availability of modern ultrasound and X-ray machines as well as high-tech laboratories along with the advanced training and evolution of surgery makes it easy for us to diagnose and treat gallstones.