Although gall bladder stones are one of the most commonly diagnosed surgical problems in Nepal, two-third of stones are asymptomatic and most of them go undetected.

About 14 -16% of the population of the United States have gallstones but the exact incidence in Nepal is not known. Diet has a major role in gall stone formation. Contrary to popular belief, it’s not fat but carbohydrate that plays the villain. 

 

The pain of biliary colic is constant and infrequent, comes in episodes lasting 1 to 5 hours, and is located in the epigastrium or right upper quadrant of the abdomen. Like ghosts, they tend to haunt especially at night. Nausea, vomiting, flatulence, bloating, indigestion and vague pain in the right upper quadrant are some common but not compulsory symptoms. The classic picture of biliary colic may be inaccurate and the connection between gall stones and flatulence dyspepsia is uncertain. Symptoms and complications necessitate cholecystectomy, while death from complications of both conservative and surgical approaches is possible. Biliary sludge may act as nidus for gallstones formation. Removal of the gall bladder will only relieve the symptoms caused by notorious stones, so decision making is challenging. 

 

Now, let’s clear up some more misconceptions!

 

Dietary fat is the culprit in gall bladder disease

Studies don’t support the notion that a high-fat diet causes gallstone. They are recognized to be associated with excess dietary carbohydrates. Diet rich in carbohydrates causes the liver to produce a type of bad cholesterol which exacerbates stone formation. Fatty liver, metabolic syndrome/insulin resistance, obesity, and gall bladder problems are closely related. Eating habits that promote overweight, insulin resistance and type 2diabetes increase the risk of gallbladder disease. Having gallstones predicts a higher risk of dying earlier—not due to the danger gallstones pose, but because of the accompanying cardio-metabolic risks. Remember the dangerous 4Fs: fat, female, forty, and fertile.

 

Gallstones are hereditary

Only about 30 percent of the risk for gallstones is inherited. Gall bladder problems are mostly a lifestyle disease, avoidable via lifestyle modification.

 

Cholecystectomy must be done after an attack or presence of gall stone

Elective cholecystectomy is suggested when symptoms have subsided to prevent further episodes. Stones more than 2cm, diabetic patients, multiple polyps, increasing size, calcification (porcelain gallbladder), pancreatitis, infection or sickle cell disease calls for surgery. Due to the advancement of surgery, it’s the call of the surgeon whether to operate or opt conservative management. Further attacks are a clear indication of gall bladder removal.

 

Around 50% of times, patients present with “post-cholecystectomy syndrome.” Symptoms present even after surgery because the root cause is not identified. Sometimes, the patient presents as choledocholithiasis. If symptoms like pain, bloating and indigestion persists, then other problems like small bowel obstruction, hydrochloric acid or pancreatic enzyme deficiency may be the cause.

 

Elderly patients are at high risk of surgery complications 

Presence of infection, anemia, and malnutrition results in delayed surgery. The latest statistics show death from elective gall bladder surgery as low as 0.15%. Age used to be a contraindication but the improvement in surgical techniques, as well as superior anesthesia, now enable patients of 80s and 90s eligible for surgery.

 

After cholecystectomy, a low-fat diet is required 

There is no work of literature to prove this hypothesis. A paper dating back to 1964, states that removal of the gall bladder does not influence the absorption of butter and olive oil and that the evacuation of the gall bladder is not essential for the absorption of these types of fat in humans. This is because the gall bile does not produce bile, it acts as a bile storehouse. So after cholecystectomy, instead of releasing stored bile to meet the occasional demands of a meal, bile is released continuously. Enough bile is usually secreted to digest fatty meals.

 

 “Gall bladder flushes” are effective at removing gallstones

Controversy surrounds this question. Many books, articles, and magazines focus on the benefit of gall bladder flush which is said to expel stones. Patients are encouraged to consume apple, lemon, herbal tea or olive oils to aid flushing.

 

A 2005 analysis in Lancet shows that the composition of these so-called “stones” does not resemble true gallstones (bile salts, cholesterol, and phospholipids), and consists only of greenish, congealed olive oil. Potassium in lemon juice creates a kind of soap, making the globules appear to stick together with a semi-solid consistency. While not effective in passing gallstones, there’s the potential risk that a high-fat flush of olive oil will trigger gall bladder contraction, precipitating a painful gall bladder attack.

Medical therapy was undertaken with Ursodeoxycholic acid, but it was found to only be successful for radiolucent gallstones—a less common kind, consisting only of cholesterol. These are useful in removing gall bladder sludge to some extents.

 

People without gall bladder suffer from fat-soluble vitamin and fatty acid deficiency

Well, no proof of this either and no papers are proving it. Patients gain weight after surgery because the gall bladder colic no longer bothers them and overindulgence with carbohydrates becomes the problem.

 

So What Is The Gallbladder

The gallbladder is a small pouch that sits just under the liver. The gallbladder stores bile produced by the liver. After meals, the gallbladder is empty and flat, like a deflated balloon. Before a meal, the gallbladder may be full of bile and about the size of a small pear.

In response to signals, the gallbladder squeezes stored bile into the small intestine through a series of tubes called ducts. Bile helps digest fats, but the gallbladder itself is not essential. Removing the gallbladder in an otherwise healthy individual typically causes no observable problems with health or digestion yet there may be a small risk of diarrhea and fat malabsorption.