posted 09-17-1999 08:58 PM
well have a look!!!
When To Say Yes, When To Say No
Gallstones are common.
Sometimes they don't cause problems and can be left alone.
But if they are causing trouble, you'll need to have your gallbladder removed.
by F. Yona Strasberg and Steven M. Strasberg
Ohhh, that was good: southern fried chicken, mashed potatoes with gravy, biscuits slathered with butter, apple pie a la mode. Another slice? Well, just a sliver.
Maybe that was a bit...(oof)...too much. Ow! That pain! What is that?
That may be a gallbladder attack.
Stones: Who, Why, What
To digest the fat in foods, you need bile. Bile is made in your liver. Between meals, it's stored and concentrated in your gallbladder, a pear-shaped organ near your liver. When you eat, your gallbladder contracts, expelling bile into your intestine.
Sometimes, stones form in the gallbladder. The most common type of stone, especially in people with diabetes, is made of cholesterol.
When a stone blocks the exit of the gallbladder, it can cause severe pain. This is called a gallbladder attack.
Gallbladder stones are very common. At age 60, about 25 percent of women and 10 percent of men have gallstones.
Some things increase your risk of developing gallstones: obesity; being a woman; and pregnancy, especially if several children are born over a short period of time.
Diet may be important, too. Our Western diet is high in calories and fat, which probably helps stones form. Stones are less common in vegetarians. Crash diets that result in rapid weight loss may also help stones form.
Gallstones are more common in people with type II diabetes. Some people think that type II diabetes itself causes cholesterol stones. However, it's probably just that both type II diabetes and gallbladder disease are more common in people who are overweight.
Some effects of diabetes (either type I or type II) may help stones form. Diabetes can interfere with the function of nerves that go to the gallbladder. This nerve damage is called autonomic neuropathy. The gallbladder can't contract well, and this favors stone formation. High blood glucose may lead to poor contraction by worsening neuropathy-yet another reason to strive for good control.
Look, Ma, No Symptoms!
If you have gallbladder stones, you may never know it. Only about 25 percent of people with stones ever develop symptoms. (However, that's still 500,000 people a year.)
Should you try to find out if you have gallstones? No. For the most part, ignorance is bliss.
Even without symptoms, you may find out you have gallstones. About 15 percent of gallstones develop calcium deposits. These make them visible on the simplest X-rays, such as chest X-rays. Gallstones might also be found when you have an ultrasound done of your abdomen for some other problem.
Still, it's no cause for alarm. There's no reason to have surgery if your gallstones aren't causing any problems, because they probably never will.
PAIN PAIN PAIN
Pain is the main symptom of a gallbladder attack. The pain usually-
is under your breastbone, or a little to the right
comes after meals or wakes you up at night.
If you have two or three of these pain features, and an ultrasound shows that you have gallstones, you'll probably need to have your gallbladder removed.
Gallstone Mimics: Don't Be Fooled
OK, let's say you've been feeling some discomfort in your abdomen. Your doctor finds gallstones on an ultrasound. Now should you have surgery? Not necessarily. You're having symptoms, but the gallstones may not be causing them.
For example, if you have diabetic neuropathy of the stomach, you may often feel bloated and nauseated after meals. These are also symptoms of gallbladder disease. But if it were your gallbladder, you'd also feel pain, unless your neuropathy is severe.
Another gallstone mimic: irritable bowel syndrome, which is one of the most common causes of abdominal complaints in adults. People usually complain of having constipation and diarrhea, bloating, gas, and lower abdominal pain. Though there is pain, as in a gallbladder attack, the symptoms of irritable bowel syndrome are usually felt every day and often have been present for years, unlike the symptoms of gallstones, and the pain is usually in a different place than it would be if it were from gallstones.
NOW You Do Something
About 2 to 3 million Americans will develop gallstones in any year. In each year of life after the stones have formed, there's a 1 to 2 percent chance that symptoms will occur.
If your gallstones start causing trouble, you'll probably experience pain called biliary colic. The pain comes when a stone blocks the exit of the gallbladder during gallbladder contraction. The pain is usually severe. You'll feel it in the mid upper abdomen just below your breast bone or slightly to the right. You might also feel it in your back. Walking or rolling about may make you feel better. Along with the pain, you might feel nauseated or be vomiting.
Often the pain comes at night, waking you from sleep. Another common time is after a meal, particularly a large or fatty meal. Usually between the attacks, you have no pain.
If you go to your doctor with these classic symptoms and an ultrasound examination shows stones, the diagnosis is secure. Particularly because you have diabetes, you should get treated promptly.
You may have gallstones but have less typical pain. Perhaps the pain isn't severe, or the pain is more in your back or on your left side. It may come during the day and not after meals. Generally, the less typical the pain is, the more your doctor will look for another cause for the pain.
If you have two of the three main features of the pain (severity, location, and timing) and an ultrasound shows gallstones, most likely the pain is from your gallbladder, and you'll need treatment.
If only one of the three pain features is present, then it's probably not gallbladder disease. There's an 80 percent chance that another explanation will be found for your pain, such as an ulcer or irritable bowel syndrome.
Note that pain is the main symptom of gallstone disease. Other symptoms, such as nausea, vomiting, and bloating, may be present at the same time as pain, because they are caused by the pain. There's no evidence that gallstone disease leads to these symptoms when pain is not present.
This is important. If you have symptoms other than pain, you may think that your gallbladder should be removed. This probably won't improve your symptoms and may make them worse.
There's an exception to this rule. Rarely, a person with diabetes has serious gallbladder problems but, because of neuropathy, there's no pain. Some people with neuropathy have even developed serious complications of gallstones without feeling pain. Thus, vague abdominal symptoms in people with diabetes who have developed nerve damage may mean gallbladder trouble. The doctor must rely on other symptoms-such as nausea, weight loss, or fever-to make the diagnosis. Fortunately, cases in which there is absolutely no discomfort are rare.
There is another exception to the rule of No Symptoms, No Surgery: Calcium deposits in gallstones present no danger. However, rarely, the wall of the gallbladder itself becomes calcified. This is linked to a higher risk of cancer of the gallbladder. The gallbladder should be removed.
Because You Have Diabetes...
We've stressed why you should leave well enough alone, if your gallstones aren't causing symptoms. Too much too soon is wrong. But so is too little too late. Once symptoms of gallbladder disease appear, the time has come to treat the stones.
Because you have diabetes, you're more likely to get an acute inflammation of the gallbladder once symptoms develop. And you're prone to get severe types of this inflammation, including gangrene, rupture, or serious bacterial infections of the gallbladder. These require emergency treatment. A person with diabetes doesn't withstand emergency treatment as well as other patients.
Other complications of gallstones may also occur within weeks or months after the warning pains, and some of these come with bacterial infection. A person with diabetes has fewer defenses against infection.
Therefore, if you have pain coming from the stones, you need to be treated promptly to avoid slipping into the complicated stage of the disease.
There are other reasons to have routine surgery before you need emergency treatment of gallstones. You should have surgery when your diabetes is under good control. If you wait and develop an infection, your body will feel stressed and your blood glucose will go up. It's not unusual for diabetes to be in poor control when a person has a gallbladder complication. This may delay diagnosis and treatment, or make treatment less effective.
These problems can be avoided by having non-emergency (elective) surgery before you develop complications. Diabetes doesn't increase the risk of elective surgery. In fact, people with diabetes come through routine gallbladder surgery as well as people who don't have diabetes.
Getting Rid Of It Once And For All
The mainstay of treatment is an operation to remove both your gallbladder and the gallstones. Because the gallbladder is removed, gallstones can't form again.
There are usually no consequences of having your diseased gallbladder removed. It probably wasn't working well anyway, and your intestine takes over its job. About 1 in 50 patients have looser stools after surgery.
Just a few years ago, the surgery entailed a 4- to 8-inch incision. Now the surgery of choice is a laparoscopic cholecystectomy.
This operation is very safe. It's done under a general anesthetic and takes about an hour. The surgeon makes four small (1/4- to 1/2-inch) openings in your abdomen. Instruments and a telescope attached to a tiny television camera are put through these incisions. Your gallbladder is separated from its attachments and removed through one of the 1/2 inch incisions. Any large stones are broken up before bringing the gallbladder out of the abdomen.
You may eat and drink within hours of surgery and go home the next morning. Usually only one follow-up visit with the surgeon is needed.
As with all types of surgery, serious complications may occur, but these are rare when the surgeon is experienced. The main serious complication is an injury to the bile ducts that join the liver to the intestine. New ways to avoid these injuries are being introduced and will lead to a drop in this problem.
Other serious complications are very rare. Patients who have heart or lung problems withstand this operation much better than the older procedure of open surgery. This caused more pain and problems with breathing after surgery.
In 2 to 4 percent of operations, the surgeon can't complete the laparoscopic procedure and has to do a standard open operation. Patients most likely to need a switch to an open operation are those who have already had a bout of acute inflammation of the gallbladder and older men who have had more than 10 attacks of biliary colic.
In about 5 percent of cases, stones have moved from the gallbladder into the bile ducts by the time the patient comes for surgery. The surgeon removes the stones from the bile ducts at the same time the gallbladder is removed, or stones are removed at a separate procedure. If you get your stones treated promptly after you develop symptoms, you'll have a lower risk of needing an open surgery or having stones in the bile ducts.
A 1/2-inch cholestrol gallstone (split). The
most common type of gallstone, especially
in people with diabetes, is made of cholesterol.
Here's the usual process leading up to surgery.
An attack of gallbladder pain sends you to your doctor. Your doctor does an ultrasound examination that shows the stones. He or she refers you to a surgeon.
The surgeon talks to you about benefits and risks of the procedure, answers your questions, and runs some tests. Your surgery is done a week or so later, as a scheduled daytime procedure.
It's also important for you to visit the doctor who'll be in charge of your diabetes in the hospital. He or she will evaluate your diabetes control, blood pressure, kidney function, and function of your heart and lungs. The surgeon will await the go-ahead from this doctor. You'll want your diabetes in the best possible control going into the operation. Good control of blood glucose levels helps your incision heal faster and may help prevent infection.
You'll be asked not to eat or drink after midnight on the night before surgery so that your intestines are clear for anesthesia and surgery. People with diabetes are usually scheduled for surgery early in the morning to avoid long fasts.
The goals of diabetes management just before, during, and after surgery are first to avoid low blood glucose, and second, to avoid very high blood glucose. If you control your diabetes with an oral hypoglycemic agent, the plan might be as simple as not taking the drug on the morning of surgery. If you use insulin, you'll probably need to reduce your dose before surgery. During surgery, you'll be given insulin and glucose in a vein as needed to keep your blood glucose in the target range.
Blood glucose that's a little high isn't harmful in the short run, and it lowers the risk of low blood glucose. Therefore, your blood glucose will be kept in the 150 to 200 mg/dl range. You'll monitor your blood glucose levels before surgery. The medical staff will monitor your blood glucose during surgery as needed.
On the morning after surgery, you'll go back to your usual diabetes care routine. You'll also be given pain killers. Fortunately, laparoscopic cholecystectomy is not a very painful procedure.
Other Treatment For Gallstones
Certain types of gallstones can be dissolved by an oral medication called ursodeoxycholic acid. The treatment is successful only when the stones are small and uncalcified, when the patient is not overweight, and when there is no blockage of the cystic duct. These conditions are present in about 5 percent of patients with gallstones. In these patients, the treatment is as good as laparoscopic cholecystectomy.
Its advantage is that it's very safe. However, the medication must be taken for 6 to 12 months or more, and the stones come back in more than 50 percent of patients. This treatment is becoming less common.
F. Yona Strasberg, RN, CDE, is a clinical nurse coordinator and Steven M. Strasberg, MD, is professor of surgery and head of liver, biliary, and pancreatic surgery at Washington University School of Medicine in St. Louis, Mo. The authors wish to acknowledge the helpful suggestions and contributions of Philip Cryer, MD, professor of endocrinology and metabolism at the same institution.
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