|
The gallbladder is a sac attached to the
undersurface of the liver and is a storage reservoir for bile. Bile
is made in the liver and passes down through a duct and up into the
gallbladder. After one eats, the bile is released into the small
intestine to mix with the food for better digestion and absorption of
fat. The removal of the gallbladder by surgery, however, does not
significantly interfere with the process of digestion or absorption.
Gallbladder Disorders
Gallstones, Cholecystitis,
Inflammation of the Gallbladder - Gallstones develop in the
gallbladder when either the amount of cholesterol secreted into the
gallbladder by the liver is too high, or the amount of other substances
in the bile is too low to prevent the cholesterol from remaining in
solution. In either condition, the cholesterol precipitates out as small
crystals which eventually form larger stones. Many people have
gallstones for years without any symptoms whatsoever. Symptoms from
gallbladder disease usually consist of upper right quadrant abdominal
pain especially after ingestion of heavy meals which contain rich foods.
The pain may radiate around to the back and up under the shoulder blade.
Sometimes nausea and vomiting occur. If severe inflammation of the
gallbladder occurs, it is called cholecystitis, and the patient may
develop severe abdominal pain and fever. The most common treatment for
patients with symptomatic gallstone disease is cholecystectomy (removal
of the gallbladder surgically). This can be done by a surgeon using the
standard technique (an incision made in the upper right quadrant of the
abdomen) or the newer technique of laparoscopic removal of the
gallbladder. This newer technique is performed with an instrument called
a laparoscope which is inserted into the abdomen through a small
incision made around the navel. In some patients who are not surgical
candidates, stones may be dissolved by medicine or broken up by
ultrasound or shockwave techniques (lithotripsy). The reoccurrence of
stones once medicine is stopped can occur. Whether these techniques will
avoid the need for surgery in all patients is unknown.
Sometimes stones from the gallbladder may
become lodged in the duct that allows flow of bile from the gallbladder
to exit into the duodenum. When this happens, these lodged stones may
cause pain, fever and elevation of ones liver function tests. Your
physician may perform an ERCP in order to evaluate if this is the
problem, and if stones are found within the ducts, he can remove them
during ERCP. A new approach to imaging of the bile duct which is less
invasive and with less complication than ERCP is called MRCP.
MRCP is a technique in which a special MRI unit with special software
produces pictures that resemble those obtained with ERCP. The
downside, if anything is found such as a stone or mass or leak of the
bile duct, then ERCP may be required to fix the problem. At
present the role of MRCP is still being defined.
In a small group of patients who have had
their gallbladder removed, they may have recurrent pain similar to the
pain that they had prior to its removal. At times this pain
may be severe and in a few cases have significant impact in ones quality
of life. Such patients may have a clinical condition known as
post-cholecystectomy pain syndrome which may be caused by sphincter of
Oddi dysfunction. The sphincter of Oddi is a small muscle
which is at the bottom of the common bile duct and it controls the flow
of bile into the duodenum. In such patients with pain, there may
be an associated elevation of their liver function tests, or they may
have demonstrated dilatation of their common bile duct on ERCP. In
such patients, often times a small cut done during ERCP of the sphincter
of Oddi will make this pain go away.
A more difficult group of patients are
those that have had their gallbladders removed and who have recurrent
pain which is severe and there is no elevation of their liver
tests in association with the pain, and neither is there dilatation of
their bile ducts at the time of ERCP assessment. In such patients a
technique called sphincter of Oddi manometry may be used. In this
technique an ERCP scope is passed to the level of the sphincter of Oddi
(The Ampulla), and through the ERCP scope, a special catheter is placed
into the muscle to measure pressures and the frequency of contraction.
If elevated, the endoscopist may elect at that time to make a small cut,
known as a sphincterotomy. This difficult group of patients may see a
50% chance of improvement. The downside: in this special
group of patients, the risk of pancreatitis post ERCP with manometry may
be as high as 25%. One way to hopefully minimize this risk is to
use a technique at the time of manometry known as aspiration manometry
which was first reported by Dr. Sherman's group at the University of
Indiana. We have been using this technique ourselves, and we too
believe, as he first reported, that it decreases the incidence of
pancreatitis considerably. The bottom line, if you are considering to
have manometry done during ERCP, be sure it is being done by someone who
knows what they are doing.
BACK
|
