"In the vast majority of
patients who have stones in the
gallbladder, the stones may not
be causing the symptoms of the
patient's illness."
That somewhat surprising
statement comes from Rakesh
Gupta, M.D., internist /
gastroenterologist.
Dr. Gupta's comment is
indicative of changes that have
occurred over the past 10 years
in the understanding of
cholelithiasis and
choledocholithiasis – a
condition marked by
the presence of calculi
(stones) in the
gallbladder and the
common bile duct.
This new
understanding has led
to a reconsideration of
the best modes of
treatment.
Dr Gupta explains.
"The incidence of
prevalence of
gallstones or gall
bladder disease
increases with age. It
is thought that 10 percent of the
adult population age 25 and
over have stones, and this
increases to one in four by the
age of 70.
"Furthermore, it is estimated
that in up to 70 percent of
patients who have gallstones, it
may not be the gallstones
themselves that are causing
significant clinical illness.
To best manage
choledocholithiasis, we must
look at the entire clinical picture
in each individual case," Dr.
Gupta says. |
Gallbladder
"Unless it is really deficient,
even bad bile won't necessarily
cause the formation of stones if
the flow is good and rapid.
There may be a problem with
the gallbladder itself," Dr. Gupta
says.
Why? The answer lies in the
function of the gallbladder. "The
gallbladder acts as a reservoir.
Therefore, if the bile flows in,
but not all of it flows out, theeffect becomes like that of a
stagnating pool."
"That's why the gallbladder
has been called the 'mother' – it
produces the stones in this
stagnant pool of bile.
"Traditionally, our approach
has been directed toward fixing
the gallbladder by removing it –
in an open surgical procedure
called cholecystectomy," Dr.
Gupta explains.
The papilla is a nipple-like
structure at the lower end of the |
common bile duct. Normally, it
assists in the bile regulation.
"The papilla functions in a
way similar to a valve. When it
is operating normally, it opens
up at the time we need bile and
releases it into the duodenum to
assist in digestion. Normally, it
is synchronized with our eating
and is controlled by the nervous
system and hormones.
"The papilla may become
lacerated when stones pass
through the opening.
When the papilla heals,
scar tissue forms.
"The scar tissue may
restrict the flow of bile to
the point at which it is
unable to move at
normal pressure. The
inability of bile to flow
freely into the intestine
can lead to the
recurrence of stones –
or merely a build-up of
pressure in this channel
that causes pain.
"This explains why a
patient who may have
had the gallbladder removed
can experience what seems to
be a 'gallbladder attack", Dr.
Gupta says.
Treatment
The course of treatment
dictated will vary according to
the patient's age, symptoms and
results of a clinical exam and
laboratory tests, which may
include functional and
anatomical analysis of the liver,
pancreas and papilla.
Generally speaking, for
younger patients the course of
treatment would probably still be |
to remove the gallbladder," Dr.
Gupta says.
Why? "For the same reason
that you would not want to keep
a worn-out part in a new
engine." Even in a case in
which the stones are not
causing the symptoms now,
they may have a significant
negative impact in years to
come."
"Therefore, it makes sense
to remove the gallbladder while
the patients is young, rather
than wait until later when his risk
factors have increased."
"For older and / or high-risk
patients, however, an
endoscopic approach may be
used. Called duodenoscopic
sphincteroplasty, this approach
has been developed only
recently."
What is involved
The scope is flexible, with a
light source at the tip that allows
the gastroenterologist to view
the papilla and see the scar
tissue. The patient is sedated,
and the scope is inserted
through the mouth.
"The scar tissue can be cut,
through the scope, using an
electric knife. If there are
stones in the bile duct they can
be pulled out using a balloon or
basket inserted through the
scope.
"If there are no stones, you
still make an incision to relieve
the spasm in the muscle."
"This procedure can be
performed even if the
gallbladder has been previously
removed," Dr. Gupta says. |
He is quick to note that
duodenoscopic sphincteroplasty
is not for every patient.
"For instance, the stones in
the bile duct may be to large.
Therefore, it may be necessary
to use a solution to dissolve
them or perhaps an open
surgical procedure."
"And often, stones are found
to be secondary to a disease of
the liver, pancreas, or other
problem. Each patient is judged
individually."
Dr. Gupta stresses that this
endoscopic technique cannot
remove stones from within the
gallbladder.
Benefits
"By using duodenoscopic
sphincteroplasty, we are able to
diagnose many people whom
we couldn't diagnose in the
past," he says.
"Nowadays, if there is scar
tissue present, regardless of
whether there are stone in the
bile duct, you can see it with the
scope and surgically cut it.
"Less hospitalization is
required – usually one to three
day's stay – and the procedure
does not require general
anesthesia."
"Clinical studies have found
that in the majority of older
patients with choledocholithiasis
who are treated with
duodenoscopic
sphincteroplasty, the gallbladder
can be left in place. And
duodenoscopic sphincteroplasty
can be used for those with
gallbladders already removed |
who are still experiencing pain –
with a high success rate," Dr.
Gupta says.
"As for the future, the
development of ultrasonic
lithotripsy and laser probes in
combination with
duodenoscopic sphincteroplasty
will further refine our abilities to
handle most gallstone-related
problems, " Dr. Gupta predicts.
Duodenoscopic
sphincteroplasty is performed in
Saint Anthony Hospital's
gastrointestinal laboratory.
Dr. Gupta attended medical
school in India. His internship
was served at the Hospital for
Joint Disease and Medical
Center, New York City, where
he trained for general surgery.
His internal medicine
residency was completed at
Cook County Hospital, followed
by a two-year fellowship in
gastroenterology at the
University of Illinois Hospital,
Chicago.
He is board-certified in
internal medicine and
gastroenterology and is a
member of the American
gastroenterology Association. |
