Stephen Pereira, MD, chief of the division of general surgery and director of robotic general surgery at Hackensack University Medical Center and founder of One Surgical Specialists in Hackensack, New Jersey. OneSurgicalSpecialists.com
The gallbladder—it’s fair to say that most of us know very little about this small organ…until something goes wrong, and then it can cause big pain. Good news: There are ways to keep your gallbladder healthy, says Stephen Pereira, MD, chief of the division of general surgery at Hackensack University Medical Center, and just as important, there are ways to recognize signs of a problem before it turns serious.
What is the gallbladder? The gallbladder is about the size and shape of a pear, nestled under your liver and connected to the pancreas, liver and small intestine via a complex ductwork. It concentrates and stores between 10% and 25% of the one liter of bile your liver makes every day. When you eat fatty food, the gallbladder contracts to release bile into the intestines to break down that fat as part of the digestive process.
How to keep it happy: The same steps you take for overall health will keep your gallbladder healthy. Eat a nutritious diet that includes high-fiber whole grains, legumes, fruits and vegetables, and healthy fats from olive oil and fatty fish. Avoid refined carbs (white flour-based and sugar-laden foods), saturated fats and high-cholesterol foods. Maintain a healthy weight, and get 150 minutes of moderate-intensity exercise every week. Don’t smoke—smoking increases risk for many types of cancer, and though rare, gallbladder cancer often is not discovered until later stages.
For reasons we don’t yet understand, sometimes the gallbladder just doesn’t work as it should. The most common problem: Small stones that form within the gallbladder. About 80% are cholesterol gallstones, which form when your bile has too much cholesterol, typically from a high-fat diet, although family history and genetics also play a role. The rest are called pigment gallstones, and they form when the balance of certain natural body chemicals—bile acids and lecithin—is off. The cause of this imbalance is primarily hereditary, but it is a poorly understood phenomenon. (Diet plays no role in this type of gallstone formation.) It’s possible to have anywhere from a few to hundreds of gallstones, and each can be as tiny as a grain of sand or as big as a golf ball.
About 20% of adults develop gallstones at some point in their lives, but they become troublesome for only about 20% of those people. Many people with so-called silent gallstones learn that they have them only when they get an ultrasound (the most likely test to detect them) for another reason. When gallstones are found incidentally on an imaging study, such as an ultrasound, and the patient has no symptoms, intervention generally is not required.
Many factors increase risk for gallstones…some are modifiable, others are not. They include increasing age…being a woman and having been pregnant…being genetically disposed to gallstones…eating too many simple sugars and saturated fats and too little fiber…being obese…having high levels of cholesterol in your blood…and carrying a lot of belly fat.
While slowly losing excess weight can reduce your risk, be wary of losing weight too quickly. That can increase risk for gallstones, so keep an eye out for subtle symptoms (see below). Up to 40% of people who have bariatric surgery develop gallstones within the following year or two, and gallstones will be problematic for up to 15% of them. One explanation for the link: Changes to your digestive system from the surgery in turn change the composition of your bile and affect gallbladder function. If you already had gallstones, they may act up. (Work with your bariatric doctor on steps to help you avoid problems.)
When gallstones attack: It is possible to experience a mild attack that feels like indigestion or reflux. You might take Tums or Pepcid and think the medicine made the pain go away—but what actually happened was the stone moved on its own, stopping the spasms. If you experience this kind of upset stomach regularly, it’s worth mentioning to your primary care doctor. Gallstones are easy to see on a simple ultrasound. If you have diabetes: Your symptoms may be less intense if you have diabetic neuropathy, which affects how much pain you experience, but still report such an episode to your doctor.
A gallstone can quickly become a health threat if it lodges in the duct or tube that drains the gallbladder, halting the outflow of bile. When this happens, the gallbladder will go into spasm, causing sharp, stabbing pain. You’ll feel the classic “gallbladder attack” in your upper abdomen, sometimes radiating to your back. It typically happens shortly after eating a fatty meal since fat triggers the gallbladder to contract or squeeze the bile out to the intestines. You may feel bloated and nauseated, and possibly have some vomiting. An attack can last for a number of hours until the stone moves and relieves the blockage. Pain that persists beyond a few hours may mean that the stone is stuck. This life-threatening situation can lead to infection, fever and chills…as well as inflammation and/or damage to the gallbladder.
An even more serious complication of gallstones is if a gallstone passes out of the gallbladder and into the bile ducts or tubes that drain the bile from the liver. This can cause bile to back up into the liver causing jaundice, which can lead to severe pain and the life-threating infection of the biliary system called cholangitis. Signs include the skin turning yellow because the flow of bile is blocked, dark urine and light-colored stools. If you experience hours of pain, don’t wait for it to pass—call 911 or go to the ER.
Another severe condition that can be caused by gallstones blocking the bile duct is pancreatitis (inflammation of the pancreas), when the duct to the pancreas is blocked. When this happens, severe upper abdominal pain comes on very suddenly and quickly. Call 911 or go immediately to the ER for treatment.
What not to do if you develop gallstones or have a gallstone attack: Any type of gallbladder “cleanse” or home remedies that claim to dissolve gallstones—studies have shown that these unapproved remedies don’t dissolve or “cleanse” gallstones.
One attack usually is just the beginning. Doctors often advise gallbladder removal after just the first attack. That’s because gallbladder attacks are very likely to recur, and there’s no way of knowing whether a stone will move along the next time…or get stuck. Even when stones do become dislodged or unstuck, repeated attacks can cause inflammation and scarring of the gallbladder, affecting its functioning and making surgery more complex with a higher risk for complications. Another reason not to wait: The younger and healthier you are, the better you’ll sail through the surgery.
Of course, it’s a medical emergency any time a stone is stuck. If a gallstone passes out of the gallbladder into the bile duct that drains the liver, a specially trained surgeon may insert a scope through your throat to your digestive tract to retrieve the stone…or he/she may remove your gallbladder and extract the stone that has lodged in the bile duct.
Doctors often advise cholecystectomy (gallbladder removal) after a first episode. Thanks to advances made in robotic 3D surgery, the gallbladder can be removed through a single incision in the navel. What’s more, the surgery can be guided by a dye called indocyanine green fluorescence, which makes it possible to visualize the gallbladder and surrounding structures before any incisions are made. This makes the operation safer, especially when there’s inflammation, infection or serious scarring, and reduces risk for serious complications. These innovations have drastically reduced the need to convert midway through the procedure to open (large-incision) surgery, which can happen during any type of minimally invasive surgery.
Most people have no post-op issues after their gallbladder has been removed. About one in five patients will experience bloating, gassiness or loose stool after meals as their bodies adjust—often within a few weeks or, on rare occasion a few months—to no longer having a gallbladder.
You can do just fine without that jolt of bile from the gallbladder for digestion. Remember that the liver supplies a continuous flow of bile into your intestine. Usually there’s nothing you need to do other than enjoy life without any more gallbladder attacks.