Coping with the common cholelithiasis

By Helena Ambele

There are some organs in our bodies that most people tend to consider unimportant and at times are unaware of the complications that may occur if such an organ is tampered with. An example of such an organ is the gallbladder.

A gallbladder is a small pouch that sits right under one’s liver. It stores bile produced by the liver - bile is the fluid your liver produces that helps digest fats in the food you eat. In addition, the bile absorbs fats and soluble nutrients like vitamins.

Just like other major body organs, there are some common issues that affect the gallbladder and amongst these are gallstones, a condition medically referred to as Cholelithiasis.

What are gallstones?

Gallstones are pebble-like pieces of concentrated bile materials. Bile fluid contains cholesterol, bilirubin, bile salts and lecithin. Therefore, gallstones are usually made up of cholesterol or bilirubin that collect at the bottom of one’s gallbladder until they harden into stone like particles.

Gallstones can range from the size of a grain of sand to that of a golf ball. They grow gradually, as bile continues to wash over them and they collect extra materials. The irony is that the smaller they are in size the bigger the possibility of the complication yet one might think that it is when it is big that it might cause a problem.

The reason for this is that smaller stones can travel, while bigger ones tend to stay still. As a result, the smaller ones which can easily move, travel and may get stuck somewhere and create a blockage.

Dr Amunga Meda, a Gastrointestinal and Liver Diseases medical specialist at Muhimbili National Hospital says that the small stones can move and block the cystic duct which results in the inflammation of the gallbladder - a life threatening situation.

Unfortunately, one might not know that they have them until they block a bile duct, causing pain that should be treated without any delay.

Speaking to Your Health, Gloria* said that she first found out that she had gallstones through a health campaign that took place at Mnazi Mmoja, Dar es Salaam. She had no idea it was harmful or that they could cause any complications because they weren’t causing any pain. Furthermore, the doctor who diagnosed her with it at the campaign just told her they would call her back and never gave her any feedback so she kept on living with them for about 10 years.

“I was not experiencing any alarming pain and had no symptoms at all so I never thought that it was something that I needed to pay attention to and that made me relax,” recalled Gloria.

“During one of my monthly clinic visits the doctor asked me how I had been feeling and I told her that I always felt bloated. On hearing so, she did an ultrasound on me and saw the gallstones. The doctor was alarmed and insisted that I see a surgeon in order to have them removed or else it would escalate to more problems,” she narrated.

After a long time of postponing to meet the surgeon, Gloria finally booked an appointment with him and after consultation, her doctor advised her to treat the gallstones through a laparoscopy instead of a normal open surgery. The doctor told her that if she had delayed a little longer the bile would have ruptured and that can cause one’s death.

Meda explains that such an occurrence is known as sepsis. “When the duct is blocked by a stone, the gallbladder swells and becomes weak causing it to burst, spreading infection into your abdomen that may result in one’s death.”

Fortunately, Gloria went in at the right time for the procedure and it was successfully carried out at Kairuki Hospital in Mikocheni. “The procedure was less painful and took a short time to heal, furthermore, there aren’t any obvious visible scars where the laparoscopy was performed,” Gloria explained excitedly.

At times, after the said procedure, the patient (or relatives upon consent) is shown the stones that have been removed to remove any doubts although Gloria did not get a chance to see hers.

When asked about her diet, she said that the only time the doctor told her to reduce foods high in cholesterol was before the procedure because when she was tested, her cholesterol level was high. In addition to eating foods with low cholesterol, she was administered with some medicines to quicken the process.

Although Meda advises that if you do not want the gallstones to recur one of the things that you have to do is change your diet especially if it was one that contained high amounts of calories or cholesterol, another more drastic option is to completely remove the gallbladder.

The fact that Gloria was not experiencing any symptoms is quite usual for patients with gallstones and Dr Primus Saidia, a Gastroenterologist at Rabininsia hospital explains that this is because gallstones can be asymptomatic or symptomatic. Asymptomatic simply means that there aren’t any signs that one can feel or see that indicate the presence of gallstones in one’s body unless they are found incidentally like Gloria’s which is the case for many gallstones patients.

In addition to that, Meda states that more than 80 percent of patients usually have no symptoms of the disease. Only 10 to 20 percent of asymptomatic patients eventually become symptomatic within five to ten years of diagnosis. Approximately 2 percent per year is the rate at which patients develop symptomatic gallstones which is evidently a low rate and explains the period of time to which one becomes symptomatic.

What causes them?

Primus explains that gallstones develop when your bile contains too much cholesterol and when this happens then they form the type of stones known as cholesterol gallstones- usually yellow in colour. Moreover, they can be caused when your bile has too much bilirubin; a chemical formed when your body breaks down red blood cells. If your bile has too much bilirubin then you are likely to have pigmented gallstones which are normally brown or black in colour.

“Another possible cause of gallstones is when your gallbladder doesn’t empty as it should. This causes your bile to be very concentrated and as a result, the stones are formed,” explained Primus further.

How are Gallstones Tested?

Ultrasound

This is the most preferred and common test used and that is because it is inexpensive, has no associated radiation and is highly sensitive for the detection of gallstones.

X-Ray

Another test that can be carried out is the X-Ray although this one is limited to the calcified stones which tend to be shiny and that is why they can be easily seen using an X-Ray.

CT Scan

This is usually contemplated in patients with indefinite or negative ultrasound results or if complications of gallstones are suspected.

However, the doctor made it clear that you cannot order X-Ray and CT scan tests for the sole purpose of making a diagnosis of gallstones.

Symptoms

Symptoms occur as a result of a gallstone causing blockage. Once you see the following signs you need to hurry to your doctor and save your life:

• Impulsive ain in the upper right portion of your abdomen that intensifies rapidly.

• Impulsive pain in the centre of your abdomen just below your breastbone that also intensifies rapidly.

• Yellow eyes, pale stool and coke, dark urine; and swelling of the gallbladder are signs of complications that are life threatening.

Risk Factors

These are the chances that expose you to the development of gallstones in your gallbladder. They are divided into two types: modifiable (can be changed) and non-modifiable (cannot be changed) factors.

Modifiable

• Environmental- Geographical location, diseases like obesity, diabetes etc.

• Rapid weight loss

• Diet - eating foods with low fibre and with high amounts of calories or cholesterol

• Total parenteral nutrition(TPN) - a method of feeding through veins

• Surgery

• Oral contraceptives

• Prolonged fasting

Non - modifiable

• Being female- a factor that shows that women are more prone to developing gallstones than men due to the presence and production of the oestrogen and progesterone hormones.

• Genes

• Age

• Pregnancy

The more the risk factors, the bigger the chances of developing gallstones. That is if you’re a woman, you’re in your 40’s, you’re obese and you have diabetes; you’re definitely at a very high risk of developing them.

Treatment

Choleliathisis best option for treatment is to have the gallbladder removed either through open surgery or laparoscopy which is a process where a thin tube is inserted into the abdomen through a small incision.

Another form of treatment is medication which can take up to a year for it to make the gallstones dissolve, the downside to this form of treatment is that there is a high chance for them to recur which will take you back to square one.

Prevention

Dr Meda advises that if you want to prevent the development of gallstones then you have to change your environmental factors that put you at risk of getting them. For instance eating a balanced diet instead of eating too much and being obese, losing weight slowly and not skipping meals.

The prevalence of gallstones in Tanzania is not quite known but Primus attests to having many patients coming in with the condition while Meda says that most of the patients he comes across are those that are diagnosed incidentally.

This calls for more up-to-date researchee to be done in the country to better understand the exact data of people who are affected by the condition and what ought to be done.