Transcription:
Gallbladder Disease

Intro: This is BayCare HealthChat, another podcast from BayCare Health System.

Prakash Chandran: Welcome to BayCare HealthChat. I'm Prakash Chandran. And in this episode, we'll be talking about gallbladder disease. Joining us today is Dr. Priscilla Thomas. She's a general surgeon with BayCare. Dr. Thomas, thank you so much for joining us today. Really appreciate your time. Let's get started with the basics. What exactly is the gallbladder?

Priscilla Thomas, MD: Sure. Thank you for having me by the way. The gallbladder is an organ that sits underneath the liver, it's in the abdominal cavity. And what it does is it stores bile that's made in the liver and it excretes that bile when hormones are sent out from the GI tract to then meet up with the food and help absorption of the food and the nutrients in the food.

Prakash Chandran: Okay you just started to touch on this. The function of the gallbladder is to help the processing of the food. Is that more or less correct?

Priscilla Thomas, MD: Yes, but it is not an organ that you need in order to process or break down the food. The bile can still be made from the liver, even if the gallbladder's removed.

Prakash Chandran: Okay. That's very interesting. Is there any other function that the gallbladder serves?

Priscilla Thomas, MD: Not that we know of. Keeping us in business, I guess.

Prakash Chandran: Fair enough. We’re talking about gallbladder diseases today. Can you talk a little bit about what they are and the most common types?

Priscilla Thomas, MD: Sure. Today because gallbladder disease can be rather complex. Of course, there's benign disease and there's malignant disease. That's its own category, so I won't launch into all of that. But benign disease is most of what we see, especially in the BayCare system. The most common is going to be something called biliary colic. And that's when you have stones or sludge that is made through the bile in the gallbladder and that can cause symptoms of pain or nausea after eating certain types of food. That would be the most common thing that we see with gallbladder disease.

Prakash Chandran: Okay. Interesting. And is there a certain demographic of people that biliary colic affects or is it just kind of across the board?

Priscilla Thomas, MD: It can be across the board. Usually, the typical, I guess, board question or medical school question are female patients around my age or in their 40s and who are overweight. And typically, it's more pronounced after eating things like fried or greasy meals. Now, of course there are some patients who have symptoms following salads or vinaigrette, but vast majority of patients have those typical textbook type of symptoms.

Prakash Chandran: All right. Understood. So that's one type of disease. Are there others that people should be aware of?

Priscilla Thomas, MD: There are. There can be infection of the gallbladder that's called cholecystitis. There can also be something called biliary dyskinesia. And what that means is that the gallbladder fails to squeeze or contract properly. And there's a specific type of scan that we can get to look for that disease process. Usually, that is also treated via removal of the gallbladder.

Now, the other disease processes that we can define under something called biliary disease is when the stones or sludge leave the gallbladder, if they get stuck in the duct that drains the liver, that's called choledocholithiasis, or it can sometimes get stuck in the duct that drains the pancreas, and that's called gallstone pancreatitis. Those two disease processes usually will start to make people sicker than just the symptoms of having stones in the gallbladder itself.

Prakash Chandran: Okay. And I want to ask a very basic lay question, I've heard of kidney stones before, and I've now heard of, you know, gallbladder stones. Are they both passed through the body naturally? Or are they treated with surgery or some other type of medication?

Priscilla Thomas, MD: It’s a little bit of different beasts, so to speak, to attack. Kidney stones can be passed by urinating them out. Gallstones are made with a different type of chemical composite and there are different types of stones that people can make depending on, you know, their risk factors for different kinds of stones. But again, that can get a little complicated, I guess.

Most of the times the gallstones remain in the gallbladder. They don't cause those other problems like choledocholithiasis or gallstone pancreatitis. It's when the gallstones leave the gallbladder. Now, there are some patients who will pass those stones, but the concern for patients who are passing the stones intermittently is that they're at high risk to pass a stone or actually to try to pass a stone and have it get stuck and then need their gallbladder disease to be addressed on an inpatient emergent basis.

Prakash Chandran: I want to talk about some of the symptoms that a patient might experience that tells them that they might have a gallbladder disease, or one of the ones that you've mentioned. You touched briefly on sometimes pain or nausea, but can you at a high-level talk about some of the things that people experience when they have a gallbladder disease?

Priscilla Thomas, MD: Yeah, the typical presentation would be after somebody eats, again, a greasy or fried meal or food. And usually after about 15 minutes to an hour, they'll start to notice like a dull ache that might be in the right upper abdomen. It can sometimes be in the upper central abdomen or even sweep over to the left side. But the traditional presentation is it starts in the right upper quadrant and then it can swing over to the right back or between their shoulder blades or to their right shoulder. And that'll follow a crescendo-decrescendo pattern where over the course of usually about an hour or an hour and a half, that pain will intensify, it'll become very intense and then it slowly dissipates and fades away. And that's why people can say, "Oh yeah, I've had attacks. I thought it was just food poisoning. I thought it was something else. And it went away, so I thought nothing of it." And then they start to notice more and more attacks. Sometimes those can happen more at nighttime as well, or they can be associated with diarrhea. And of course, like I mentioned before, nausea or vomiting. When folks start to have things like fevers and chills and increasing intensity of pain that doesn't fade away. That's when we get more concerned about cystitis or infection of the gallbladder developing.

Prakash Chandran: Okay. Let’s say someone is experiencing some of these symptoms, what is your recommendation around when they should actually come in and see someone?

Priscilla Thomas, MD: Yeah. It’s of course easier to address gallbladder disease on an elective basis when it's not acutely infected and inflamed. If patients are noticing that, "Yeah, I'm starting to feel just really icky after I eat, you know, a piece of pizza or a cheeseburger. It happens more at night and I'm having nausea with it. And I'm having that pain in my right upper quadrant or in my upper abdomen," then the next step is usually to notify their primary care doctor. And then they usually will then get like an ultrasound to the gallbladder. If they notice that there are stones or there's sludge in the gallbladder, then they seek surgical opinion or referral to a surgeon.

Prakash Chandran: And in terms of the assessment process, I've heard of a radiographic workup for the gallbladder before. Can you touch on what this is?

Priscilla Thomas, MD: Yeah. The most common baseline scan or radiographic study to get for gallbladder disease is an ultrasound. The ultrasound helps dictate, "Okay, are there stones or sludge in the gallbladder? What's the thickness of the gallbladder wall?" Because usually a thick gallbladder wall means that it's infected. And, then also, the diameter of the ducts that drain the liver because that can also point to what I mentioned before, a choledocholithiasis, if there's like a stone stuck in the duct that drains the liver. That would be the very first initial study that's usually obtained.

And then, if that doesn't really give you any answers, if there's no stones or sludge, the ducts look good, the gallbladder wall looks good, that still doesn't rule out biliary dyskinesia. If there's concern for that, then there's a specific test called a HIDA scan, and that scan is done to look at how well the gallbladder contracts. If it shows that the gallbladder fills, but it's not really squeezing that contrast out well, then that's biliary dyskinesia. And more often than not, the pathology on those gallbladders come back with chronic infection or chronic cholecystitis.

Prakash Chandran: And, you know, if it comes back that you found something, whether there are stones or there's something wrong with the ducts, what are the procedures for actually providing treatment? Is it always surgical? Are there nonsurgical methods that you would leverage first?

Priscilla Thomas, MD: The vast majority of the patients who walk in through the clinic are usually healthy enough to have surgery, which is going to be our definitive means by which we can get rid of the gallbladder and the stones within it and thus mitigate those other risks or other disease processes from potentially developing.

There are some patients who just are too sick to have gallbladder surgery. If they have just that biliary colic symptom, where they eat certain things and it precipitates symptoms, but it goes away on its own and everything else looks normal, then for those patients, we say, you know, "Do a low-fat or a no-fat diet in order to avoid those kinds of symptoms." And for some patients, that works. For other patients, they go along their way and then they start noticing more symptoms despite diet modification. And then we start trying to look into, "Okay, what other options do we have?"

There are some patients who have really bad infection of the gallbladder and they get very, very sick. And then the concern is if you do an operation when they're that sick, it can actually make them sicker. Radiology can oftentimes put in a tube into the gallbladder to help decompress the infection and decompress the gallbladder to get them over that acute cholecystitis bout and let their body recover enough so that hopefully later on we could take their gallbladder out if they're deemed to be good surgical candidates. But as far as like certain medications or I've had some patients ask me, "Well, can't I take something to dissolve the gallstones?" There's really not much out there that has good data to support that.

Prakash Chandran: Yeah. Understood. Let's talk about the different techniques for gallbladder surgery. Can you talk to them at a high level?

Priscilla Thomas, MD: Yeah. So old school way, many, many years ago was the old school open way, because we didn't have technology for minimally invasive techniques. Then around the 1980s to 1990s, we started implementing the laparoscopic techniques for removing the gallbladder and that took off and has now become the gold standard for how to remove the gallbladder. Not everybody is able to have that done that way, but usually laparoscopy is the most common.

Prakash Chandran: And when you say laparoscopically, what exactly does that mean?

Priscilla Thomas, MD: Yeah. What it means is we actually use small incisions, and we use a camera to be able to see what we're doing and long instruments that go through those small incisions and these things called trocars to allow us to introduce the instruments without causing a lot of trauma to the abdominal wall. When we do it laparoscopically, usually the recovery from that operation is a lot quicker.

Prakash Chandran: Than the traditional open method, right?

Priscilla Thomas, MD: Usually, yeah.

Prakash Chandran: And what is that recovery time like? Are you out the next day? Is it a couple days?

Priscilla Thomas, MD: When we do most laparoscopic cholecystectomies, at least for the outpatient elective ones, they go home the same day. And then, they come back to see us in about two weeks. In which case, we make sure that their incisions are healing well and we go over the pathology results. For patients who are admitted with acute cholecystitis or, you know, other disease processes that we talked about, they might need to stay overnight or a few days until they get better. And then they go home.

When it's done open, usually, the pain is too intense to be able to just go home that same day and have good pain control with just pills. They're usually in the hospital for at least three to five days until their pain is well-controlled with just pills and then they go home.

Prakash Chandran: And, you know, when I hear minimally invasive, oftentimes it's referring to robotic surgery. Is that the same thing as laparoscopic or is that something different?

Priscilla Thomas, MD: It's very similar. It's a very similar approach with the trocars through small incisions and the long instruments, but it's a little bit of a different technology. With the robot, we're able to utilize a little bit of artificial intelligence with the technology. Not that the machine's doing all the work, you're actually as a surgeon still operating through that machine. But yes, there are more and more robotic techniques that we have nowadays for operations that they didn't have back in the '90s. But, yeah, it's very similar to laparoscopy.

Prakash Chandran: All right. Well, wonderful. This has been a truly informative conversation, Dr. Thomas. Is there anything else you want to leave our audience with before we close?

Priscilla Thomas, MD: Not really. We're here to help, you know, anybody in this area and, you know, if somebody wants to travel, we're happy to help as well. But it's pretty easy to get into our office. If people are noticing that they're having things that they might think are biliary colic symptoms, or they're wanting to seek a surgical opinion as to how they can treat their gallbladder disease, we're happy to help out. They can call and come in time and we're usually able to get people in our office within a week of them calling.

Prakash Chandran: Wonderful. Well, Dr. Thomas, thank you so much for your time.

Priscilla Thomas, MD: Yeah. Thank you. I appreciate your time today. Have a great day.

Prakash Chandran: Thanks so much for listening to this episode of BayCare HealthChat. For more information, visit BayCare.org. If you enjoyed this podcast, please remember to subscribe, rate and review this podcast and all other BayCare podcasts. For more health tips and updates, you can visit our website at BayCareHealthChat.org. Thanks again for listening. My name is Prakash Chandran, and we'll talk next time.