Scott Webb (Host): Gallstones are common and treatable, but there are times when removal of the gallbladder is the right option. And I'm joined today by Dr. Ryan Enders. He's a General Surgeon with BayCare, and he's here to tell us more about gallstones, the treatment options, and when surgery is the best option.

 Welcome to BayCare HealthChat. I'm Scott Webb. Dr. Enders, thanks so much for your time today. We're going to talk about gallstones, which are fairly common, I'm guessing, and I don't know a lot about them. I sort of think I do, and I'm sure a lot of folks do, but what are gallstones?

Ryan Enders, DO: Gallstones they're usually some hard objects, they're usually generally small, they kind of resemble a stone, that's where they got their name, they're contained within the gallbladder. There are two different types of gallstones; there's cholesterol gallstones and pigmented gallstones.

Cholesterol gallstones are most common, around 75 to 80 percent of gallstones are these type and they're made up of cholesterol, which is a fatty substance that's in the bile of your gallbladder. The liver makes bile to help you digest fat, and the gallbladder stores the bile. So just an accumulation or a high concentration of cholesterol can predispose you to cholesterol gallstones.

The other type is pigmented gallstones and they're made of bilirubin, which is also in the bile. However, bilirubin is a byproduct of red blood cell breakdown. So generally patients with cirrhosis or hemolytic anemias are at higher risk for pigmented stones, and they're rarer. It's more 20 percent of the cases are pigmented stones.

Host: Right, so the cholesterol stones are more common, and just wondering, are some folks at higher risk? You know, is it males, females, is there family history, genetics involved, that kind of thing?

Ryan Enders, DO: Gallstones are very common. Over 40 percent of the U.S. population has gallstones, so there is some environmental concerns in terms of a fatty diet and obesity are definitely related to gallstone development. Additional factors, females are a little bit more likely to have gallstones and problems with gallstones.

Pregnancy can also predispose issues with gallstones. And then, additionally, usually middle aged folks tend to have problems with gallstones. Usually it's, you know, in their 30s or 40s. Older folks less likely and very young folks also less likely.

Host: Sure. Now, I'm pretty familiar with kidney stones, having had them, and it's unmistakable when you have kidney stones, in my experience, anyway, unfortunately, wondering if it's the same for gallstones, like how do folks know if they have gallstones?

Ryan Enders, DO: Well, again, most people who have gallstones are asymptomatic. They're just there. The only time gallstones become a problem is there's three main conditions that can occur. One is called symptomatic cholelithiasis, or that just simply means that the gallstones bother you.

Another one is called choledocholithiasis, which is where the gallstone slips out of the gallbladder into the main bile duct that drains the liver. And then the last one is cholecystitis, and that's when the gallstone gets stuck in the duct of the gallbladder and then an infection of the gallbladder ensues.

So symptoms of each are a little bit different. Symptomatic cholelithiasis, you typically have intermittent pain associated with eating fatty food. It's usually delayed, so you'll eat and then maybe an hour later develop right upper quadrant abdominal pain and some nausea, although these are classic symptoms, not everybody fits in this box, but those are the most common symptoms.

 They usually last for several hours, and then they kind of go away. Cholecystitis is very similar in presentation, although the pain doesn't go away, it worsens, and then sometimes you do get systemic infectious symptoms like fevers and chills and things like that. Choledocholithiasis can have pain associated with it, but a lot of times you'll also have attributed jaundice as well.

Jaundice is yellowing in the skin or the eyes, and that's when the bilirubin builds up in the blood and it causes that discoloration. Because the bile duct is drained, you can't get rid of the bile and it builds up in the blood. An infection can ensue in choledocholithiasis as well, and that's called cholangitis.

 And you'll develop symptomatic fevers, chills, and things like that when that occurs. Typically symptomatic cholelithiasis, it can be treated electively, which means you can see me in the office. We can discuss surgery, we can plan it out at your leisure. The other two, which are choledocholithiasis, and cholecystitis are typically more urgent, not emergent, but urgent. Usually within 24 hours, should be addressed.

Host: Yeah, I want to talk about treatment options. First of all, is there anything we can really do other than maybe avoiding some of the trigger foods and things like that? And then what are the treatment options once we're, we've gone to the ED perhaps, but certainly, met with you in the office?

Ryan Enders, DO: So if you have asymptomatic gallstones, there's not really anything you need to do. You can try a low fat diet to avoid any future complications. But when you start having symptoms, that's when surgery is generally indicated. Surgery just involves taking out your gallbladder and that's usually done with small incisions. I do it robotically. It's about a 40 minute procedure and you usually go home the same day.

Host: Yeah, and you mentioned robots there and that always piques my interest. Tell us a little bit about the surgical procedure.

Ryan Enders, DO: So I use the da Vinci XI. I trained on both the SI and XI, but the XI is obviously the later one and it's a lot easier to use and it's better. Basically you make four small incisions in the mid abdomen. The robot magnifies things about five times, so it's very good visualization. The gallbladder is kind of like a water balloon attached to the liver.

I'll identify it, I'll grab it, and I'll kind of lift it up. There will be a duct and an artery that go to the gallbladder. With the robotic platform, we can do what's called an IGC cholangiography, and that's where we put a fluorescent dye within the IV and it's processed by the liver and it's placed into the bile ducts and then under a black light the bile ducts will light up green so I can identify the anatomy better and then after I've identified the anatomy and I've freed up the surrounding structures from the duct and the artery, I will clip and cut those and remove the gallbladder from its attachments to the liver.

Host: Yeah. And for folks that have had their gallbladders removed, what's life like? I always want to ask doctors, ask experts. You know, we have these things in our bodies like gallbladders and if we can live without them, you know, what does that mean for us? Is it any sort of change in lifestyle or diet or anything like that?

Ryan Enders, DO: So the most common side effect of not having a gallbladder is you may get some loose stools after you eat fatty food and the reason is, is the gallbladder stores bile, and that helps you digest fatty foods. So if you can't digest the fatty food, that can cause some loose stools. However, after the gallbladder is removed, your bile ducts do dilate naturally, and then they can actually accommodate more storage of bile, and most people after a few months don't have any symptoms.

Host: That's perfect. Well, just give you a chance here. This has been really educational. As I said, when prefaced here, I want to learn more about gallstones and I'm sure listeners do as well. Just final thoughts and takeaways, folks who may be suffering and they don't know why they're suffering or they know they have gallstones and there's an issue with their gallbladder, but are reluctant to go into the office. Final thoughts and takeaways.

Ryan Enders, DO: Well, I mean, I think it's always worth a discussion to, you know, first figure out if the symptoms you're having are related to your gallbladder. There are some specific things to look for, like we discussed before, you know, association with eating, delayed onset of pain, the location of the pain, and then also the presence of gallstones on an ultrasound.

Those are all part of the workup. And then once you're confirmed that you do have a gallbladder issue, having a discussion in the office about surgery, the risks and benefits of surgery. It's one of the most common operations that's performed. I mean, I perform hundreds of them a year and with relatively low risk.

Although there are some risks, but the benefit is obviously that you won't have to suffer anymore with the ailments that you have. So the having that educated discussion and making a decision that's best for you in your independent case is always the best thing to do. And, sometimes just coming to the office and getting information is enlightening and helps people make those decisions.

So if you think, you have a problem, I recommend that you come see a specialist and kind of discuss it and find out if you need surgery and if you do, what that all entails.

Host: Yeah. That's perfect. Right. Speak with your primary, see a specialist. Knowledge is power, all that good stuff. So thank you so much.

Ryan Enders, DO: Yeah, you're welcome. Thank you for having me.

Host: And for more information, go to baycare.org. And that wraps up this episode of BayCare HealthChat. Always remember to subscribe, rate and review this podcast and all of the other BayCare podcasts, so we can share the wealth of information from our experts together. I'm Scott Webb. Stay well.