Joey Wahler (Host): This is Health Matters: Insights from WCH Medical Experts. Thanks for joining us. I am Joey Wahler. Our guest is Dr. Peter Lalor, a general surgeon. Doctor, welcome.

Peter Lalor, MD: Thanks, Joey. Thanks for having me again. Good to see you.

Host: Yeah, same here. Great to have you aboard once again. So first, I guess, it's kind of a mystery to many, right? So in a nutshell, what is the gallbladder and what does it do for us?

Peter Lalor, MD: So, the gallbladder is a small little organ part of the gastrointestinal tract. It sits right under your liver in the right upper quadrant. What it does is it stores and concentrates bile, so your liver makes bile to help digest food when the time comes. And when you're not eating, the bile is stored in the gallbladder. So when you do eat, the gallbladder squeezes that bile out down the main duct into the intestines to help digest food.

Host: Gotcha. And so, we hear about gallstones. What are they?

Peter Lalor, MD: So, the recipe of the bile that is stored in the gallbladder is made of three main ingredients, and it's supposed to be a very watery, bilious fluid. But when those ingredients change a little bit in their concentrations, and normally there's cholesterol in it, there's what we call bilirubin in it, which is made in your liver and some calcium salts, and when the ratio of those things changed, the bile tends to thicken up a little bit. And it can thicken up to the point where it even starts to crystallize and form what we call sludge or even little stones. And that's your classic gallstone.

Host: And so if you have them, how might someone know?

Peter Lalor, MD: So, what actually happens is, when you have these little stone or sludge in the gallbladder, and you have to remember that the gallbladder is this little bag. And there's one way in and one way out. So if that gallbladder squeezes and one of those little stones gets stuck in the outlet, you can start to have symptoms.

So, the classic symptom would be I ate something, usually maybe a fatty, greasy food, and sometimes 20 or 30 minutes later, I start having pain in my right upper quadrant. It's crampy in nature. It might radiate to my shoulder and back. It might make me a little nauseous and it might last for minutes, maybe hours. And usually, it resolves in early cases.

Host: Well, you say early cases, if you have it and that happens, will it typically get progressively worse if it's not addressed?

Peter Lalor, MD: Yeah. That's what I'm describing as kind of the classic gallbladder attack. And certainly, although most people that have gallstones don't have any symptoms from them, when you start getting symptoms, it's more than likely that you're going to continue to get symptoms. And if you just get the occasional attack after eating something maybe that wasn't the healthiest, that may not be a big deal. But if this keeps happening often, then that blockage of that gallbladder from these stones can get worse and worse to the point where the gallbladder can get infected. And when that happens, we call that cholecystitis. And when that attack happens, it does not get better, and you feel even sicker. And at this point, oftentimes the patient will have to go to the emergency room, because those symptoms are not getting better. And of course, the more infected or inflamed or irritated the gallbladder becomes, the harder it becomes to treat it, especially when it comes to surgery.

Host: Gotcha. And so when does, speaking of which, someone know if it's time to see a doctor? Where's that line, if you will?

Peter Lalor, MD: So if a patient is told on a routine x-ray or a CAT scan, like, "Oh, by the way, you have gallstones and they're not having any GI symptoms," there is nothing to do about it, but be aware. But if they're told they have gallstones and they're having GI issues like I've described with nausea or vomiting after eating or pain or even fever and symptoms that keep coming back, even after one or two attacks, then you might want to get it evaluated. Because like I said, if you deal with the gallbladder early when symptoms start, it's much easier to remove the gallbladder. Recovery is easier and the complications are much less.

Host: So, who's most at risk for having gallstones?

Peter Lalor, MD: Everyone is at risk, especially with our western diets and our weight fluctuations and so forth. But patients that tend to be at higher risk are females of childbearing age because of their hormones that contribute to some of the discrepancies and the recipe of the bile, if you will, and obesity, that contributes to the same kind of problems with the recipe of bile that can create gallstones and subsequently problems from that.

Host: So, I would imagine if a woman is, as you mentioned, of childbearing age and is either pregnant or trying to become, and all of a sudden gallstones are in the picture, that can be stressful, to say the least, yeah?

Peter Lalor, MD: Yeah, I mean that can be a common problem. A woman gets pregnant and, of course starts to gain weight normally in pregnancy and can develop some gallstones that can become symptomatic. If that happens in the first trimester and the symptoms are very, very severe, we may consider taking the gallbladder out. Although obviously, there's risk involved to both the mother and baby. But getting to the second or third trimesters, we really try to wait until the postpartum period before doing that, because obviously the risk is higher to both mother and child.

Host: Speaking of gallbladder surgery, the gallstones are typically treated just that way. So, what does that involve?

Peter Lalor, MD: One might think, well, hey, if you have these gallstones, wouldn't it be great if there was a medicine that just got rid of them? And there is a medicine out there called ursodiol that can help dissolve gallstones, but it's never been shown to be that significant to prevent all these problems. And so, really, when someone starts to become symptomatic from these things, that surgery is really the best option.

And what that surgery is called a laparoscopic cholecystectomy, which is removing the gallbladder through four little incisions. It's an outpatient surgery under general anesthesia. The patient goes home the same cday with some pain medicine. They take a week or two off. And it's generally tolerated in the elective setting. It also can be performed robotically assisted, which is essentially the same thing through small little incisions with the help of a robot. The complication rates are similar and the recovery rates are similar, so it's really surgeon preference at that point.

Host: And so, that begs the question, if you no longer have your gallbladder, what does that mean for you down the road?

Peter Lalor, MD: That's a good question. So, there's almost a million people that get their gallbladders out every year. And the side effects of not having a gallbladder are pretty minimum. If you don't have that storage bag of bile, then there is a slight increased bile in your GI tract when you eat.

Now, at first when you have the gallbladder removed, people tend to have looser stools. The classic scenario is, "Hey, I had a piece of pizza. And, you know, 10 or 15 minutes later, mm, I feel like I have to go to the bathroom and it's a little bit loose." Now, over time, the GI tract compensates for that, and your guts get better at absorbing that bile. So, the bowel movements tend to firm up a little bit. But overall, they're probably a little bit more loose than they used to be. But it's rarely a problem. If it is a problem in less than 1% of people, we call that post-cholecystectomy syndrome, and there are medicines that you take before you eat that help bind that extra bile up, and it usually takes care of the problem.

Host: And I'm smiling because you mentioned that your system typically knows to compensate for that. Another example of how amazing the body is, right?

Peter Lalor, MD: Yeah, it's quite amazing that, with a major surgery like this and removing an organ, that the body compensates well in what we call the bilioenteric circulation. We don't really need our gallbladder. Like I said, it's a storage bag. And there are millions of people in America there are living without it with no problem.

Host: A couple other things. A patient could also have gallbladder disease requiring removal, yes?

Peter Lalor, MD: So, there are some other, types of diseases, if you will, or functional issues with the gallbladder. There's a whole spectrum of problems with the gallbladder, and we've talked kind of on the left side of the spectrum from the presence of asymptomatic gallstones with nothing to do with, as you go down the spectrum to the right, the gallbladder can tend to act up And we call that biliary colic or symptomatic gallstones, where we recommend the gallbladder taking out.

And then, of course, I mentioned cholecystitis, where the gallbladder gets blocked to the point where it can get infected or inflamed. But beyond that, we can have even more problems. Those stones can get caught in the main ducts draining the liver, and we can call that common bile duct stones or even cholangitis, which is an infection of that bile duct. The gallbladder duct goes through the pancreas. So if that irritates the pancreas on the way out, you can get pancreatitis or gallstone pancreatitis, and that can be a life-threatening problem overall. So, there's a whole spectrum of disease from gallstones in itself.

And then, separate to that, there's a whole 'nother thing when we talk about the function of the gallbladder. And there's a disease, if you will, called biliary dyskinesia, and that's a fancy word for my gallbladder doesn't function very well. And although there's not gallstones there, it doesn't squeeze very well. And when it doesn't squeeze, or it kind of is paralyzed, you can have symptoms that mimic gallstones. And the treatment for that in America anyway is removing the gallbladder to get rid of those symptoms.

Host: And the fact that you need to be familiar with all of these different possibilities. Just another example of the myriad of almost endless things that a general surgeon like you needs to know, right?

Peter Lalor, MD: Yeah. I mean, like I said, it is such a common thing to have gallbladder problems. And the easy advice is if you're having pains or GI issues that are not getting better in a short period of time, then they should be evaluated either in the emergency room or your primary care doctor. Or if it's a little more clear, then a general surgeon would be the best to take your gallbladder out.

Host: And you led me beautifully into my next question, namely, what could be the consequences if you do put off addressing gallstones for too long?

Peter Lalor, MD: And we've kind of alluded to this a little bit, we haven't been direct. If you leave it go, then taking out your gallbladder becomes much harder. There's more inflammation. More infection. It's harder to see the anatomy. That means the surgery's longer. There's more complications. There can be serious complications like bile leaks and injuries to organs, and even pancreatitis. There's a higher chance, if you let this go, that you might need an open surgery, which is a bigger incision, and that recovery is a lot harder, which can be six to eight weeks and a few days in the hospital. So, the minute this starts to act up, we want to be on the proactive side of this and get this out on our terms before it becomes very difficult.

Host: Absolutely. But for those that don't heed that warning, Doctor, when are gallstones considered an emergency case?

Peter Lalor, MD: So again, when those symptoms don't get better, if the patient's had hours of severe pain and that right upper quadrant, they're having fevers, they're nauseous, they're vomiting, they can't tolerate oral stuff, they have the sweats and the chills, that is an emergency and you need to come to the emergency room. They'll put you on antibiotics, work you up accordingly. And if it turns out that it is cholecystitis, which is an acute infection, then you'll more than likely be admitted to the hospital and your gallbladder will be coming out shortly.

Host: And so just to drive that one big point home in summary here, Doc, for those that think they may have gallstones or possibly another gallbladder issue, this is not something to procrastinate about.

Peter Lalor, MD: I mean, again, it's the degree of symptoms and, you know, if once in a while you have a problem, it would be good to get that worked up a little bit so that, you know, if it gets worse, you know what it is. But in the acute setting, people can actually rarely die from gallbladder surgery. It's not without serious complications. So again, if you have symptoms that persist over hours and are not improving, you need to seek medical attention.

Host: Well, folks, we trust you are now more familiar with the gallbladder and gallbladder surgery. Dr. lalor, thanks so much again.

Peter Lalor, MD: Thanks for having me, Joey.

Host: Absolutely. And to learn more about surgery is offered at Wood County Hospital, please visit woodcountyhospital.org and simply search surgery. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler. Thanks again for being part of Health Matters: Insights from WCH Medical Experts.