The gallbladder is a small hollow organ that stores bile which is produced by the liver. It is a pear shaped organ that lies beneath the liver and is attached to liver. It is usually 7-10cm in length and is divided into 3 sections: the fundus, the body and the neck. The fundus is the rounded end that faces the abdominal wall. The body lies in a depression in the undersurface of the liver. The neck tapers and is continuous with the cystic duct which joins the common hepatic duct and forms the common bile duct (CBD). The CBS tapers and joins the duodenum (first part of the small bowel). The gallbladder may vary in size, shape and position in different people.
The main purpose of gallbladder is to store the bile. When the food that contains the fat enters the stomach and small bowel, the body produces a hormone that stimulates gallbladder to release bile. The bile is required as emulsifier for our body to digest fat. The easiest way to think about the role of bile, is to compare it to the dishwashing liquid. If there is no dishwashing liquid when dishes are washed, then the fat is just smeared over the plates. If it is present, it breaks down the fat and plates are able to be washed.
Gallbladder can cause several medical conditions:
Gallstones – we are not sure why some people develop gallstones and other don’t. Gallstones are formed when the bile gets saturated by cholesterol or bilirubin. Some parasitic infections also cause gallstones. Development of gallstones also runs in some families. Presence of gallstones may or may not cause any symptoms. Symptoms that may be caused are: severe colicky (in waves) upper abdominal pain (biliary colic), inflammation (cholecystitis), jaundice (yellow skin) if it blocks main common bile duct and pancreatitis (inflammation of pancreas). The only treatment for symptomatic gallstones is surgery to remove the gallbladder. Medication or lithotripsy to dissolve stones are not very successful or these may cause more problems (like small stones lodging in the common bile duct, or going down the duct and causing pancreatitis).
Cholecystitis is inflamed gallbladder. It is usually caused by stone blocking the gallbladder. Inflamed gallbladder causes worsening pain and fever. It is treated by with intravenous antibiotics and immediate of delayed surgery most of the time.
Gallbladder polyps are benign growths in the gallbladder. With increasing size of the polyp there is increased chance that it may turn cancerous. Due to this gallbladder removal is recommended if these reach 1cm in size.
Gallbladder cancer is uncommon type of cancer. It happens in 1 in 100,000 people throughout their lifetime. It usually develops later in life. Often cancer does not cause any symptoms, otherwise it may cause pain or jaundice. This is an aggressive type of cancer and best treatment is surgery where gallbladder and usually part of liver are removed. This surgery should be performed by trained hepatobiliary surgeon.
Investigations:
Blood tests that are performed at liver test including bilirubin, AST, ALT, ALP and GGT. Often GGT and ALP are raised in presence of gallstones. Raised bilirubin is indication of a stone with in the common bile duct.
Ultrasound is best investigation for gallbladder. It shows presence of gallstones and thickness of gallbladder and presence of polyps.
CT scan is only used when there is suggestion of gallbladder cancer or in large polyps to exclude invasion into liver.
MRI scan is only used when there is suggestion of gallbladder cancer or in large polyps to exclude invasion into liver.
Surgery
Cholecystectomy is a surgery that involves removal of gallbladder. It may be performed as open or laparoscopic (keyhole) surgery. Cholecystectomy is always performed under general anaesthesia.
During laparoscopic cholecystectomy 4 incisions are usually made. One around the belly button (umbilicus) tends to be a bit bigger (1cm on average), while other three (one in midline in the upper abdomen and 2 on the right side) tend to be around 5mm in size. Abdomen is inflated with gas and lining around the gallbladder (peritoneum is divided) and cystic duct and cystic artery are identified and clipped and cut. Gallbladder is then peeled of the liver using diathermy and removed in the bag through the umbilical incision.
This surgery is very safe. Rates of infection in the incisions is around 2%, other risks are even more uncommon. Bleeding is rare, around 0.5% risk of blood transfusion. Bile leak, injury to surrounding structures like common bile duct, duodenum and large bowel are also very rare. Conversion to open procedure may happen and risks range from 1-10% depending on the underlying condition (less for biliary colic and polyps, more for inflammation). Most people go home the next day, although some may go the same day. Most people will be back to work in 1-2 weeks time.
In open cholecystectomy a 10-15cm cut is made 3-4 cm below the right sided ribs. Muscles and all layers of abdominal wall are cut. This procedure is usually performed when laparoscopic surgery shows that there is too much scarring/inflammation to perform laparoscopic surgery safely. Gallbladder is removed through the large incision. Most patients stay in hospital 3-4 days and are back at work within 3-4 weeks.