My brother had his stone broken up. Why do I have to lose my gallbladder?

“My brother had his stones broken up with ultrasound and they were gone. Why do I have to have my gallbladder taken out?” It is a question I am asked by patients who have come in after a screening test found gallstones and have just been told an operation is being considered.

The stone the brother had treated is, in most cases, a stone in the kidney. Stones that form inside the body are treated according to where they form. A stone in the urinary tract is usually fragmented or retrieved and passed out in the urine, and it is uncommon for treatment to go as far as removing part of the kidney. A stone in the gallbladder is different. Taking out the stone alone is difficult, so when treatment is judged necessary, the standard is to remove the gallbladder along with it.

How the stone forms#

The process itself is simple. The gallbladder is a reservoir: it stores bile made in the liver and contracts to release it when food arrives. When the cholesterol in that bile is concentrated for long enough it thickens like sludge, and from there it hardens into crystals and grows into a stone. As diet has westernised, cholesterol stones have come to account for most of them, though other kinds exist — black pigment stones among them. Whatever the composition, the point at which it becomes a problem is the same: the stone blocks the path bile takes to leave.

Why the stone cannot simply be taken out#

Gallstones are not resolved by medication or a minor procedure. Taking a drug to lower cholesterol does not mean gallstones will not form. A stone that has already formed can sometimes be helped by a dissolution agent based on bile components, but that alone does not clear every stone.

Nor is there a good way to take out only the stone. Unlike the stomach or the colon, the gallbladder has no channel an endoscope can pass through. There is a route in which a fine tube is placed through the flank and the stones are taken out through it, but as long as the gallbladder that produces them remains, they tend to come back. After the gallbladder is removed, most people carry on much as they did before.

Not every stone is operated on#

Many people live with no discomfort at all for as long as the stone is not obstructing the passage of bile, and a small stone found incidentally on a screening ultrasound is often watched rather than treated when there are no symptoms.

There are broadly two grounds on which I come to recommend an operation. The first is the size of the stone. Around 3 cm counts as large and becomes a reason to treat, though that figure is not an absolute threshold. The second is the state of the gallbladder itself. Even below that size, a thickened gallbladder wall is a reason to consider treatment. The gallbladder is by nature a thin, elastic sac that contracts and relaxes; once the wall thickens it loses that elasticity, and with it the ability to do what it is for.

The state that changes without warning#

The difficulty is that this situation can change suddenly. If the stone shifts and blocks the outlet through which bile leaves, acute cholecystitis follows. If a feeling of indigestion recurs after fatty food, or pain in the right upper abdomen wakes you at night, it is better to be seen than to let it pass.

When bile cannot escape, the gallbladder continues to distend and can fill with pus. The liver is a richly perfused organ, so inflammation there can spread through the body, and adhesion of neighbouring organs or a rise in liver enzymes may appear alongside it.

Stones are not confined to the gallbladder#

They also form in the bile duct itself, and a stone sitting in the gallbladder can press on the duct beside it. If a stone blocks the channel leading to the pancreas, pancreatitis follows. A stone lodged in a duct inside the liver is recognised as a factor raising the risk of cancer arising at that site.

When the duct is also full of stones, they may be retrieved from the duodenum with an endoscope passed through the mouth, or the duct may be opened during surgery, cleared, and closed again. Sometimes an anastomosis between the duct and the bowel is required, and after any of these the patient has to be watched closely for a bile leak.

The same operation is not the same operation#

Appendicitis makes the point. Treated as soon as the pain begins, it is finished through a single small incision at the navel; left until the inflammation has spread, part of the bowel may have to be resected. The gallbladder behaves the same way. Once inflammation has been running for a long time the operation becomes more complicated and recovery slower.

So if a gallstone has been found, rather than hearing the size of the stone and leaving it there, it is worth establishing three things at the same time: whether the gallbladder wall has thickened, whether there are stones in the bile duct as well, and whether there is any prospect of the duct needing treatment. Knowing those three in advance helps both in deciding when to operate and in understanding how far the treatment will reach.