Gall bladder diseases
Since the bile contains numerous substances that are only poorly soluble in water, the risk of crystallization is increased. In order to prevent the formation of stones, it is necessary that the individual components of the bile are present in the correct proportion to each other. Frequently, an increased cholesterol level (cholesterol) in the blood and thus also in the bile disturbs this ratio and leads to the formation of gallstones.
In most cases (>60%) the affected person does not even notice this (silent stones).Only when this gallstone blocks the flow of blood (cholestasis) does it cause reflex-like spasms of the muscles and sudden, very severe colicky pain, which is usually located on the right side of the upper abdomen, but can also radiate into the right shoulder. The obstruction of the bile ducts leads to two problems:
- Before the blockage, the bile accumulates and over time can even damage the liver cells that produce it (hepatitis). This leads to a transfer of bile-requiring substances (including bilirubin = bile pigment) into the blood and thus to jaundice.
- Behind the blockade no more bile arrives.
As a result, the digestion of food fats is no longer possible and the fats are excreted undigested. This leads to the classic clinical picture of fatty stools, yellowish-pulpy excretions containing the undigested fat. Another problem caused by the lack of fat digestion is the fact that the fat-soluble vitamins (vitamin A,D,E,K) can no longer be absorbed.
Especially the lack of vitamin K causes problems, because this vitamin is needed for the synthesis of some factors for blood clotting.
Inflammation of the gall bladder (cholecystitis) is a complication of gall bladder stone disease (cholecystolithiasis). Blocking the only inflow or outflow creates an environment in the gallbladder, which ultimately leads to an inflammatory reaction in the gallbladder. This inflammation leads to a thickening of the gallbladder wall by immigrated inflammatory cells (white blood cells: lymphocytes and granulocytes), a greatly increased sensitivity to pain and possibly to systemic complications such as fever, chills, formation of acute phase proteins (CRP).
For bacteria, the constellation of a cavity (here: the gall bladder) without direct contact to the outside world (because a stone blocks the outflow) provides excellent growth conditions. Individual bacteria of the normal intestinal flora (mainly Enterobacteriaceae and Enterococci) can then multiply almost undisturbed in the gallbladder and cause a purulent inflammation (gallbladder empyema). This is very dangerous because the bacteria can cause blood poisoning (sepsis) and are also often resistant (insensitive) to numerous common antibiotics (bacteria-killing drugs).
The therapy usually consists of a surgical removal of the gallbladder (cholecystectomy). Gall bladder cancer is a rather rare (5 cases per year100,000 patients. For comparison: bronchial carcinoma 60 cases per year100.
000 patients; lung cancer) but very malignant cancer. The cancer is caused by an accumulation of genetic mutations (change in genetic information). Risk factors are gallstones (cholecystolithiasis) and inflammation of the gallbladder (cholecystitis), although no evidence of a direct causal relationship has been found.
The problem of gallbladder cancer is the lack of typical symptoms in the early stages of its development. In most cases, the cancer is only discovered when it has already spread (metastasized) via the lymphatic or bloodstream. In such cases the prognosis is very poor.
Possible, but very unspecific symptoms are jaundice (icterus), biliary colic, weight loss or diffuse pain, especially in the upper abdominal region. Gall bladder polyps are benign tumors that can form in the wall of the gall bladder. These growths are usually asymptomatic and are only discovered by chance during sonographic examinations (ultrasound).
Possible symptoms are pain in the right upper abdomen, nausea and digestive problems. The causes of polyp formation can be manifold. One possibility is that the cholesterol content of the bile increases due to a diet high in cholesterol.
The excess cholesterol is then either deposited on the wall of the gall bladder (cholesteatosis) or the cholesterol is deposited in the mucous membrane, which leads to bulges. This form of tumor is also called cholesterol polyps. Other possibilities are proliferations of the mucous membrane and the glandular tissue of the gallbladder wall, which are also called polyps.
The degeneration risk of gallbladder polyps is very low. In case of tumors <1cm in size, regular check-ups are recommended, but no further therapeutic measures are taken. Only if the size is > 1cm or if the growth is particularly rapid is removal of the entire gallbladder (cholecystectomy) recommended.If damage to the liver tissue slows the flow of blood through the liver (e.g. cirrhosis of the liver), the blood will back up into the portal vein.
The resulting increase in blood pressure is called portal vein hypertension. Other ways (the portal-caval anastomoses) are now being sought to transport the blood past the liver and back into the heart. The removal of the gallbladder is medically known as cholecystectomy.
Since a person can also live without a gall bladder, the operation does not usually cause any major impairment to the patient. The operation is indicated for various diseases and should then be performed. Indications for gall bladder removal: The gall bladder is removed if the patient suffers from gallstones, develops biliary colic through a stone discharge into the bile duct or in the case of severe inflammation of the gall bladder.
In the case of chronic inflammation of the gall bladder, a porcelain gall bladder may develop, which has a thickened and hardened wall. This can later degenerate and lead to gallbladder cancer, so a porcelain gallbladder is also removed. A further indication for removal is therefore polyps in the gallbladder, as these can also become malignant.
The same applies, of course, to an already existing cancer of the gallbladder. If the bile duct of the gallbladder (Ductus cysticus) is obstructed and this leads to a build-up of bile, the gallbladder must also be removed frequently in this case. Surgical procedure: There are various procedures with which the gallbladder can be removed.
In most cases, a laparoscopic removal of the gallbladder is performed, which means that no large abdominal incision is required. Alternatively, the gallbladder can also be removed in an open operation, i.e. through a large abdominal incision. Laparoscopic cholecystectomy: For the laparoscopic removal of the gallbladder, the patient is put under general anesthesia.
The various access routes are then opened. A small skin incision is made directly above or below the navel, below the sternum and to the right of the navel, through which an instrument can be inserted into the body. The laparoscope with the camera is inserted through the access at the navel.
This allows the surgeon to see exactly where he is on a screen. The abdomen is also inflated with carbon dioxide (CO2) through this access, making it easier to see the gallbladder and surrounding structures. The cutting and grasping tools are inserted through the other accesses.
Finally, the gallbladder is detached from its bed by the liver under visual control and wrapped in a so-called recovery bag. This ensures that during the subsequent removal – usually through the access at the navel – the entire gallbladder is pulled out and no piece of tissue is lost. Once the gallbladder has been removed, a wound drainage can be placed, which allows wound secretions and blood to drain for a while after the operation.
The drainage is removed later. The small skin incisions are closed again with a few stitches and the stitches are removed after a few days. Later, usually only small, unobtrusive scars remain from the operation.
Single-port surgery: The so-called single-port surgery is a variant of laparoscopic gallbladder removal. Only a single access is required in the region of the navel, which is why no visible scars remain after the operation. The SILS (Single Incision Laparoscopic Surgery) technique is used for this procedure.
The surgeon inserts a special angled instrument into the abdomen through the access at the navel. This allows the gallbladder to be removed and pulled out through the navel as in the conventional laparoscopic variant. Open surgical cholecystectomy: The open variant of gall bladder removal is also performed under general anesthesia.
This involves making an approximately 10 cm long skin incision in the area of the right costal arch, through which the surgeon gains access to the gallbladder bed. There, the gallbladder is freely prepared and can then be removed. As soon as bleeding vessels are closed, the surgical site can be closed again with sutures.
This procedure is especially used when the removal of the gallbladder is more complicated, for example, in cases of strong adhesions between the gallbladder and surrounding tissue or large accumulations of pus.Advantages and disadvantages: The procedure used to remove the gallbladder is selected according to the patient and health conditions. The advantage of laparoscopic removal is the reduced stress on the organism and circulation, the smaller wound area and the more inconspicuous, shorter scars remaining after the operation. In addition, patients are more quickly mobile and able to recover their strength after the operation than with the open surgical method.
Especially the single-port technique provides a cosmetically good result, as the scar in the navel is not recognizable as such. However, the open surgical option should still be chosen in more complicated cases, as the surgeon can then salvage the gallbladder more safely without damaging any neighboring structures. Indications for gall bladder removal: The gallbladder is removed if the patient suffers from gallstones, develops biliary colic through a stone discharge into the bile duct or in the case of severe inflammation of the gallbladder.
In the case of chronic inflammation of the gall bladder, a porcelain gall bladder may develop, which has a thickened and hardened wall. This can later degenerate and lead to gallbladder cancer, so a porcelain gallbladder is also removed. A further indication for removal is therefore polyps in the gallbladder, as these can also become malignant.
The same applies, of course, to an already existing cancer of the gallbladder. If the bile duct of the gallbladder (Ductus cysticus) is obstructed and this leads to a build-up of bile, the gallbladder must also be removed frequently in this case. Surgical procedure: There are various procedures with which the gallbladder can be removed.
In most cases, a laparoscopic removal of the gallbladder is performed, which means that no large abdominal incision is required. Alternatively, the gallbladder can also be removed in an open operation, i.e. through a large abdominal incision. Laparoscopic cholecystectomy: For the laparoscopic removal of the gallbladder, the patient is put under general anesthesia.
The various access routes are then opened. A small skin incision is made directly above or below the navel, below the sternum and to the right of the navel, through which an instrument can be inserted into the body. The laparoscope with the camera is inserted through the access at the navel.
This allows the surgeon to see exactly where he is on a screen. The abdomen is also inflated with carbon dioxide (CO2) through this access, making it easier to see the gallbladder and surrounding structures. The cutting and grasping tools are inserted through the other accesses.
Finally, the gallbladder is detached from its bed by the liver under visual control and wrapped in a so-called recovery bag. This ensures that during the subsequent removal – usually through the access at the navel – the entire gallbladder is pulled out and no piece of tissue is lost. Once the gallbladder has been removed, a wound drainage can be placed, which allows wound secretions and blood to drain for a while after the operation.
The drainage is removed later. The small skin incisions are closed again with a few stitches and the stitches are removed after a few days. Later, usually only small, unobtrusive scars remain from the operation.
Single-port surgery: The so-called single-port surgery is a variant of laparoscopic gallbladder removal. Only a single access is required in the region of the navel, which is why no visible scars remain after the operation. The SILS (Single Incision Laparoscopic Surgery) technique is used for this procedure.
The surgeon inserts a special angled instrument into the abdomen through the access at the navel. This allows the gallbladder to be removed and pulled out through the navel as in the conventional laparoscopic variant. Open surgical cholecystectomy: The open variant of gall bladder removal is also performed under general anesthesia.
This involves making an approximately 10 cm long skin incision in the area of the right costal arch, through which the surgeon gains access to the gallbladder bed. There, the gallbladder is freely prepared and can then be removed. As soon as bleeding vessels are closed, the surgical site can be closed again with sutures.This procedure is used particularly when the removal of the gallbladder is more complicated, for example, in cases of severe adhesions between the gallbladder and surrounding tissue or large accumulations of pus.
Advantages and disadvantages: The procedure by which the gallbladder is removed is selected according to the patient and health conditions. The advantage of laparoscopic removal is the reduced stress on the organism and circulation, the smaller wound area and the more inconspicuous, shorter scars that remain after the operation. In addition, patients are more quickly mobile and able to recover their strength after the operation than with the open surgical method.
Especially the single-port technique provides a cosmetically good result, as the scar in the navel is not recognizable as such. However, the open surgical option should still be chosen in more complicated cases, as the surgeon can then salvage the gallbladder more safely without damaging any neighboring structures.
