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This is a gallbladder. Specifically this is my gallbladder (lovely, isn’t it?) after it was removed laparoscopically this past February and as is routine, sent for pathology. As you can see, there was a lot going on in my gallbladder at the time. While gallbladder disease and surgical treatment is pretty much routine medicine, I thought this was a good example to illustrate that the pathophysiology behind it can be varied in nature.
The simple explanation for what causes gallbladder disease is an over concentration or saturation of a particular substance. What causes the saturation is not always known and there are a couple of substances involved. When it comes to explaining to my patients the concept of concentration, I like to describe to them a very simple example. I use the example of putting sugar into water or iced tea. I remind them that when you put in a little sugar, it dissolves very easily but if you put in too much, the sugar precipitates out and you can see it. In much the same way, this is what happens with gallstones.
- Pigment stones (1): Pigment stones are composed of Bilirubin, which is the result of the breakdown of red blood cells. Certain conditions cause the liver to make too much bilirubin such as cirrhosis, biliary tract infections, and some blood dyscrasias. Again, the end result is a hyper concentration of, in this case, bilirubin that precipitation out. Pigment stones make up about 20% of gallstones, are black or brown in color, and have smoother (but not completely smooth) edges than their cholesterol counterparts.
- Cholesterol stones (2): Your liver excretes cholesterol and normally the bile in your gallbladder can dissolve this. However, in some people, the liver excretes more cholesterol than the bile can handle. The cholesterol eventually precipitates out, crystallizes, and eventually forms a stone or stones. These stones are typically yellow in color with jagged edges and account for about 80% of gallstones. Of note, one does not need to have high cholesterol for this to occur.
- Impaired Emptying: Sometimes, the saturation of cholesterol and/or bilirubin can be due to impaired emptying of the gallbladder and not increased excretion / production from the liver. Impaired emptying can be due to pathology of the smooth muscles and epithelial cells of the gallbladder wall, contractile dyscoordination of the gallbladder wall and cystic duct, cystic duct resistance, and gallbladder polyps near the opening of the cystic duct. The net result is a slower and/or irregular emptying of bile. The longer the bile pools in the gallbladder without moving, the more risk of bilirubin or cholesterol precipitating out. This can lead to stones or gallbladder sludge.
- Sludge: This is a mixture of particulate solids that have precipitated from bile. Such sediment consists of cholesterol crystals, calcium bilirubinate pigment, and other calcium salts. The precipitates cause the bile to become thicker, more viscous in nature but not yet concentrated enough to form stones. Many patients may be asymptomatic but some may develop biliary colic symptoms as is seen with gallstones.
- Polyps (present but not seen in the picture): These are growths that arise from the inner wall of the gallbladder. About 95% of polyps are benign in nature with cancer’s being rare. In addition, a majority cause no symptoms and in most cases are monitored with serial ultrasounds to make sure they don’t increase to a size concerning for malignancy. Sometimes, the polyp can arise near the opening of the cystic duct (as in my case) and cause an outflow obstruction leading to sludge and/or stone formation resulting in biliary colic symptoms.
So as promised, here are my musings after personally undergoing a laparoscopic cholecystectomy. It is my second day post-op and overall I feel quite good. Still having some pain at the epigastric incision with coughing and moving around quite well none the less. That said, lets go back to the beginning.
We all know that saying “a little knowledge is a dangerous thing”. I think for medical providers it can be twice as dangerous. All too often we have symptoms and we are usually tempted to self diagnose the issue. That can lead to a isolated case of hypochondria and over diagnosing ourselves. It can also lead to us being correct, which sometimes we don’t want to be. In my case it was the latter. Working a shift one night this past January, I felt a pain in my right upper quadrant. It wasn’t my GERD, it was different. Dull, achey, colicky, and radiating to my back, though not related to eating. I thought to myself, “could this really be my gallbladder?”. I am 41 years old now, I’m getting pudgy around the mid-section, and technically I am fertile, even though male fertility is not the risk factor. While we all learn the “five F’s” of gallbladder disease, we’ve all encountered those cases which fall outside those risk factors. I immediately thought back to a prior case I had of a 29 year old man with an acute cholecystitis and more recently to a male colleague a little younger than I who just had his removed. Still suspecting my gallbladder, I took advantage of the fact I work in a hospital and I went down to the ultrasound tech on that evening to get a preliminary look. Sure enough, it looked as though I had a stone in my gallbladder.
The next day, I called my primary to set up my official ultrasound and pre-op blood work. The official ultrasound was read as my gallbladder having stones vs. polyps, with one of the polyps right near the neck of the gallbladder. The radiologist and surgeon where I work both agreed it appeared more consistent with a polyp but the end result is the same, it needed to come out. So here is where the “being right” not being a good thing comes into play. Certainly there are worse conditions I could have but my immediate thoughts are “Am I going to be able to get coverage?”, ” How long will I be out?”, “Can I miss that much time financially?”, oh and “can I handle being a patient?”.
For the past 11 years I’ve worked as a health care provider in Emergency Medicine and some Family Practice where other patients have trusted me to care for them. Where they have put their faith in my skills and knowledge. This was the first time I would really have to do the same. While laparoscopic cholecystectomies are routine in the realm of surgery, it’s still surgery. This would be my first time under general anesthesia for a procedure (not counting eye surgery I had as a child which I don’t remember). This would be the first time having an organ removed. Honestly, it was an odd feeling for me. Please don’t equate my trepidation with lack of trust. The surgeon I chose to do my surgery I have known for a while. I know his reputation. I know his bedside manner and he knows me. That is one advantage of working in medicine. Still, one is very prone while under general anesthesia and having surgery. It is a complete role reversal for those of us in medicine.
Oddly enough, I was up bright an early the day of my surgery even though I did not have to be there until 9:30am. It was rather like when I was a kid the morning of leaving for a trip, up and ready to go. I can’t say I felt scared. Definitely not scared to have the operation. I was anxious to get it done though. Some of that was mitigated by my girlfriend waiting with me. Some of that was exacerbated by my parents also waiting with me… and bickering causing me to say to myself , “Please just put me under already”. I guess it was also quite evident to the pre-op nurse who pointed out I had been tapping my hands persistently. Then something happened. One by one, nurses, residents, staff, and physicians who knew me stopped by one by one to say “hello” and joke around. The obligatory “rectal exam” joke. Another who thanked me for the time I took care of their family in the ER. My hand tapping slowly stopped. I was brought back to the operating suite, placed on the table with my hands out to the side very reminiscent of Jesus on the cross. I made a joke about how I’ll even have a stigmata scar. They asked if I was ready and I said “see you later”.
Anesthesia is a wonderful and at the same time bizarre thing. Something that can put you under to allow a surgeon to cut and work inside of you is amazing, obviously necessary, and at the same time, the resulting amnesia and disorientation of waking up in a different room is baffling to experience. My post-op time was uneventful and routine. I got wheeled out through the ER to say hello to my colleagues working that day and the rest as they vapidly say is history. I can’t generalize and say that anyone who works in medicine will experience the same feelings I had anticipating surgery. Perhaps for some, the role reversal is of no consequence. For others, like me, it is something to contend with and still others may just be in denial of it. I’m glad I experienced it though. It gave me further appreciation for my colleagues who work in surgery, it gives me a different perspective that I can now apply to my patients, and it gave me a surprise, unplanned, stay-cation.