By Tedler D. Depaynos, MD
The patient was diagnosed to have “multiple stones” in her gallbladder several months ago after a routine yearly check-up while still employed which included some laboratory examinations, chest x-ray and abdominal ultrasound (UTZ). Because her daughter abroad had a baby and she and her husband had a hard time scheduling their work, she opted for an early retirement and decided to go abroad to take care of her “apo”. Before going however, she was advised by her daughter to consult a surgeon and have her gallbladder removed because surgery abroad in case she will have “gallbladder problems” in the future would be difficult and expensive.
Except for slight epigastric discomfort which was diagnosed by their company physician as “hyperacidity”, she never complained of significant abdominal pain. When she consulted a white haired town mate surgeon, she brought with her her previous medical records. The repeat examinations done were practically the same including the result which is the “multiple stones” in her gallbladder. The surgeon then agreed with the patient’s daughter that she should undergo elective surgical removal of her gallbladder or cholecystectomy. She however argued that she probably had this for quite some time and was always asymptomatic so that why the need for surgery? Her town mate surgeon then lectured her on the risks involved.
Severe pain is usually experienced by patients having inflammation of the gallbladder associated with stones. The main pathology is the obstruction of the gallbladder opening so that bile cannot exit when it contracts stimulated mainly by the intake of fatty foods which it helps to digest. When the obstruction is dislodged, the pain is relieved. The stone could either be dislodged back into the gallbladder or into the main duct called common bile duct or CBD, where the bile passes going into the small intestines or specifically the duodenum. In short, this is one of the complications of gallstones, obstruction of the CBD causing obstructive jaundice aside from inflammation of the gallbladder or cholecystitis.
Stones in the CBD could also come from the liver where in some cases stones are formed or in rare cases it could just be formed in the CBD if the patient is really a stone former. In the majority of instances, however, the stones come from the gallbladder.
When obstruction occurs, damming of the bile formed and secreted by the liver occurs. There is continuous accumulation and a retrograde flow develops distending the ducts, the gallbladder and causing enlargement of the liver. The bile then goes into the general circulatory system causing yellowing of the skin or jaundice which is progressive unless the obstruction is relieved. This is the simple patho-physiology of obstructive jaundice.
Obstructive Jaundice may however have other etiologies like tumors of the surrounding organs like the pancreas. Ultrasound (UTZ) or in more complicated cases, CT Scan or MRI could confirm the clinical diagnosis.
Treatment is obviously to relieve the obstruction but in some cases the surgery may be complicated especially if there is inflammation where the organs are swollen or there may be adhesions making the dissection difficult. Sometimes the anatomy is not what we read or see in our textbooks so that the removal of the gallbladder and the stone in the CBD requires super meticulous surgery. To aid the surgeons in their dissection, special x-ray procedures are done during the actual surgery where dye is injected into the duct and x-rays are taken called Introperative -Cholangiography or IOC. In some cases, intra – operative UTZ is also done. Hence, surgery without the inflammation is much easier and recovery is usually uneventful. In layman’s terms, Elective Surgery is done before complications occur.
Despite the lengthy lecture of her town mate surgeon, she was still undecided. Anyway she had 2 or 3 months more to think about it before leaving for abroad.
A month after consultation, she experienced occasional tolerable pain at the right upper quadrant of her abdomen where her gallbladder is located. She did not mind it at all but a week before her flight, she was noticed to have her eyes getting “yellow”. She was getting jaundiced. They were in Metro-Manila at that time doing some shopping for their “pasalobong” so she sought consultation in a Medical Center.
In her abdominal UTZ, the “multiple stones” in her gallbladder was again appreciated but her CBD was slightly dilated. It was not clear if there was a stone but because of the absence of severe abdominal pain a “pancreatic tumor” was entertained. She underwent a more extensive work-up with a CT Scan and MRI and a “stone” in the common bile duct was the final impression. Her case was unique because she did not manifest the usual severe pain expected in her case. She was glad that no malignancy was seen. Surgery was then suggested but because she was in a distant place from home and she was unprepared, she opted to come home against the advice of the surgeons who saw her at the Medical Center.
Her town mate surgeon removed her gallbladder and the stone in her CBD doing the classical surgical technique. She was able to reschedule her trip and was lucky that the surgery was done before her flight. Because of the unpredicted Covid 19 quarantine, however, her trip was cancelled. Her surgeon was just with all smiles when the patient related this during her follow-up. If only the elective cholecystectomy was done earlier, the complications would have been avoided and she would have had no reason to reschedule her trip.**
