Gallbladder

Gallbladder

"You have a lot of gall!"

Well, if anybody ever says that to you, tell them that you only have a couple of tablespoons. And tell them that gall is a good thing.

Gall is an old word for bile. And bile helps us digest the fat in our food. The liver, not the gallbladder, actually makes gall--out of a soup of cholesterol, salts and pigments. But the gallbladder simmers the soup down to a concentrate and then stores the greenish brown bile. It is either stored or released internally when we eat.

The gallbladder resembles a piece of food, specifically fruit--a three-inch-long green pear. Snuggled under the right lobe of the liver, it''''s muscular but thin-walled. It uses its strength to spit a wad of stored bile into the small intestine after a meal, teaming up with the deconstruction gang that turns our food into fuel.

Unlike the stomach or the liver or the small intestine, though, the gallbladder is a disposable worker. Take it out, and the liver and small intestine fill in for the missing organ. "The gallbladder isn''''t that important. It just concentrates the bile for digestion," says Thomas Nolan, M.D., associate professor of obstetrics and gynecology and internal medicine at Louisiana State University in New Orleans.

Lucky for us we can live without it, because cholecystectomy--as gallbladder removal is called--constitutes a large chunk of the surgical docket. Roughly half a million of us will give up our gallbladders this year, mostly because of gallstones. And women are three times as likely as men to be "chole" patients.

Gallstones happen because bile is a tricky liquid. If the liver puts too much cholesterol into the basic mix, or not enough of the bile salts and detergents that keep cholesterol floating free, then bits of the cholesterol can solidify in the gallbladder. They begin to grow like grit in an oyster. About half of the 20 million people who walk around carrying gallstones have "silent stones"--pearls that produce no symptoms.

The opposite of silent stones is more than just noisy stones--they''''re also painful.

Throwing Stones

When gallstones start to move, they can get stuck in the cystic ducts that lead out of the gallbladder. That causes nasty bouts of biliary colic: The gallbladder clamps and contracts, trying to spit out the bad seed.

Before the organ gives up and rests, our right sides may ache. Or we may have abdominal pain that moves around to the back. Nausea and vomiting are other symptoms. If the stone doesn''''t fall back into the gallbladder and unplug the duct, then inflammation or infection can occur in the gallbladder.

A stone could also get caught in the main bile duct leading from the liver--the same duct that catches whatever leaves the gallbladder. When the stone gets trapped there, it causes bile pigments to build up, turning the skin a pale shade of yellow, which is a condition called jaundice. Other problems could result from this type of buildup, including pain, fever, infection and inflammation of the pancreas.

Researchers aren''''t sure why women get so many more gallstones than men, but they do. Not only that, the more children a woman has, the more likely she is to get gallstones.

Doctors can also name some factors that just seem to complicate the puzzle. Certain racial and genetic groups--among them, Mexican-Americans, Native Americans and Swedes--are at higher risk of getting gallstones. But since women in all groups get more gallstones than men, experts conclude that hormones definitely figure in the gender phenomenon.

Even pregnancy and childbirth can precipitate gallstones, Dr. Nolan says. "And I hate to say it, but hormone replacement therapy (HRT) increases the incidence of stone formation. It''''s two times greater with the lower doses of estrogen and four times greater with the higher doses."

This doesn''''t mean that you should avoid HRT just to avoid gallstones. "The benefit-to-risk ratio of HRT is still extremely high," Dr. Nolan adds. "I wouldn''''t advise anybody to go off HRT because of the risk of gallstones."

What is it with hormones, anyway? "One possible explanation is that hormones tend to relax smooth muscle--and the gallbladder is a smooth muscle organ. So if the gallbladder is sluggish, cholesterol crystals can grow and grow. When the organ is vigorous, it can contract and squirt small crystals out into the small intestine when we eat meals and get rid of them," says Roger Gebhard, M.D., professor of medicine at the University of Minnesota in Minneapolis.

Scaling Back Your Risk

While we can''''t do anything about being born female, Mexican-American, Native American or Swedish, we can tackle our weight.

"Obesity is the single biggest risk factor for gallstones," says Dr. Gebhard. "Obesity is associated with increased secretion of cholesterol in the bile. This allows supersaturation, which causes cholesterol crystals to precipitate out and become stones."

One landmark study of 88,837 women done by researchers at the Harvard School of Public Health found that slightly overweight women had almost twice the chance of developing gallstones as women of normal weight. Obese women were six times more likely to form stones.

But the way we lose weight is important, too. So doctors give this advice to help women dodge stone problems.

Don''''t crash and burn. "Rapid weight loss has been associated with gallstone formation," says Janice Rothschild, M.D., general surgeon and assistant professor of surgery at Tufts University School of Medicine in Boston. "Some of the diet programs have been implicated, but I don''''t think it''''s a matter of a specific diet program. Any alteration of the concentrations in bile can start stone formation."

If you''''re out to lose weight, take it slow and continue to eat regular, healthy meals. Maximum weight-loss velocity shouldn''''t be more than two pounds a week. If you''''re losing less than that, be satisfied, as long as the progress is slow and steady.

Don''''t go too low. While low-fat diets are recommended for weight loss, a diet that contains very low fat, such as a less-than-two-grams-a-day diet, may not be fatty enough for some women. When dietary fat goes that low, you may potentially run into gallbladder problems.

"You may benefit from having some fat in your diet to empty the gallbladder and preserve its function," says Dr. Gebhard.

Don''''t smoke it off. Reaching for a cigarette instead of a cheeseburger never was a good weight-loss strategy. Now here''''s one more brick to hurl at the butts.

"Smoking has recently been implicated in gallstone formation," says Dr. Gebhard. "We don''''t know why. The studies are just epidemiological--they only associate smoking and gallstones. But we think it''''s a factor. So avoiding smoking is something you can do for your gallbladder."

When Good Gallbladders Go Bad

Maybe you had one heck of an upset stomach last night. Or it seems like you burp and pass gas too often. Or it could be that you can''''t eat fatty foods anymore without paying the fat tax--a grumbling gut.

If you mention those symptoms to your doctor, she may send you for an x-ray or an ultrasound to test for gallstones. Then, if she finds one, she''''ll roll out some options. Oral drugs can dissolve gallstones, but they take a year or two to do it. Lithotripsy uses sound waves to pulverize gallstones, but few hospitals use lithotripsy machines for anything but kidney stones. In any case, the success rate is low for both techniques. Gallbladders can always produce more stones, so most often gallstones are cured by removing the gallbladder.

Gallbladder surgery used to be a big deal--major surgery that left fair-size scars and cost weeks of recovery time. Then, in the late 1980s, Nintendo surgery came along. That''''s a popular term for laparoscopic surgery, which involves high-tech miniature scalpels and forceps and a kind of periscope equipped with a tiny camera that transmits blown-up pictures of your insides to a TV screen. With Nintendo surgery you could have your gallbladder out on Monday--through a dime-size hole in your belly button--and go home on Tuesday. You could be back at work in a week.

"Laparoscopy just swept the world, and it seems to make a substantial difference. People can be out of the hospital and back to work in a couple of days," marvels Dr. Gebhard.

By 1990, thanks to "lap choles" (laparoscopy cholecystectomies), doctors reported that surgery rates for gallbladder removal had jumped almost 60 percent. Meanwhile, the use of ultrasound in diagnosis made spotting gallstones a snap--even when they weren''''t the problem in question. So, if you or your doctor knew that you had a gallstone, the temptation would be to remove it, whether it was silent or not.

But it''''s so easy now that some doctors are skeptical about how many operations are being done.

"There''''s a real controversy about who needs to have her gallbladder out," says Dr. Nolan. "Who do you operate on? And when? It should be the patient with symptoms. The controversy is ongoing."

Even if you''''ve had what you and your doctor think may be a gallbladder attack, "Be cautious," says Dr. Gebhard. "It could be an isolated gastrointestinal attack. So it''''s important to work with your physician to make certain that your symptoms are actually related to a gallstone."

See also Digestive System