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Can symptomatic gallstones develop into cholecystitis?

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Posted on Fri, 27 May 2016
Question: Hello. I would like to know what the real chances are for someone who has symptomatic gallstones to develop cholecystitis at some point or to end up in emergency surgery. I have heard numbers anywhere from a 1 in 250 chance to a 1 in 3 chance to develop serious inflammation/infection of gallbladder requiring hospital stay and possibly surgery This is a wide range! I ask because I have had gallstones for over a decade. They do bother me from time to time but I have never had an infection, duct blockage or ended up in hospital. Have I just been very lucky and eventually be forced to have emergency surgery? Am considering elective surgery to remove gallbladder, but I am debating if this is an unnecessary risk given my history of painful episodes/attacks that always resolve themselves without complications?

Thanks for any insight that you can provide on quantifying real risks of gallstones versus risks of surgery .

Here is one study with some numbers - some excerpts:
"Between 1 - 3% of people with symptomatic gallstones develop inflammation in the gallbladder (acute cholecystitis), which occurs when stones or sludge obstruct the duct.
Infection develops in about 20% of these cases, which increases the danger. Acute cholecystitis can progress to gangrene or perforation of the gallbladder if left untreated."
http://www.nytimes.com/health/guides/disease/acute-cholecystitis-gallstones/symptoms.html

doctor
Answered by Dr. Iven Romic Rommstein (1 hour later)
Brief Answer:
See next

Detailed Answer:
hi and welcome.

Ok,first,the official recommendation for symptomatic cholelithiasis is to perform cholecystectomy. There are several reasons for that: first, it is simple and routine procedure today which can be done laparoscopically,second, risk and complications rate is minor,third, there are no negative effects of gallbladder removal on digestion and fourth, it prevents possible future complications caused by gallstones.
now,it is hard to talk about exact numbers and it is hard to predict complications rate,but it is bigger than1-3% since we must calculate all complications,not just cholecystitis. This includes cholangitis , pancreatitis and gallbladder carcinoma. Long presence of gallstones is proven to be risk factor for gallbladder carcinoma which I'd very rare but very serious disease. When we calculate all this then complications rate for lifetime is 5-6%. However,most of these are related to cholecystitis which is again pretty easily treatable in early phase but may complicate if not treated. So it is up to you to decide about next steps,but we recommend surgery because of these reasons I 've mentioned. Wish you good health. Regards



Above answer was peer-reviewed by : Dr. Naveen Kumar
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Follow up: Dr. Iven Romic Rommstein (4 hours later)
What are the risks of surgery in terms of:
1) general anesthesia - allergic reaction , brain damage, death
2) complications post surgery - infection etc. . I heard somewhere 1 In 3000 chance of puncturing intestines . Other risk is damage to bile duct. damage to liver?

I have never undergone surgery before. It have great anxiety thinking about it, especially being under anesthetic.
doctor
Answered by Dr. Iven Romic Rommstein (52 minutes later)
Brief Answer:
Hi

Detailed Answer:
I understand your concerns, but if risk of surgery is significant then it would be performed so widely. There is no purpose of such calculations since serious complication rate is very small. Everything has it pros and cons and you can decide. in every case, urgent surgery for cholecystitis brings 20times more risks than elective one.
Above answer was peer-reviewed by : Dr. Raju A.T
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Follow up: Dr. Iven Romic Rommstein (51 minutes later)
I notice you are a surgeon. May I ask if you done laparoscopic surgery to remove gallbladder and what is the worst complication you have seen?

Also, what is the greater risk, complications from anesthesia on the operating table or post-surgical complications?

I am debating whether to have the surgery performed because yes it would improve my lifestyle by eliminating symptoms and also remove chance of future serious complications. But on the the hand, it is something I have learned to live with for many years without serious problems, so I don't feel it is absolutely necessary, especially when I weigh it against the risk/anxiety of surgery. But if I knew with some certainty that I would likely need surgery one day, I would have rather have it done now when I am younger. Yet when you say 5-6 percent lifetime chance of emergency situation, that seems low risk. It really is a tough decision. Would you say most people with symptomatic gallstones, example being episodes of pain at Least once a month, undergo survey from your experience?
doctor
Answered by Dr. Iven Romic Rommstein (12 hours later)
Brief Answer:
Detailed answer given below

Detailed Answer:
Hi....
Welcome back.

Yes, I am surgeon and hepatobilliary surgery is my subspecialty so I ve done around 150 cholecystectomies of which 90% laparoscopic so I can tell you from own experience.

If this is done by skilled surgeon then there is absolutely no need to be concerned about risks and comolications since these are very rare and even when occurs,these are not life threathening.

I ve seen complications of cholecystectomy, I ve had them, and every surgeon has it.
However, in very majority of cases, complications are related to difficulties in tissue dissection and visualizations which generally happens in acute gallbladder inflammation (cholecystitis) and in elective surgeries, complications are minimal.

Also, if there are difficulties during laparoscopy, then surgeon can in every time convert procedure to open one and remove gallbladder through abdominal incision.

Complications in elective surgery are rare as I said, less than 3%, especially in young and healthy people and usually include minor ones, such as wound infection, prolonged pain, nausea which are self limiting. Some more serious such as biloma, abscess or small bleeding may just prolong hospital stay but also dont require another surgery.

Serious ones are always possible of course but extremely rare and include injury of common bile duct, liver vessels or intraabdominal infections. As I said, these usually happens when there is some preoperative risk factor such as diabetes, advanced age or cholecystitis.Even these complications are in most cases managed successfuly without permanent consequances if discovered fast enough.

Of my 150 procedures, I had 7-8 complications, 3 were wound infections managed by antibiotics, 3 were small "leaks" of bile through bile duct which was managed sucessfully and 2 were related to abscess that were also managed by external drainage. All patients were fine. Also, studies shows that risks are minor. Reports about serious complications and death say that it happens as isolated case and there are large studies about 2000-3000 procedures in sngle hospitals where in average there is 2 serious complications in 1000 cases.

Death as the worst one may be seen in 1/3000. But again, it is usually related to patients with some serious comorbidity.

When we talk about gallstones then it is good to know that bog stones (larger than 1.5cm) will never pass through bile duct and it can just become larger. If it causes pain then it will cause it again,it is just questionable when and how often. Some people live with more large stones with no symptoms, some have symptoms once a year or once in 3 years,some once in a month,but since you have 5 years, you can expect problems with your gallbladder especially if stones enlarge or multiply. Of course, it is possible that you have only 1-2 attacks in next 10 years ,but also it is possible that stone stuck in neck of gallbladder and causes cholecystitis at any period of your life.

SO, this is again up to you.
Wait and see for a start, if there is no pain, if you don't have diabetes and if you don't have significant comorbidities then nothing will happen in sort time. If there are no frequent attacks,try to have healthier diet, regulate body mass and thats it. If attacks become frequent, more intensive or stones become larger then see a surgeon.

In your place, however, I would undergo surgery now. This is permanent solution, it prevents futures risks. In future, some other surgeries may be necessary or another diseases may develop so it is better not have diseased gallbladder in this case. In advanced age it may be much more serious to have cholecystitis,even life threatening. Now it can be done laparoscopically, when you are healthy and younger. You ll recover in few days.

Regards.


Above answer was peer-reviewed by : Dr. Deepak
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Follow up: Dr. Iven Romic Rommstein (10 hours later)
Thanks, very useful reply. Ultrasounds I have done show two moderately large gallstones, usually indicated as 1.5 cm but sometimes shown as bigger up to 2 cm.

When you say bigger stones cannot pass through bile duct, do you mean also they cannot get in there and cannot get stuck? Therefore, bigger stones means cannot block duct, so cannot cause infection , nor pancreatitis or other serious complications? My common bile duct measured at 2.5 mm. So stone of 1.5 cm (15 mm) cannot possibly get in there, right?

In other words, is it better to have bigger stones or
smaller stones? What is risk of bigger stones like the ones I have? Why see a surgeon if stones are large or get larger? Seems to me they will stay in gallbladder and not cause serious problems because they cannot get into to the duct or affect other organs like pancreas? Am I incorrect?

doctor
Answered by Dr. Iven Romic Rommstein (11 hours later)
Brief Answer:
hi

Detailed Answer:
Small stones are dangerous because it may cause pancreatitis and bile duct obstruction, but cholecystitis is caused by larger stones which can press gallbladder walls or may stuck in the neck of gallbladder and then it is more difficult to move them back .
Also,small pieces may break and travel into distal parts of bile duct. If there is constant evidence that stone is growing or new one developing then it means that there is higher risk of small stones to cause pancreatitis or bile duct obstruction so this is why surgery should be performed.

Regards.
Above answer was peer-reviewed by : Dr. Deepak
doctor
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Follow up: Dr. Iven Romic Rommstein (10 hours later)
Thank you. Very informative answers. A few final questions to help me make a decision on elective surgery.

1) 1 in 3000 chance of death seems scary high. Are you saying this is for someone in poor health? Someone in good health would have much better odds?
2) In your surgeries, have you ever seen serious complications or death from anesthesia? Do you know what sort of numerical odds we might be talking about here?
3) Overall, would you say there is greater risk of emergency surgery situation from small gallstones or larger gallstones? I have read that acute cholecystitis is caused 90% of time by stone getting stuck in bile duct. So the greater risk of serious complication seems to be smaller stones, because larger stones cannot get into duct Does my interpretation sound accurate?
4) My BMI is 28, high. Overweight. But not obese. Should I be concerned with risks that laparoscopy surgery will be converted to open cholecystectomy? Have you seen this in your surgeries? I have read that high Body mass index might make keyhole surgery more difficult.
doctor
Answered by Dr. Iven Romic Rommstein (19 hours later)
Brief Answer:
hi

Detailed Answer:
1. this is just statistics and mortality cases are always related to critically ill patients who die from cardiorespiratory disorders, not directly from the surgery so this is not so dramatic.

2. I ve never seen any serious complications due to anashesia,this is rare and again statistically it is 1 case per 25 000 surgeries, but most deaths are related to more complex and longer procedures. Cholecystectomy lasts for around 30 min and anasthesia related complications in this case are extremely rare and minor

3. yes, it is easier for smaller smaller stones to enter cystic duct but also, pieces of bigger stones may break and new one may form. So if you have predisposition for stone formation then you have certain risk for complications.

4. yes, but you have good BMI. We have difficulties with morbid obesity 35 and more and your BMI would not affect success of the procedure or anasthesia.

To conclude, cholecystectomy is routine today and I dont think you should have any doubts about it. More complex surgeries may carry some risk but this one is proved to be beneficial in all symptomatic patients.


Above answer was peer-reviewed by : Dr. Naveen Kumar
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Follow up: Dr. Iven Romic Rommstein (6 hours later)
One final question. I just learned I may have sleep apnea. This is apparently a possible risk factor for general anaesthesia. http://www.apsf.org/newsletters/html/1997/summer/sleepapnea.html

I will be referred for a sleep study to diagnose sleep apnea. But this may take months. I can schedule a gallbladder surgery more quickly. Should I wait to do the sleep study first because undergoing surgery with sleep apnea is an unnecessary risk? Or is it safe to do general anesthesia with POSSIBLE sleep apnea (based on symptoms but unconfirmed diagnosis)?

"For someone who has not already been formally diagnosed with OSA, but manifests the clinical signs, surgery may need to be delayed to allow for sleep studies and, possibly, the initiation of PAP therapy."
http://www.sleepapnea.org/treat/treatment-options/warning-to-anesthesiologists.html

doctor
Answered by Dr. Iven Romic Rommstein (11 hours later)
Brief Answer:
It is up to you

Detailed Answer:
Hi.
This should be discussed with anashesiologist that will perform anesthesia.
We don't usually require such tests since sleep apnea is not contraindication for surgery and this is important only for aneshesiologist who should be more prepared for possible incidents in people with sleep apnea.
So if you have some symptoms you can do testing, there is no need to hurry with surgery, you have time.

Regards.
Above answer was peer-reviewed by : Dr. Deepak
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Can symptomatic gallstones develop into cholecystitis?

Brief Answer: See next Detailed Answer: hi and welcome. Ok,first,the official recommendation for symptomatic cholelithiasis is to perform cholecystectomy. There are several reasons for that: first, it is simple and routine procedure today which can be done laparoscopically,second, risk and complications rate is minor,third, there are no negative effects of gallbladder removal on digestion and fourth, it prevents possible future complications caused by gallstones. now,it is hard to talk about exact numbers and it is hard to predict complications rate,but it is bigger than1-3% since we must calculate all complications,not just cholecystitis. This includes cholangitis , pancreatitis and gallbladder carcinoma. Long presence of gallstones is proven to be risk factor for gallbladder carcinoma which I'd very rare but very serious disease. When we calculate all this then complications rate for lifetime is 5-6%. However,most of these are related to cholecystitis which is again pretty easily treatable in early phase but may complicate if not treated. So it is up to you to decide about next steps,but we recommend surgery because of these reasons I 've mentioned. Wish you good health. Regards