Signs and Symptoms of Gallstone Pancreatitis
In the right upper quadrant of the abdominal cavity, the liver produces bile, which is a liquid that digests fats like oils, greasy foods, butter and other products. The main bile duct, or tube, runs from the liver to the small intestine; it sends a constant flow of bile into the digestive system when we eat. If you eat a lot of fats in one meal, like a greasy burger and fries, the body signals the gallbladder—which sits against and just below the liver and is a storage bag for bile off of the main duct—to release extra bile into the system, and it squeezes out more to digest the extra fat. In some people, the bile solution is not in balance, and stones can form in the gallbladder from cholesterol or other substances. When the gallbladder tries to squeeze out bile, a stone can block the exit to the cystic (gallbladder) duct, causing pain and blockage of the bile system. Sometimes, this blockage is temporary, and the pain gets better within hours. This may be referred to as biliary colic, or a gallbladder attack. Other times, the blockage and pain persist, and the gallbladder wall becomes inflamed and swollen. This is known as cholecystitis. If the stone gets into the main bile duct but gets caught just before it empties into the intestine, it can block the pancreatic duct, which comes out in the same place, producing gallstone pancreatitis. This means inflammation of the pancreas, an organ just behind the stomach, which produces enzymes that digest our food. These enzymes get backed up into the organ itself, and it starts digesting its own tissues, causing pain which can be severe. For most patients, the pain is felt in the middle upper abdomen and sometimes goes through to the back. Fever is possible, and if the main bile duct is also blocked by the stone, the bile can back up in the liver, causing leakage of pigments into the blood and a yellow color to the skin, called jaundice. Some patients with pancreatitis feel like throwing up, whether they do or not.
Diagnosis of Gallstone Pancreatitis
The doctor will take a careful history, asking about when and how your symptoms started, like pain or vomiting, and whether there have been changes since they started. A physical examination enables your doctor to evaluate for presence and degree of tenderness, and blood is drawn to check labs including blood counts, liver and pancreas enzymes, and to look for other possible causes of your symptoms. Imaging may be performed, including an ultrasound, which would show the presence of stones in the gallbladder, whether its wall is inflamed, and if blockage of the main duct is suspected. On CT scan, the doctor may or may not be able to see stones, but will be able to tell whether the pancreas is inflamed. If your pancreatic enzymes (amylase and/or lipase) are elevated, and there are gallstones in the gallbladder, the diagnosis is presumed to be gallstone pancreatitis. An MRCP (magnetic resonance cholangiopancreatography) is an imaging study which enables the doctor to see if there are stones still present in the main bile duct (choledocholithiasis), as well as to evaluate the pancreas.
Treatment for Gallstone Pancreatitis
Most often, gallstone pancreatitis is treated with IV fluids and bowel rest. Antibiotics are not usually needed, unless cholecystitis is also present. If MRCP shows that there is still a stone blocking the duct, a gastroenterologist (GI specialist) will perform an ERCP, an endoscopic procedure involving a camera on the end of of long tube, which is passed down the esophagus and through the stomach, while the patient is asleep. Special instruments are used to identify the duct from the inside of the intestine, evacuate the stone(s), and widen the opening to allow bile and any other stones to pass more easily.
Surgery to remove the gallbladder is generally recommended during the same hospital admission, but is usually delayed until the pancreatitis pain resolves. In most cases, the gallbladder can be removed laparoscopically, with a few small incisions, through which a special camera and instruments are used to perform the operation. Carbon dioxide is introduced into the abdominal cavity, which expands, allowing the surgeon to see the gallbladder and liver clearly. An anesthesiologist puts the patient to sleep for the operation, and wakes them up afterward. Pain from the incisions is managed with oral medication, and you should be able to eat again soon after surgery. Recovery time is usually shorter than with a longer incision directly over the gallbladder (“open” cholecystectomy), although one may still be necessary in some cases.
Without a gallbladder, bile still flows from the liver to the intestine, and fats still get digested. But a meal which is very high in fat may overwhelm the system, since there is no longer a storage reservoir to provide extra bile. Early after gallbladder surgery, if a patient does eat too much fat in one meal, they may experience bloating, gas, cramps and diarrhea, as the undigested fat moves through the intestines. Most patients’ bodies slowly adjust to the absence of the gallbladder, and they are eventually able to eat much as they did before their surgery. But if they do overdo it with a fatty meal, it is easy to recognize and correct by moderating the fat content the next time.