Gallstones causing pancreatitis

The most common cause of pancreatitis world wide is “alcohol”. But the second most common cause is stones inside the gallbladder. It is also known “biliary pancreatitis”. The common notion amongst the surgeons is if the gallbladder has small stones, the patient is more likely to have jaundice or pancreatitis as these have a larger probability of slipping down in the common bile duct. But if the patient has large stones, they are more likely to get impacted at the neck of the gall bladder and cause distension, swelling and infection of the gallbladder. In fact, in some cases of long standing obstruction, the color of the bile inside the gall bladder turns white from green and this is known as “white bile” and the gall bladder is known as “hydrops of the gall bladder or mucocoele”.

Now coming to the incidence of having pancreatitis due to gallstones. Most cases, it is of mild variety. The stone may spontaneously pass out of the bile duct. The patient will experience excruciating pain the in the midline and above the naval area in such a situation. If the stone remains impacted at the level of the valve and does not fall down spontaneously, then it has to be removed urgently by a procedure called ERCP. It is an endoscopic technique to clear the bile duct of stones. It will prevent aggravation of the attacks of pancreatitis and the inflammation in the pancreas will gradually settle down. Once the serum amylase returns to near normal and the liver enzymes show a decreasing trend, the patient should under go the surgery for cholecystectomy in the same index admission. If the surgery is delayed, there is strong likelihood that another stone may pass down the bile duct causing recurrent pancreatitis.

In a small percentage of cases, the pancreatitis is severe and has to be managed by a multidisciplinary team of gastroenterologist, Intensivist, and the surgeon together along with a interventional radiologist. It can be an alarming and a serious situation. This can easily be avoided if timely intervention is done, and surgery for gallstones is performed as soon as they are diagnosed

Large stones in the gall bladder: what should be done.

This picture is representative of how big the stones can become if the surgery for the gall bladder stones is delayed. The usual question when a patient is diagnosed and operated is, “Dr how long do you think, these stones have been inside the body”. The answer is not straightforward. It can be a couple of years or more. And the next thing they want to know is why it did not show any symptoms.

The irony here is that sometimes very small stones can be extremely symptomatic and have complications like pancreatitis and jaundice and some times very large stones will keep sitting silently inside and patient will never know. So, what is an anticipated problem if the stones become large.

1. There is a risk of pressure and erosion in the surrounding area of the gall bladder and it may at times cause compression of the common bile duct (the tube which brings the bile from the liver to the intestine).
2. There can be chronic inflammation and it can have communication with the colon and the duodenum (a part of the small intestine)
3. In endemic areas, large stone can predispose to the formation of gall bladder cancer also.
4. The surgery in limited circumstances can become challenging and may have some immediate postoperative sequel which may merit another endoscopic treatment in the form of ERCP.
So, if the Ultrasound is showing the presence of stones which are more than 2 cms in size, but you do not have significant symptoms, even then you should consider timely surgery to prevent the complications which are mentioned above. Remember that these stones did not become so big overnight, they have been there and have the potential to cause harm in the long run.

AWR Deep Impact An abdominal wall

Hernia conference dealing with all aspects of hernia with 1500 delegates across 40 countries. An absolute delight to hear the world renowned faculty and share the experiences. Thanks for the invitation as faculty by Dr Ramana Bala Subramaniam Dr Arun Prasad Dr Vivek Bindal Dr Abhishek Tiwari.

Glad to be a part of a group of talented ”lady surgeons” making a great show and building up from strength to strength. They reveled in each other’s presentations and cheered and supported each other with delight. Dr Soumya Khuller and Dr Meenakshi Sharma making it happen. The #Gen Next looks spirited and motivated.

Also the Robotic Program at Apollo with an awe inspiring show of expertise by Dr Flavio was an extended cherry on the show.

The old friends are always a pleasure to catch up with and quiet a few from UAE enjoyed the stay.

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