Forty-two-year old Ram Devi came to the clinic complaining of a burning pain in her upper abdomen, which got worse when she ate spicy and fatty food. She had been taking antacids to relieve the ache. After performing specific tests, the doctor diagnosed Ram Devi with stomach ulcer and began her successful treatment.
But her ultrasound also revealed gallstones in the abdomen and she was recommended to undergo an operation to remove the stones and prevent further complications. However, the patient decided against surgery because she was scared. Five years after the stones were discovered, Ram Devi has had no problems and is able to carry out her daily activities comfortably. Was she correct in ignoring the doctor’s advice?
Approximately eight per cent of men and 17 per cent women worldwide suffer from gallstones and the problem is common in Nepal as well. Medical students are taught the ‘fat, female, fertile, and forty’ rule which means those who fit this description are more predisposed to stones in their gall bladder. Importantly, the take-home message here is that while gallstones are widespread, most patients will not need an operation. In fact it is estimated that only one per cent of patients suffering from the disease require surgery. If Ram Devi had severe, sustained pain on the upper-right side of her abdomen, accompanied by nausea and vomiting on several occasions, she would have been a candidate for surgery. Acute abdominal pain caused by a diseased gall bladder (cholecystitis) is usually unforgettable once it is experienced.
Vague abdominal pains and bloating should not be regarded as gall bladder disease even if gallstones are detected during ultrasound examination. Often after the stones are surgically removed, the symptoms by which the patient suffered will persist. Hence, gallstones may just be ‘incidental’ findings. That is, the actual disease may be elsewhere, but since gallstones are so common in the general population and are noted on the ultrasound, abdominal pain symptoms may be incorrectly ascribed to the stones.
Besides frequent attacks of cholecystitis which may necessitate gall bladder surgery, other indications for surgery may be a very large stone (more than 3cm), or inflammation of the pancreas (pancreatitis) caused by gallstones. Obesity, cholesterol rich, or high-calorie diets are triggers for gallstone formation. In Nepal, those who eat large quantities of rice everyday with minimum physical exercise are clearly at threat.
Some health authorities believe that gallstones are a risk factor for gall bladder cancer, a very rare form of cancer. Statistically, however, this has not been proven because very few patients (about 0.2 per cent) with stones develop gall bladder cancer. Many other factors could easily influence the development of this uncommon cancer. Finally, performing surgery to remove gallstones is not without life-threatening risks, however small.
As medical science gets more advanced with CT scans, MRI scans, and sensitive screening tests, increasing number of incidental findings suggestive of many diseases are likely to be noted. Hence, careful assessment needs to be made so that unnecessary and dubious treatment is not prescribed for patients.