All Posts tagged abdominal pain

Gallbladder Blues

Gallbladder Blues

“Toe in, toe in!  Come on, retract, I can’t see what I’m doing!”
These were the commonly heard urgings by gallbladder surgeons when I was a med student nearly thirty years ago.  Gallbladders were removed through large incisions followed by long recovery periods.  We students would scrub in and stand for a few hours in the OR pulling on wound retractors to keep open the incisions so the surgeons could have good visibility.  Boredom or fatigue occasionally caused us to slacken at our duty and the surgeon would quickly chide us. Happily for med students, surgeons, and especially for patients, most gallbladders are now removed laparoscopically through small incisions with much more rapid recovery and far less suffering.
Some things haven’t changed though – when there’s pain in the upper abdomen, especially if it’s the right upper abdomen, the gallbladder is still one of the suspects considered.  This isn’t surprising since in the U.S. about 20 million people have gallstones, and each year about 700,000 patients have their gallbladders removed to relieve troublesome symptoms.  The gallbladder follows the appendix as the other sack-like organ next most frequently removed due to disease or malfunction.
So what does the gallbladder do when it’s working correctly?  The gallbladder is a 3 to 4 inch long pouch-like organ tucked up into a pocket of the liver in the right upper abdomen.  Bile and other digestive enzymes are secreted and stored by it.  When we eat a meal, especially a large fatty one, this little sack contracts, squirting its digestive enzymes through a little duct or tube into the intestine where the enzymes help digest the meal.
So far, so good.  But things can go wrong.  The gallbladder can develop gallstones of varying sizes.  Then when the gallbladder contracts one of these stones can become wedged in the duct leading to the intestine.  Depending on where the obstruction occurs, this can sometimes also block off the pancreas causing still more problems.  Either way, there is tremendous crampy pain, usually in the right upper abdomen or upper mid abdomen and sometimes radiating through to the back.
The pain typically starts shortly after a meal and may last for a couple of hours or more, until the stone passes into the intestine or falls back into the gallbladder after it finally stops contracting.  Occasionally the pain persists and a trip to the emergency department, sometimes followed by emergency gallbladder removal (cholecystectomy) is the only solution.  An ultrasound of the gallbladder and lab work are usually able to diagnose this problem.
Gallstones are not the only problem that can arise in the gallbladder.  A situation can arise in which it excretes less and less effectively even though it has no stones.  In this condition, the gallbladder may look OK on ultrasound and a special scan is needed to identify the problem. Or, even more dangerous, the gallbladder can become infected with bacteria, often due to one of these other malfunctions already mentioned.   This requires urgent treatment with antibiotics and eventual surgery.  And like most organs in the body, cancer can occasionally occur in the gallbladder.
Anyone can have problems with their gallbladder, but certain groups are more at risk.  The most common group would be Caucasian females around their forties who are overweight.  Also, during weight loss there is a temporary increase in gallbladder attacks as the person processes their own fat.
For these reasons and more, the gallbladder may sometimes have to be removed.  Often this affords a huge amount of relief for the person.  However, besides infrequent complications of residual stones, infection or problems with wound healing, about 10-15% of people have ongoing symptoms after the gallbladder is removed.  This has been given the long name post cholecystectomy syndrome (PCS).  This is not surprising since God puts things in place for a reason; when we have to remove them, sometimes there are issues to deal with.  The loss of the gallbladder can cause symptoms such as heartburn, indigestion, loose stools or cramping.  These can be managed but are certainly a nuisance.
So if you’re getting symptoms that make you wonder about this little 3 inch sack, see your doc and get it checked out.  It’s helpful when it’s healthy; but if it’s betraying you, it just might have to go.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835



Today my first patient was my own co-worker. He was walking gingerly toward me holding his abdomen and wincing. “Could you check out my abdomen, I was up most of the night with pain.”

As I pressed around his abdomen, the left lower quadrant was obviously the tender spot. A few more questions and labs showed no diarrhea, but nausea, a high white blood count and a fever. Judging from the marked pain in his abdomen from even light pressure, it was soon obvious my co-worker was going to be heading home and downing some antibiotics.

So, what did his symptoms indicate? Diverticulitis. Let’s look at some terms: diverticulosis refers to having little pockets off of the bowel, most commonly the colon. They are usually the size of a small marble and approximately 10% of Americans over the age of 40 have them. But as we age, the condition becomes even more common so that over half of people older than age 60 have them and by age 80 two-thirds of individuals have diverticulosis. If these pockets aren’t infected or bleeding, people often don’t even know they have them. Occasionally they cause some lower abdominal bloating, bleeding, constipation, or, less often, diarrhea.

In developed countries such as the United States the typical diet is low in fiber and high in highly processed carbohydrates. This diet causes harder stool and slower transit time through the colon, which in term increases the pressure inside the colon. The current theory is that over time this results in out-pouchings along the colon. So, in countries with this kind of low fiber diet, diverticulosis is common.

If someone has these little pockets (diverticulosis) and they get infected, it’s then called diverticulitis. Now this patient can have all the symptoms we’ve mentioned, with left lower abdominal pain being the hallmark. In fact, diverticulitis is sometimes called “left-sided appendicitis” because it hurts like appendicitis but usually occurs on the left side of the abdomen instead of on the right side where appendicitis would occur. However, diverticulitis can sometimes affect the right side of the colon as well.

If you happen to know you have diverticulosis, usually due to having had a colonoscopy (but also visible on other tests such as a barium enema or sigmoidoscopy), what can you do to avoid attacks of diverticulitis? A high fiber diet seems to be key. The average American gets 15 grams of fiber daily, but the recommendation is for 25 grams daily for females, and a whopping 38 grams for males. This comes from sources such as whole grains, legumes, seeds, nuts, and vegetables.

There used to be a theory (and it is still often repeated) that nuts, seeds, corn, and popcorn increase the likelihood of diverticulitis attacks. But subsequent studies have not borne this out, and a 2008 study actually showed that diets higher in nuts and seeds had a lower incidence of diverticulitis. Besides a higher fiber diet, drinking lots of water, and if you’re prone to constipation, using a daily fiber supplement can be helpful.

If, despite your best efforts, you start feeling lower abdominal pain, especially on the left side, it’s time to have your doc check you out. Blood work, and occasionally some imaging by x-ray or CT if needed, can help diagnose the problem. A combination of antibiotics along with bowel rest (fluids only) for a few days will usually allow the problem to pass. However about 50% of people who have one bout of diverticulitis will get one or more recurrences in the future. Occasionally the frequency and severity of attacks is so great that surgery is recommended to remove the worst section of colon. Another uncommon complication is where a diverticulum ruptures allowing stool into the surrounding abdominal cavity and causing a severe abdominal infection. Severe pain and fever results and hospitalization is needed.

So, when you’re wearing shorts or pants, it’s handy to have pockets; in your colon… not so much. And if those colon pockets start holding on to some nasty, infected stuff, it’s definitely not handy. So like your mama told you, eat your vegetables and drink lots of water, and don’t be afraid to toss in some nuts, seeds and whole grains.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835