I am Mary's Gall Bladder

This article was to be written in the old style of the readers digest articles. The ones that, in the old days, would explain organ function in simplistic terms. I have modified that idea somewhat. (editing will be complete in 24hrs)

I am writing it because my daughter has been diagnosed with cholecystitis. She has one very large stone that at the present time is not completely obstructing bile flow. It has been causing moderate to severe pain for 4 months. The frequency of the pain, has increased in the past several months. ..The pain is classic, upper right quadrant. It radiates to the back. She has also had some nausea and vomiting. She didn't tell us about her symptoms right away. Kids keep secrets like this for too long. I suppose because they fear their parents will "make a big deal. " Kids don't like big deals.

The pain level can range up to 8 on a scale of 10. Mary says her pain has caused many sleepless nights. Sometimes position changes eased it. The cause of the pain is a Gall stone and it is causing inflammation in the Gall Bladder, and in bladder common duct.
At times it is brought on by food. Fatty food.

Gall stones can occur in all age groups, there is a higher incidence in females than there is in men. A higher incidence in obese persons than those of normal weight. Proclivity to develop stones that result in bladder inflammation is apparently genetic.

The stone was visualized by ultrasound. There were two visualization tests done. The second test was a HIDA scan - which involved radioactive dye, and cat scan like imaging - I believe, I will check that (how it works) The stone was visualized/ localized very clearly with that scan using that dye. the stone was quite large. "a probable cholesterol stone" It would seem paradoxical that Mary was given Morphine during the HIDA scan...unfortunately pain relief is difficult , narcotics are given to induce an attack on purpose. Not to relieve pain. That induced attack helps for visualization for HIDA scans. Morphine probably causes the gall bladder to contract around the stone by sympathetic, or parasympathetic nerve stimulation.

But, after gathering lot of information:from general lab work: liver enzymes, pancreatic enzymes, fasting cholesterol lipid profiles, and ultra sound results, and HIDA scan - a few days ago - we went to see a surgeon at Boston Children's Floating hospital, on the recommendation of a GI specialist. I was not happy about the idea of surgery. And I was hoping for conservative treatment, breaking up the stone with ultrasonic waves so she could pass it, laprascopic removal. with lifestyle changes.

My wife and I went with Mary, who is 19 years old. She brought a friend with her too. Her doctor did a brief exam. He was mostly probing, to see what kind of pressing, brought on discomfort. We sat behind a screen, but we could tell he'd hit the spot. The location of the stone. After the exam, there was some discussion. As Mary's dad, I had one very focused question, as I am a nurse. Here's what I asked, hoping to hear about numerous options: "Given what we have in terms of testing, of a total 100 GI people 50 specialists and 50 GI surgeons, how many would recommend cholecystectomy, versus Stone removal only (along with lifestyle changes. low fat diet, weight loss,) "How many would recommend the conservative approach - stone removal"
He said:
" Zero."
The conservative options were out the window. It meant gall bladder removal.

It wasn't the option I wanted to hear. But I didn't have any other questions at the time, except that I had some concerns about risks: In particular, bleeding risks.The thing that worried me most was risk nicked blood vessels. There are major vessels in that area. I was satisfied that this surgery took that risk into account and that over the years, the surgery has been perfected. I remember a woman dying when an the aorta was nicked during open surgery for gall bladder. This was a memory from when I was an orderly in community hospital in the 1980's.. The biggest vessel this doctor was focused on, was the cystic artery, it feeds the gall bladder. He went into some detail about how the problem of bleeding risk would be decreased. I was also relieved to hear that the surgery can be done by laprascope. The gall bladder is teased out through a small incision after the major vessel is clipped with titanium That means no big incision, in the old days, there was a significant abdominal wound, requiring a lengthy hospital stay to manage pain and wound care.. He said conversion risk was 10 percent, that they'd have to open the abdomen.
My daughter asked me what the gall bladder does,and even though I didn't explain it to her in quite this way, as a literary exercise, and for sake of deference to those old readers digest articles, I will use that device. I am personifying Mary's gallbladder.,

I am Mary's Gall Bladder

I sit beneath her liver. I am a small sac that feeds bile through the common bile duct into the duodenum of Mary's digestive tract - it begins just beyond stomach.
So why I am I so special? To understand me better, we have to go all the way back to Mary's bone marrow. And even though that doesn't seem sensible, it needs to be done. We'll make it brief, so that you can understand me better.
When we go back to Mary's bone marrow we will see new red cells are kicked out every day. They deliver oxygen to everybody in here. To every cell, to every organ. Including me. But like people, they get old and tired and after a long life of 120 days they retire
to Mary's spleen, where they have a little rest, and then they leave this world. Their bodies are not wasted. They are broken down in the spleen, into hemoglobin fractions and then they are turned into bilirubin.

Bilirubin is not a Jewish kid from the Bronx. It's a chemical compound residual , made by little biochemists in the spleen. They package it with Albumin because otherwise, it is not soluble in blood. Albumin gives the bilirubin a nice balanced electric charge so the molecules of the albumin/bilirubin complex are suspended nicely in the blood.That is called Unconjugated bilirubin. That is transported into the liver, where it is conjugated into direct bilirbin. The total amount of bilirubin in the blood should remain fairly steady as bilirubin can damage cells.

In mononucleosis, for example, it can stain teeth yellow if the liver is too involved. In new born babies, whose blood cells are subjected to the mothers antibodies developed by the immune system, from the blood of the first child, washed into the mothers blood stream years before - can result in jaundice. Bilirubin is released into the new baby's blood stream, coloring the skin and eyes yellow. Bilirubin can cause a problem then. Putting the baby under lights, can break the bilirubin down. Bilirubin is essentially toxic. In advanced liver disease, we see high bilirubin levels, because the liver cannot process it - It does damage to brain cells. And we get encephalopathy.

But in a healthy young person, such as Mary, these levels stay pretty much normal. Anyway before she got this nagging gall stone. bilirubin would enter me. the gall bladder, in conjugated form. Here it combines with salts, cholesterol, and other compounds and bile is made. Bile is a .A green chemical

This bile is important:. Because....as Mary eats a greasy pizza, it will play a role in breaking down fat..

Mary chews the pizza first and the fatty cheese. She swallows it partially broken down.. It is ground up by her stomach to some extent, but not by much (the stomach does a number on protein) and the fat passes into duodenum. This is when I go into action. Bile comes from me down my common bile duct into the intestine to cope with the fat. - the small intestine. That's when the gall bladder ( That's me!) is stimulated. I squeeze green bile into the duodenum. My Bile pummels fat. What were globs of fat become globules and smaller bits.of fat. Then fat moves more distal down into the intestine, and it is broken down into finer bits called chylomicrons - the result of chemical action from the pancreas. The pancreas is my next door neighbor, it lives in the mid to upper quadrant of Mary's abdomen. Mary has no pain there, and that organ is working fine.
Pancreatic lipase and bile break down fat. Eventually into particles so small, they can be absorbed into the intestinal lining - and used as energy or it will get stored, in fat cells.

Sadly, my life and usefulness is cut short. Because, like Mary's grandmother who developed gall bladder disease at the same age, I have a big gallstone. It is made of cholesterol and it will not pass through the sphincter at the end of me, into the duodenum. It is inflaming my endothelial cells. And I could could get infected. Conjugated bilirubin could back up into the blood stream and cause problems like it does in other diseases. Jaundice.

Mary thinks I'm a pain.


So, I have to come out. Woe is me. It's been nice knowing you Mary.


****
Ok, well, I ve got the readers digest out of my system. That is the brief on the gall bladder. The circuit of fat metabolism, or part of it, was explained to Mary something like this -when she asked. A 19 year old girl is at sea when comes to things going wrong with her body. As her dad I am a bit worried. I was hoping for a more conservative approach. But I feel good about a few things. The hospital is great, and her doc is pediatric surgeon, and he has a good feel. I will let you know how things turn out. One question I have, is this: Absent bile, how does fat get broken down. Is there some type of shunt from the liver, where does the bile go? What happens to the bilirubin. When I find out the answers, I will let you know. I never claimed to know everything. Even though Mary's primary who has known her 19 years, calls me "The Professor."

No it is a term of endearment. Her primary is great. He is used to my questions, and he likes them. We kept each other sharp. His Name is Doctor Howard Rashba. Howard, has helped me raise my kids for 20 years. And, I would like to take this opportunity to thank him. Dr. Rashba, is like family in some sense, and the concern, diligence, vigilance he has shown my kids when they were distressed, sick - has been outstanding. He isn't just a good doctor, he is a dedicated doctor, a personal physician in a sense. He has seen my kids grow up, he knows them - he asks about the other, who is not in his care anymore, Matthew. He asks about me, or my wife. Dr. Rashba feels like family. God Bless Him, because his breed is increasingly more rare. Soon Mary too will be too old to see him, and makes me sad, but grateful. Dr. Rashba practices in Reading, Mass.
There's a decent image of the gall bladder here:

I have found information about life after gall bladder surgery

And a description of the laparoscopic Procedure

Since I wasn't present when the HIIDA scan was done, I've found out today, the imaging tracks bile flow throughout the hepato biliary tract, conduction through the liver, the duct entering the gall bladder, the lower excretory duct (common bile duct.) I am researching more on the surgery itself, and how bile is handled, post op. And how the mechanics of fat absorption are affected in the absence of this bladder:recommended diet etc. Since i am very aware that the gall bladder is not vestigial - I am wondering how this disruption affects the rest of the body over time, in terms of how people should eat. (That information was found, see above)

Post Note

Getting people in my house to change difficult, my wife took Mary out for eggs this am. And, this irritates me, that she doesn't see how important it is now - to avoid that type of meal. Education can't come from me, it has to come from post op follow up....otherwise, because I have a wife who feels food is love, and many women do, we get rebellion if it come from me. I am sure many women realize that they have a problem with food, and that they communicate it to their children. This isn't a universal statement, but it is true, often true, that behind too many over fat kids, is a mother who rewards their children with food. Many Mothers, who mean well, can't see that they are killing them with kindness, setting them up for health problems later in life. Food is food, love is love. So, I've committed an abomination, I've chastised mothers on Mother's Day.

Test Question for nursing students, and lab tech students:

Since bilirubin continues to get conjugated even in the intestine, what does it mean, if urobilinogen turns up in the urine in high amount? Hint: uro bili in some amount is normal, too much is indicative of a problem, and so is too little. The answer can almost be figured out, it you realize that, along with fat moleculres, excess bilirubin is absorbed into the intestinal lining too, and is excreted in the urine. Too little bilirubin getting into the intestine, means what? Since nurses sometimes do dip sticks on urine, while looking for something else, sugar, or ketones, white cells - they may ignore a too high or too low bilirubin (urobilinogen). Pay attention to all the reactions on the strip.

Update: Mary had her gall bladder out Friday, July 1 2011. The surgery was an unqualified success, she was home next day. Laprascopic removal was successful, no major incisions were necessary. This is a big relief. Second day post op, she is a little sore. But no major issues. We are all glad this is over. Incidentally, I found out where teh bile goes. The ducts that conduct bile to the small intestine are not removed. If those are visualized as two pipes with a ball attached (representing the bladder) only the "ball is removed. So bile is still available to emulsify fat.