Disorders of the Gallbladder the Pancreas and the Liver

The gallbladder has a single, nonessential role in digestion: it stores bile produced by the liver until it is needed in the duodenum to digest fats. Both the pancreas and the liver help regulate metabolism (the chemical processes that take place in the body) and have essential roles in digestion. The pancreas releases hormones and enzymes critical to the breakdown of proteins, carbohydrates, and fats. The liver, one of the most complex organs in the body, performs more than

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5,000 life-sustaining functions. It produces, monitors, recycles, and stores a wide range of chemicals that are essential for life. Everything that is absorbed by or injected into the body is filtered through the liver, which removes toxins and other potentially harmful substances from the blood. Unlike other organs, the liver receives blood from two sources: the hepatic artery, which supplies fresh, oxygenated blood, and the portal vein, which brings blood directly from the digestive tract for filtering before it goes on to the heart and the lungs. If the liver does not function properly, the consequences can be life-threatening.

Gallstones

The gallbladder is a small, pear-shaped sac beneath the liver where bile is stored and concentrated. Gallstones can form when an imbalance in its chemical composition causes the bile to harden into solid pieces. If the bile contains too much cholesterol, a tiny particle can gradually grow into a gallstone as more and more material hardens around it. Cholesterol stones are the most common type of gallstone. Another type of gallstone, a pigment stone, is small, dark, and made of bilirubin (the major pigment in bile). There may be one or more gallstones in various sizes, from the size of a grain of sand to the size of a golf ball.

Cystic duct

To liver

Gallstones

Gallstones are solid lumps, consisting mostly of cholesterol, that form in the gallbladder. In some cases, a small gallstone passes on its own out of the gallbladder through the bile duct and out of the body in stool, causing no pain. But if a large stone blocks the cystic duct, which causes intense pain, both the duct and the gallbladder are removed surgically.

Gallstones

Gallbladder

Cystic duct

To liver

Gallstones

Gallbladder

Common hepatic duct

Common bile duct

To small intestine

Common hepatic duct

Common bile duct

To small intestine

The risk of developing gallstones increases with age. Obesity and frequent fasting also are risk factors. People who have diabetes or who take cholesterol-lowering drugs also may have an increased risk of developing gallstones.

A gallstone may block the normal flow of bile in the ducts that lead from the liver to the gallbladder and from the gallbladder to the small intestine. A backup of bile in these ducts can cause inflammation of the gallbladder, the ducts them-

selves, or (rarely) the liver. If a stone gets stuck in the common bile duct, diges- 277

tive enzymes from the pancreas may flow backward and cause pancreatitis (see Digestive below). Symptoms of a stone-related blockage include fever, jaundice (yellow- System ing of the skin and the whites of the eyes), nausea or vomiting, and constant, severe pain in the upper right abdomen. Pain also may occur in the chest or the back or between the shoulder blades.

If your doctor suspects that you have gallstones, you probably will undergo an ultrasound examination (see page 90), in which sound waves are used to create images of the abdominal organs. Blood tests also may be performed. Specialized procedures performed to more closely examine the gallbladder include cholecystogram (in which X rays are taken after a special iodine dye is injected or swallowed) and endoscopic retrograde cholangiopancreatography (ERCP; see "Diagnostic Procedures," page 282).

Surgery to remove the gallbladder is the most common treatment for gallstones that are causing symptoms. (Gallstones that are not causing symptoms usually are discovered by chance during an examination for some other reason and are usually left alone.) The surgery to remove the gallbladder is called a laparoscopic cholecystectomy (see box on next page). After the gallbladder is removed, bile flows directly from the liver to the duodenum. A medication called ursodiol is sometimes used to slowly dissolve small cholesterol stones. The drug is taken by mouth every day for 6 months to 2 years, until the stones are dissolved. However, this treatment does not always dissolve the stones, and it does not prevent their recurrence.

Pancreatitis

The pancreas is a large gland located behind the stomach and close to the duodenum. The disease most commonly associated with the pancreas is diabetes. However, the pancreas can become inflamed when the digestive enzymes it produces become activated and attack its own tissues. This condition is known as pancreatitis.

In acute pancreatitis, the pancreas suddenly becomes inflamed and then returns to normal. Most people experience only one attack, but the condition can recur. Acute pancreatitis usually is caused by alcohol abuse or by gallstones. An attack usually lasts about 48 hours and begins with severe pain in the upper abdomen. The pain may appear suddenly and be severe, or it may worsen gradually, especially after eating. The abdomen may be swollen and tender. The pain is often accompanied by nausea, vomiting, fever, and a rapid heart rate.

These symptoms are often sufficient to diagnose acute pancreatitis, but a blood test to check for high levels of amylase (an enzyme produced by the pancreas) can confirm the diagnosis. The doctor also may recommend a computed tomography (CT) scan or an ultrasound of the abdomen. Unless complications such as bleeding from the pancreas or infection in the abdomen occur, acute

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Laparoscopic Surgery surgeon can examine the abdomen and perform certain surgical procedures using a laparoscope (a viewing tube). The laparoscope is equipped with a precision optical system that sends clear images to a video monitor. Laparoscopic surgery can be used to remove an inflamed appendix or a diseased gallbladder.

For laparoscopic surgery, the patient is given general anesthesia, a small incision is made in the abdomen, and the laparoscope is inserted. Other tiny incisions are made around the abdomen through which tiny surgical instruments are inserted through instrument tubes. The surgeon inflates the abdominal cavity with carbon dioxide gas to provide sufficient room in which to examine the tissues and manipulate the surgical instruments. For laparoscopic cholecystectomy, the surgeon uses tiny scissors to cut the cystic artery and the cystic duct and to separate the gallbladder from the liver. He or she then seals off the blood vessels to the gallbladder, draws the gallbladder out through the incision beneath the navel, and stitches up the incisions.

Gallbladder

Liver

Gallbladder

Liver

Gallbladder removed through incision

Laparoscope

The surgeon performs the operation while viewing the inside of the abdomen on the video monitor. Usually the surgery is videotaped at the same time. The diseased tissue is removed through one of the instrument tubes. After surgery the patient will have only a small dressing over the incision. Often he or she can go home later that day and resume normal activities shortly thereafter.

Digestive System pancreatitis usually will clear up on its own. However, most people with acute pancreatitis will need to be hospitalized to receive intravenous fluids and electrolytes to replace those lost through vomiting. Narcotic analgesics such as codeine are prescribed to relieve pain. Future attacks can be prevented by treating the underlying cause.

Chronic pancreatitis is more common in men than in women and usually develops after many years of alcohol abuse. Symptoms are usually the same as those of acute pancreatitis, but the attacks become more frequent as the disease progresses. People with chronic pancreatitis experience pain, weight loss (due to malabsorption of nutrients), and diabetes (due to insufficient production of insulin by the pancreas). Blood tests and other procedures such as ultrasound scanning, CT scanning, or endoscopic retrograde cholangiopancreatography (ERCP; see "Diagnostic Procedures," page 282) can be used to assess the condition of the pancreas. The disease is treated (but not cured) with pain medication, insulin (to control blood sugar levels), and pancreatic enzyme preparations (to correct enzyme deficiencies). In some cases, surgery to remove the pancreas (pancreatectomy) is required to relieve pain. All people with either acute or chronic pancreatitis must stop drinking alcohol.

Cirrhosis

Cirrhosis is a progressive liver disease that results from long-term damage to liver cells. The liver is continuously exposed to potential toxins, including drugs (over-the-counter, prescribed, or illegal) and alcohol—all of which can damage liver cells over time. Eventually the tissue becomes scarred, which blocks the flow of blood through the liver, causing liver failure and portal hypertension (high blood pressure in the veins from the intestines and spleen to the liver). In the United States, cirrhosis is among the leading causes of death. Men are more than twice as likely as women to die of chronic liver disease and cirrhosis.

Heavy alcohol consumption is the most common cause of cirrhosis. Other causes of the disease include viral hepatitis, hemochromatosis (excess iron in the body), Wilson's disease (excess copper in the body), cystic fibrosis, blocked bile ducts, and adverse drug reactions. Cirrhosis does not always cause symptoms and may be detected during a routine physical examination (the doctor may feel an enlarged liver) or blood test (the test may reveal abnormal liver function).

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In the early stages of cirrhosis, some people may experience vague symptoms such as fatigue, weakness, exhaustion, loss of appetite, nausea, and weight loss. As the disease progresses, bile pigment builds up in the blood, causing jaundice (yellowing of the skin and the whites of the eyes).

Other common symptoms of cirrhosis include mental confusion due to a buildup of toxins in the brain, and hematemesis (vomiting blood) due to internal bleeding. In men, breast enlargement and hair loss may occur, possibly due to a sex hormone imbalance caused by liver failure. Possible complications of liver failure include ascites (accumulation of fluid in the abdominal cavity), malnutrition, and esophageal varices (enlarged veins in the wall of the esophagus), which can rupture and cause the person to vomit blood. Hepatoma, the most common form of liver cancer, is another possible complication.

The symptoms and signs of cirrhosis and the results of liver function tests (special tests of blood chemistry) are indicators of possible cirrhosis. However, a liver biopsy (removal of a small piece of tissue for microscopic examination) is required to confirm the diagnosis. To exclude rare causes of cirrhosis, special blood tests and cholangiography (X rays of the bile ducts) may be performed. Computed tomography (CT) scanning or magnetic resonance imaging (MRI) may be performed to evaluate the condition of the liver.

There is no cure for cirrhosis, so treatment focuses on slowing the progression of the disease and reducing the risk of complications. People with cirrhosis must not consume alcohol. Ascites may be treated with diuretics (drugs that increase urine production) and by restricting sodium (salt) intake. Portal hypertension may be treated with antihypertensive medication. Esophageal varices may be injected with a sclerosant (an irritant solution) to stop any bleeding. Mental confusion can be treated by reducing the levels of toxins in the bloodstream. This may require reducing the amount of protein in the diet, and taking antibiotics to reduce the number of bacteria in the intestinal tract. In cases of advanced cirrhosis, a liver transplant may be required.

Viral Hepatitis

Hepatitis is a contagious viral infection that causes inflammation of the liver. It is caused by one of the hepatitis viruses, A, B, C, or D. Most people with hepatitis recover on their own without treatment. Some people may experience mild recurrences over months or years. Still others may die of the infection. Hepatitis A and B are the most common types of viral hepatitis; hepatitis B, C, and D are the most dangerous. All donated blood and blood donors are routinely screened for all of the hepatitis viruses.

Many people with hepatitis experience no symptoms, and the disease may be detected during a routine physical examination because the liver feels enlarged or because a blood test shows abnormal liver function. A simple blood test is used to determine whether a person is infected with one of the hepatitis viruses.

Some people with hepatitis experience flulike symptoms such as fatigue, slight 281

fever, nausea, vomiting, loss of appetite, weight loss, weakness, mild abdominal Digestive pain, muscle and joint aches, and diarrhea. People with chronic hepatitis often System experience fatigue, joint aches, skin rashes, or memory loss.

Hepatitis A is spread through poor hygiene practices. It also is spread through contaminated food or water. The infection varies from mild to severe. Once you recover, you are immune to hepatitis A infection for life.

Hepatitis B is the most serious form of the disease. It is spread through unprotected sexual contact and sharing of contaminated needles by intravenous drug users. Many people who are infected with hepatitis B are carriers (they have the virus in their body but do not have symptoms) and can transmit the disease to other people. A woman can pass hepatitis B to her baby during childbirth. Vaccines are available to prevent hepatitis A and B. Your sexual partner should be vaccinated if you have hepatitis B.

Hepatitis C is spread primarily through sharing of contaminated needles by intravenous drug users. Symptoms of hepatitis C are similar to those of hepatitis B. In adults, the course of hepatitis C infection is influenced by several factors. In people who are older, the disease usually has a more rapid development. Many people infected with hepatitis C will develop severe liver disease, such as chronic hepatitis or cirrhosis, within 20 years of acquiring the infection. Rates of such disease are higher in people who are also infected with either hepatitis B or the human immunodeficiency virus (HIV). Even moderate long-term drinking of alcohol is associated with a higher likelihood of cirrhosis or liver cancer in people infected with hepatitis C. Certain forms of hepatitis C are not treatable. Other forms seem to be controlled with the use of antiviral drugs.

Your doctor will recommend that you be tested for hepatitis C if you:

• had a blood transfusion or organ transplant before July 1992

• were treated for clotting problems with a blood product before 1987

• have ever received long-term kidney dialysis

• had frequent ongoing exposure to blood products before 1987. (Recent exposure to blood products is not a risk because all blood products are screened for hepatitis C.)

• are a healthcare worker who was exposed to blood containing the hepatitis C virus

• are an intravenous (IV) drug user or former IV drug user

Hepatitis D usually is spread through sharing intravenous drug needles. It occurs only in conjunction with hepatitis B, and usually causes severe illness. There is no vaccine for hepatitis C or D.

Treatment of hepatitis focuses on controlling symptoms. Most people will recover within several weeks or months. Your doctor will want to know what medications you are taking (both prescription and nonprescription) to make sure

282 they cannot damage your liver. Your doctor will recommend that you rest, eat a

Common well-balanced diet, and avoid alcohol.

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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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