Gallstones and The Gallbladder: Who Needs Them?

Dr. Robert Kurrle, M.D., Senior AME

Everyone is born with a gallbladder. Why do we have one? Can we do without it? What does the FAA think?

The gallbladder is a sac, about the size and shape of a pear that lies just beneath the liver in the right upper abdominal cavity. The liver produces bile, which helps digest fats and cholesterol with enzymes from the pancreas. The liver is connected to the small intestine by a duct. The gallbladder connects to that duct by a "T" connection. As bile is produced by the liver, it is stored in the gallbladder until it is needed. Hormones in the stomach signal the gallbladder to contract forcing the bile out of the ducts into the small intestine. Small muscles at the base of the ducts constrict to act like valves to direct the bile flow. Bile contains bile salts, cholesterol, bilirubin, and lecithin. About three cups of bile are produced each day.

Gallstone disease is a common medical problem that affects more than 25 million people in the US. Gallstones (cholelithiasis) are precipitates from the bile that form in the gallbladder. Most are composed of cholesterol (75%), with much of the remainder bilirubin. They can range in size from a grain of sand to as large as a golf ball. Often several are present. If large enough, the gallstones can block the outflow of bile from the gallbladder and cause pain, infection, and inflammation (cholecystitis). Stones can also lodge and block the common duct just before the small intestine. This blockage can lead to inflammation, infection and even pancreatitis.

Symptoms of a blockage can include a steady pain in the right upper quadrant. This often occurs about an hour or more after eating, usually at night, and especially after a fatty meal. Acute gallbladder inflammation (cholecystitis) begins abruptly as pain and tenderness in the right upper abdomen and is accompanied by a fever. It generally continues until treated with medicine or surgery. This is a more serious problem. Most people with gallstones, however, have no symptoms because the stones are not forming a blockage.

No one knows why some people develop gallstones and others do not. We do know, however, that some people are more at risk than others. Women are about three times as likely to develop gallstones as men. Gallstones are unusual under age 50. Obesity, rapid weight loss, high fat diets, and some medicines, including birth control pills and cholesterol lowering drugs, can lead to the formation of gallstones.

Diagnosis is made with a medical history, blood tests, and ultrasound or other imaging techniques. Asymptomatic gallstones (most cases) require no treatment. They are usually discovered coincidentally from imaging being done for other reasons. Mild symptoms may be treated with dietary restriction and observation. When recurrent gallbladder symptoms exist, both surgical (cholecystectomy) and medical treatments are available. Surgery removes both the gallbladder and the stones. Bile can no longer be stored in the gallbladder and is secreted directly into the intestine by the liver. This seems to work fine. There are two main types of surgery. The traditional surgery involves a large five to eight inch incision just under the right rib cage, a several day hospital stay, and many weeks of recovery. Laproscopic surgery was introduced in 1998 and involves small ½ inch incisions for the laproscope, an overnight stay and a few days of recovery. It is now used in 90% of cholecystectomys. Each has advantages and your physician will recommend the appropriate method. Alternatives to surgery include endoscopy, medicine to dissolve the stones, and lithrotripsy to breakup the stones, although the stones often will return. Only about 10% of patients are candidates for medical treatment.

The FAA policy for pilots with gallstones is pretty simple. If surgery is required, the pilot may return to flying once healing is complete and the surgeon has released him/her to full activity. The surgery is then reported at the time of the next airman medical on line 18x, "surgery". If the gallbladder is inflamed, but does not require surgery, the pilot should not fly until the symptoms subside. When chronic inflammation exists, the pilot should not fly until definitive treatment is complete. Again, report episodes at the next airman medical. If the pilot has gallstones that are aymptomatic, he/she may continue to fly. Remember to watch your fat intake. Happy flying!