Disorders of the Gallbladder, the Pancreas, and the Liver
The gallbladder has a single, nonessential role in digestion: it stores bile pro- duced by the liver until it is needed in the duodenum to digest fats. Both the pan- creas 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 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.
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 com- position 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 gall- stone. 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.
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.
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- tive enzymes from the pancreas may ﬂow backward and cause pancreatitis (see below). Symptoms of a stone-related blockage include fever, jaundice (yellow- 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. Special- ized 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 gall- stones 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.
The pancreas is a large gland located behind the stomach and close to the duo- denum. The disease most commonly associated with the pancreas is diabetes. However, the pancreas can become inﬂamed when the digestive enzymes it pro- duces 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 gradu- ally, 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 pan- creas) 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
Asurgeon 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 instru- ment 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.
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.
pancreatitis usually will clear up on its own. However, most people with acute pancreatitis will need to be hospitalized to receive intravenous ﬂuids and elec- trolytes to replace those lost through vomiting. Narcotic analgesics such as codeine are prescribed to relieve pain. Future attacks can be prevented by treat- ing 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 con- dition of the pancreas. The disease is treated (but not cured) with pain medica- tion, 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 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 symp- toms 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).
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), malnutri- tion, 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 con- fusion 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 cir- rhosis, a liver transplant may be required.
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 hepati- tis 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 fever, nausea, vomiting, loss of appetite, weight loss, weakness, mild abdominal pain, muscle and joint aches, and diarrhea. People with chronic hepatitis often 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 unpro- tected 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. Vac- cines 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 peo- ple 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 expo- sure 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
• 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
they cannot damage your liver. Your doctor will recommend that you rest, eat a well-balanced diet, and avoid alcohol.
Other Gastrointestinal Disorders
The following less common disorders of the digestive system affect men far more frequently than women:
• Primary sclerosing cholangitis. Primary sclerosing cholangitis is a rare con- dition that occurs most often in young men and often is the result of inﬂam- matory bowel disease such as ulcerative colitis. With this disease, the bile ducts (the tubes that carry bile from the liver) inside and outside the liver become narrowed due to inﬂammation and scarring. This causes bile to accu- mulate in the liver, which, in turn, damages liver cells. There are no initial symptoms, and the disease is usually detected by chance through a routine blood test for liver function. Symptoms develop between ages 30 and 50 and include fatigue, itching, and jaundice (yellowing of the skin and the whites of the eyes). Specialized tests are needed to conﬁrm the diagnosis. No speciﬁc treatment exists for this progressive disease other than treating symptoms; cholestyramine may be prescribed to relieve itching.
• Hemochromatosis. Hemochromatosis is an inherited disease in which the body absorbs and stores too much dietary iron. The excess iron accumulates in the liver, pancreas, heart, testicles, and other organs, where it damages sur- rounding cells. The disease can result from excessive iron absorption (such as from having frequent blood transfusions) but usually is caused by a genetic error. Hemochromatosis is most common among men of northern European descent. The disease is diagnosed with blood tests to measure levels of iron in the blood and a liver biopsy. Symptoms usually appear during middle age and include weakness, weight loss, joint pain, and abdominal pain. The disease eventually causes changes in skin pigmentation (bronze coloration), liver damage, diabetes, and cardiac arrhythmia as it progresses. Liver failure or liver cancer may result. The disease cannot be cured, but its progression can be slowed through regular removal of blood (phlebotomy), such as by routine blood donation.
If you have symptoms of a digestive disorder, your doctor may need to use one or more of the following diagnostic procedures to examine your gastrointestinal tract and determine the cause of your symptoms. Your digestive tract must be empty before undergoing any of these procedures. For an examination of your esophagus, stomach, or duodenum, you will need to fast (abstain from food and drink) after midnight the night before the procedure. For an examination of your
ileum, colon, or rectum, you will need to follow a special liquid diet beginning at least 2 days before the procedure and then fast the night before the procedure. All of these examinations are usually performed on an outpatient basis.
• Gastrointestinal series. A gastrointestinal (GI) series is an examination that is used to diagnose or monitor problems in the digestive tract. An upper GI series examines the esophagus, stomach, and duodenum; a lower GI series examines the colon and rectum. These examinations are used to identify blockages, growths, ulcers, inﬂammation, and other structural abnormalities. Both procedures use barium sulfate to coat the lining of the digestive tract and provide clear images of the digestive tract on a ﬂuoroscope (a special video monitor) or on X-ray ﬁlm. For an upper GI series, you drink a barium mixture (a thick, white, chalky liquid called barium meal or barium swallow); for a lower GI series, a barium mixture (called a barium enema) is injected into the colon through the anus and rectum. You may be asked to change positions dur- ing the examination as the barium reaches different locations in your digestive tract. Usually you can go home immediately after the procedure and should experience no side effects other than constipation and white or gray stools until the barium is completely out of your system.
• Endoscopy. Endoscopy is a diagnostic examination in which a doctor uses a long, thin, ﬂexible lighted tube called an endoscope to look inside the esoph- agus, stomach, and duodenum. You will be awake during this procedure, but before the examination begins, your throat will be sprayed with a numbing agent so you do not gag when the endoscope is passed down your throat. You also will receive pain medication and a sedative to help you relax. The endo- scope has a precision optical system that works like a video camera, allowing the doctor to see inside each organ as it travels through the digestive tract. The endoscope also can blow air into the digestive tract to inﬂate it and make it easier to examine. Tiny surgical instruments then can be passed through the endoscope to remove tissue for microscopic examination. This procedure is usually brief—about 20 to 30 minutes—but you will need to lie quietly after- ward at the doctor’s ofﬁce for an additional hour or two until the sedative wears off. You may have a sore throat after the procedure.
• Endoscopic retrograde cholangiopancreatography (ERCP). This diagnostic procedure allows your doctor to examine your liver, gallbladder, bile ducts, and pancreas using an endoscope. In ERCP, the initial steps are the same as those described for endoscopy. However, when the endoscope reaches your duodenum, the doctor injects contrast medium (a type of dye) through the endoscope and into your bile ducts. X rays are taken as soon as the contrast medium is injected. If the doctor sees a gallstone or narrowing of the ducts, he or she can pass tiny surgical instruments through the endoscope to remove the obstruction or widen the duct.
• Colonoscopy. Colonoscopy is a diagnostic examination of the entire length of the large intestine, from the rectum all the way up through the colon to the ileum. Colonoscopy can be used to look for polyps in the colon or to diagnose colon cancer. The procedure is performed with a special type of endoscope called a colonoscope. Before the procedure, you will receive pain medication and a sedative to help you relax. While you lie on your left side, your doctor will insert the colonoscope into your rectum and guide it up through the entire large intestine. As the doctor slowly withdraws the colonoscope, he or she examines your colon directly through the colonoscope or on a video monitor. Air can be blown through the colonoscope to inﬂate the colon and give the doctor a better view. Instruments can be passed through the colonoscope to take tissue samples or to remove polyps. If there is any blood in the colon, your doctor can use a special instrument or drug to stop the bleeding. Colonoscopy usually takes about 30 to 60 minutes, and you will need to lie quietly for an additional hour or two after the examination. Because of the medication you have been given, you should make arrangements in advance for someone to take you home after the procedure.
• Sigmoidoscopy and proctoscopy. As an alternative to a colonoscopy, your doctor may use a type of endoscope called a sigmoidoscope to examine only the rectum and the sigmoid (lower) colon. Or your doctor may use a type of endoscope called a proctoscope to examine only the anus and rectum. These procedures are similar to colonoscopy, but they examine only a limited por- tion of the gastrointestinal tract, and each procedure takes only about 10 to 20 minutes.