Friday, December 30, 2011

DO NOT OPERATE OR OPERATE? That is the question

Always working and silent, the gallbladder is where bile is stored, a greenish liquid, bitter and slimy, secreted by the liver and that, through its own system of channels, led to the duodenum, participating in important ways from digestion. But sometimes, a dysfunction, there is a change in the production of bile, precipitating the formation of crystals, which, little by little, get bigger and give rise to so-called gallstones. Most people who have no symptoms calculations. Although laparoscopic surgery is widespread, it is only indicated in certain cases. What is the development of asymptomatic gallstones? The frequency of symptoms and complications of gallstones discovered by chance is relatively small. In general, those who have gallstones never have symptoms or complications arising from calculations asymptomatic gallstones. Still, many researchers have been trying to establish which patients could biliary disease throughout his life. To our knowledge, there seems no relationship between symptoms and age, sex and number of calculations. So far, there is consensus that the evolution of the calculations without symptoms is benign and requires no intervention. What is the development of symptomatic gallstones? On the other hand, since the calculations cause typical symptoms of biliary disease, the risk of persistence of these problems is relatively high. Moreover, most of the complications of gallstone disease is preceded by an attack of biliary colic. Therefore, once the patient has presented biliary colic, the trend is that these episodes are repeated until they culminated in a complication, if nothing is done. Because biliary colic is expressed? The main complaint of patients with biliary colic symptoms is. Most clinicians agree that biliary colic - the most characteristic symptom of gallstones - is not an appropriate name because the pain is crampy. Rather, it is a very intense and continuous pain in upper abdomen, and during which alternate periods of worsening and improvement. This pain lasts from 15 minutes to hours and is commonly accompanied by nausea and vomiting. Evolves, often without precipitating factors. The interval between episodes can vary from days to months or even years, and, rarely, daily symptoms can be attributed to gallstones. The biliary colic must be differentiated from nonspecific symptoms that characterize functional dyspepsia. Gas, heartburn, abdominal discomfort, intolerance to fatty foods are frequent complaints in clinics. However, both occurring in patients with stones and in patients without gallstones. This differentiation is critical to successful treatment, since this is only indicated for biliary colic. In the episode of uncomplicated biliary colic are not detected changes in laboratory tests. The main test to confirm the diagnosis of gallstones is the abdominal ultrasound. What are the main complications of gallstones? When the frame persists for more than six hours, the suspicion of acute cholecystitis should be dismissed. Most patients with acute cholecystitis have previous episodes of biliary colic. The pain of acute cholecystitis is more prolonged, may be located precisely on the right side of the upper abdomen and is associated with fever. In the presence of acute cholecystitis, the gallbladder wall is thickened on ultrasound examination. Once the gallbladder becomes inflamed, signs of infection and elevated liver enzymes appear in blood tests. In some patients, the calculations can escape from the vesicle. If they are small, can go straight from the bile ducts into the intestine, leaving the faeces. If you are a little bigger, can become lodged in the bile ducts, causing complications such as jaundice, cholangitis or pancreatitis. The obstruction of the passage of bile results in jaundice (yellowing of the skin and whites of the eyes) and itching. Calculations in the main bile duct are often associated with infection, resulting in severe acute cholangitis framework, which is characterized by biliary colic, jaundice, fever and chills, requiring urgent treatment. Acute pancreatitis (inflamed pancreas) can also be caused by the passage of the bile duct calculations. Some experts recommend the removal of the gallbladder with calcified walls (also called porcelain gallbladder) the risk of developing gallbladder cancer. Although calculations large (greater than 3 cm) can be associated with gallbladder cancer, withdrawal prophylaxis is still controversial. What is the best treatment option? There is a consensus that asymptomatic calculations should not be treated. Only the calculations with symptomatic or complications and the calcified gallbladder should be treated. The options include surgery (cholecystectomy), dissolution or fragmentation of the calculations. Cholecystectomy is the only definitive treatment. It is a simple, safe, and suitable for most patients with stones. Currently, laparoscopic cholecystectomy facilitated the procedure with a shorter hospital stay, fewer complications and quicker return the patient to your routine. It is for this reason that cholecystectomy is now chosen by the majority of patients with gallstones. However, in about 5% of cases and in the presence of complications, conventional cholecystectomy may be a better option. The non-surgical treatment is reserved for patients who do not want to undergo surgery or have a very high surgical risk. Importantly, both dissolution and fragmentation of the calculations are not definitive procedures. Because the gallbladder is not removed, the calculations can, over time, reappear. The calculations present in the bile ducts can be removed through an endoscopic procedure called endoscopic retrograde cholangiopancreatography (ERCP). This test may be performed before, during or after cholecystectomy. Symptoms may persist after cholecystectomy? The persistence of symptoms after cholecystectomy should be observed and discussed with patients before subjecting them to surgery. Many doctors tend to indicate cholecystectomy before the occurrence of specific symptoms such as intolerance of fatty foods, gas, belching, heartburn, nausea. Although some patients may improve these symptoms after surgery, several studies have shown that these may be present in the presence or absence of gallstones, and therefore are not specific to biliary disease. Performing a cholecystectomy just to see if symptoms improve is not recommended. In addition, cholecystectomy is not an innocuous procedure and may lead to other symptoms such as diarrhea after cholecystectomy. The wide spectrum of clinical presentation, the possibility of improvement in some patients and the facility provided by the laparoscopic cholecystectomy, surgery could even occasionally be indicated in patients with such symptoms, provided that they are intolerable, have negative investigation for other causes, or the subject has been previously discussed with the patient and has even accepted the possibility that the symptoms are not relieved by surgery.

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