Among the most common conditions that affect the elderly population are those of the gallbladder and the common bile ducts (CBD). According to the University of Michigan Health, bile duct stones are gallstones in the bile duct. They can start in the gallbladder and migrate into the bile duct or they can form in the bile duct itself.
A review in the BMJ says that with age and the passage of time, asymptomatic gallstones are a common feature of gallbladder dysfunction. The increasing formation of stones also predisposes the gall bladder of the elderly to various diseases.
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The longer one has gallstones, the more likely one is to develop various ailments related to this. Most doctors find it challenging to tackle this issue mostly about whether and when to operate, along with the associated complications that old age brings about.
Dr Manish Kak, consultant, gastroenterology, Manipal Hospitals, Ghaziabad, explains how CBD stones are formed. “The gallbladder evacuates its bile through the cystic duct. So, we have a system where there is bile coming from the liver that is stored in the gallbladder and then it is released into the intestines. Now for the gallbladder to receive this bile from the liver and drain it further into the intestines we need this structure known as the common bile duct,” says Dr Kak.
“When we have gallstones, what happens is that in ten per cent or twenty per cent of people these slip down through the cystic duct and then into the bile duct. So it becomes a CBD stone. This happens when the stone size is small or if there is sludge or sand in the gall bladder stone which has a tendency or space to move down into the bile duct. Now if the stone is large, the chances are less. This condition is called choledocholithiasis,” says Dr Kak.
What causes gallstones?
Some studies say that a very low fat and rapid weight loss diet in people with obesity could lead to gallstone formation.
Other reasons could be the use of birth control pills or hormone replacement therapy and pregnancy. Family history, diabetes, sudden weight loss, sickle cell disease, cholesterol drugs and old age can also increase the risk for gallstones.
Some of the most common symptoms of gallstones are abdominal pain, nausea, indigestion or fever.
“It could be silent or there could be pain, dyspepsia or a burning sensation behind the chest bone or some heaviness after consuming food. If this stone comes down into the bile duct, it can lead to severe pain and previously there may not be any symptoms. Even dyspepsia may develop suddenly,” says Dr Kak.
He adds that the affected person may land up with cholangitis, which is an inflammation in the bile duct.
“It can go lower down too and cause a block in the pancreas. That can lead to acute pancreatitis,” explains Dr Kak.
He also points out that in rare cases in older women, the gallstones might migrate into the small intestine and block the passageway into the large intestine with symptoms like severe and frequent vomiting. This can prove to be a dangerous condition.
Gallstones diagnosis and treatment
One can get it diagnosed by going in for an ultrasound or a liver function test (LFT). If an increase in bilirubin, liver enzymes and jaundice is noticed, it could point to the presence of CBD stones.
A study published in the Korean Surgical Society, in 2011, explored LCBDE (laparoscopic common bile duct exploration is a minimally invasive method of treating choledocholithiasis.) as a first treatment strategy, for the geriatric population versus the younger population. From January 2000 to November 2009, 132 patients underwent LCBDE. The study concluded that LCDBE is a safe and effective treatment modality for CBD stones not only for younger patients but also for elderly patients.
Dr Kak explains, “Sometimes, CBD stones cannot be seen in an ultrasound, so an MRCP (magnetic resonance cholangiopancreatography) test is done. This is a type of MRI used to detect the different diseases around the liver, pancreas, gallbladder, bile ducts and pancreatic duct. It produces a detailed image of the organs and based on the images, the tissue and their structures are analysed.
And if there are even more complications and the stones cannot be seen, then an endoscopic ultrasound is needed to see small sludge, stone or sand that exists in the lower regions of the bile duct that opens into the intestines. The treatment is usually an ERCP (endoscopic retrograde cholangiopancreatography).”
Can stones in the CBD be prevented?
Dr Amit Jain, gastrointestinal surgeon at Max Super Speciality Hospital, Vaishali, Ghaziabad says that, unlike kidney stones that may be prevented by even simple methods such as drinking a lot of water, CBD stones are not that easy to prevent or even dislodge. For the elderly, that can become a more serious issue. So immediate diagnosis and removal is the prime need of the hour.
“There are various methods advocated such as cutting down on high-fat diets, increasing fibre in daily foods or attaining an ideal body weight, yet most of these measures are not foolproof as people can get CBD, despite it all,” says Dr Jain.