Fly Well

A rolling stone…

January 1, 2011

A rolling stone gathers no moss. Fast-moving stuff doesn’t get gunky; think engine oil or a swiftly moving stream. But what of bile? The liver makes a quart a day, which flows through bile ducts, tubes like tree branches, becoming a main trunk draining into our gut near the stomach. A side branch feeds the gallbladder, the villain of this article. This hollow, muscular, pear-shaped organ sits under the right ribs. Upon seeing, smelling, or tasting fatty food, bile stored and concentrated in the gallbladder squirts out, enabling digestion of yummy burgers and fries. This all goes horribly wrong when unfortunate patients build an internal abdominal rock garden. “Gut Wars: Episode 1, Attack of the Gallstones!”

Alexander of Tralles described finding “Dried up humors concreted like stones” in the gallbladder 1,600 years ago. In 1341 Gentile da Foligno of Padua reckoned stones caused the gallbladder containing them to look nasty (he saw this doing an autopsy, so everything looked nasty). Gallstones were first removed from a living patient in 1618 by German surgeon Wilhelm Fabry. A diseased gallbladder was first removed surgically by another German, Carl Langenbuch, in 1882.

Gallstones occur when there is too much of certain substances in the blood or bile, or sluggish muscle impedes gallbladder emptying. Soft and tan, cholesterol stones are most common. A single large stone might entirely occupy the organ’s cavity; when many are present, they may fit together like an attractive garden patio. Pigment stones, either black or brown, derive from bilirubin. Cholesterol stones develop in the presence of high blood fats, obesity, diabetes, and pregnancy; pigment stones in conjunction with anemia, alcoholism, malaria, and increasing age. Sometimes stones are a mixture of both varieties.

The typical patient is “all Fs”: Female, forty, fertile (has children), fair (hair or complexion)—and the other “F” is “fairly chubby.” However, chaps, don’t relax just yet, this disease commonly afflicts men too. Certain ethnic groups such as Native Americans are especially prone.

Sometimes an incidental finding (e.g., during a total body scan), gallstones usually declare their presence—on eating a fatty meal, patients experience sharp pain under the right ribs spreading into the back, associated with nausea, vomiting, diarrhea, and fever. Imagine the scene: gallbladder central, a bag of stones hanging in the breeze. You fancy some pizza, heavy on the pepperoni. One mouthful and the gallbladder contracts down on those spiky stones inside, and ouch! The gallbladder becomes inflamed, and stones may migrate into the main duct—blocking bile flow, which backs up, causing the patient to turn Piper Cub yellow. A rolling stone may gather no moss, but if it rolls toward the pancreas, it can cause a very nasty condition called pancreatitis.

If you do not want your “concreted humors” diagnosed by the likes of Gentile of Padua (i.e., at autopsy) see your doctor where a history and examination will ensue. Tenderness under the ribs, worse on deep inspiration—together with hypersensitive skin—raises the likelihood of gallstones. At this point say to the doc: “Ah, I see you elicited a positive Murphy and Boas sign!” I guarantee a quizzical look and preferential treatment. A confirmatory ultrasound will show stones and their “acoustic shadow” (ask to see pictures, very cool!). Other investigations will be dictated by particular circumstances.

Avoiding fatty foods makes good health sense anyway, but if symptomatic, gallstones merit surgical treatment, removing the diseased organ and contained stones alike. Stone dissolution with medicines occasionally has merit, but for the active audience reading this article, an operation is likely the best option.

Many may recall President Lyndon Johnson’s famous photo displaying the cholecystectomy scar clear across his belly. Nowadays a similar photo would show next to nothing, as most gallbladders are removed under guidance of a telescope with a video camera attached inserted via one hole in the belly button and two or three quarter-inch incisions. Such laparoscopic cholecystectomy is dear to my heart—an operation I was privileged to teach internationally. One note of caution, if you need this procedure ask your surgeon about how they intend to view the common bile duct, the tree trunk mentioned above. Rolling stones can sneak in and odd anatomy can confuse some surgeons into inadvertently lopping off the wrong branch. And we don’t want that to happen.

AOPA Director of Medical Certification Gary Crump states that for asymptomatic stable stone disease or uncomplicated cholecystectomy more than six months ago, with good documentation, the AME may issue a medical certificate requiring no further followup. If surgery was less than six months from the FAA exam, a status report from the treating physician confirming full recovery without complications may allow the AME to issue, and no further followup will be required. The AOPA Medical Services Plan can help pilots deal with exactly this sort of situation with the minimum of fuss.

Ending with my rolling stone theme I am moved to reference “Dear Doctor,” the 1968 song by the Rolling Stones: “Can’t ya please tear it out, and preserve it right there in that jar?” Professors Jagger and Richards should have been surgeons.

E-mail the author at jonathan.sackier@aopa.org.

Jonathan Sackier