For internists/surgeons, please -- why does my BIL still have a gallbladder?

Factual Questions
1

This is a pretty long one; please bear with me.

My brother-in-law, 53 y-o, morbidly obese, living with type II diabetes, is now hospitalized. During the past year, he was working in a grocery-industry-related job, and his duties included handling chickens (dead and butchered, AFAIK), and he contracted a (possibly salmonella-related) infection to his heart muscle.

That was the focus of his medical treatment until last month, when, during a business trip to Texas, he suffered a medical emergency, the exact nature of which I have not learned, but probably involved jaundice. While investigating the causes of his liver problems, the medical team discovered what they believed to be stage III cancer in his pancreas. He was returned to California for hospitalization and the beginnings of a treatment strategy. A stent was placed in his liver, and became infected rather quickly, but they replaced it, stabilized him, and sent him home (with antibiotics to continue treating the infection).

A couple of days later, he was back in the hospital, this time with a very low blood sugar. I’m unclear on exactly why, but he was in ICU for about a week during that visit, although I do understand that an abscess was found on his gallbladder. He was sent home with an antibiotic regimen again, and the same evening, he went back to the hospital in respiratory distress. While he was intubated on a respirator, the medical team discovered that the abscess on the gallbladder had become septic. The team evidently decided that surgery to remove the gallbladder would be too dangerous, given his condition, and that further antibiotic treatment would be safer.

They did get one bit of good news, during this third hospitalization; apparently the head of his medical team believes that his particular type of cancer can be effectively treated with surgery. He’s just not healthy enough to go in for any such surgery yet.

He came off the respirator after about half a week, and has been undergoing tests to monitor the progress of that treatment. Yesterday, the team decided to aspirate the septic fluid from the abscess on his gallbladder. During this process, they discovered that the abscess had become gangrenous. So they opened him up, performed a lavage of his abdominal cavity (about ten times, I’m told), and closed him up gain (they may have debrided the abscessed tissue from the gallbladder, but my wife and I seem to be at the bottom of the pecking order, for the purpose of disseminating information, and the next person up the ladder from us is not the most reliable of messengers, so I don’t actually know). One thing I DO know is that his gallbladder is still in place.

WHY, though? ISTM that as long as they were in there, in an already-traumatized region, taking out an organ that is not exactly necessary (and has been the focus of a lot of problems) wouldn’t be a tough choice to make. Does this just seem like a conservative philosophy wrt organ-removal surgery (caution level high, but not exceptionally so)? Or is there something about a patient with a stent in his liver that makes him really NEED to have a place to store all the bile his liver is going to be producing, such that a cholecystectomy is a last resort?

I hope I’ve delivered this information concisely and effectively, and I thank you very much for the sharing of your professional knowledge.

2

I probably should keep quiet but . . .

Sounds like he might have what’s called acalculous cholecystitis. That is a form of cholecystitis (gall bladder inflmmation/infection) not due to stones and usually occurring in critically ill people. Treatment is usually surgical but if the patient is at high risk from surgery (and even a gall bladder excision is high risk in a patient who is already septic, etc.), there are other options. For example stents (tubes) and/or drains can be placed to drain the infected gall bladder. Might he have had one those procedures without you being aware of it? If you search for ‘acalculous cholecystitis’ it’s easy to find relevant references (assuming that is, in fact, his diagnosis).

It’s also possible that unlike in the “usual” cases of cholecystitis where stones block the duct draining the gall bladder, your BIL’s problem might have stemmed from the gall bladder tube (duct) being blocked by the cancer. If that’s the case, the key the thing is to open up the blockage - it may not be necessary to remove the gall bladder.

3

Thank you for the response, KarlGauss; it was quite informative. I presume you’re not a doctor (because of your first statement); do you mind sharing some context for how you happen to know that acalculous cholecystitis is a thing? Did you have a family member or friend or self experience it? Did you happen to see it featured on an episode of House?

I’m really interested in how somebody comes across something like that; I’m not being sarcastic at all, and I really DO appreciate your input.

4

Since KarlGauss hasn’t shown up yet himself, I just thought I’d mention he is a doctor. He identifies himself as one here.

5

I am not a surgeon, but the answer to your question is actually in the OP

Actually removing the gall bladder is a more complicated surgery than simply draining it especially when there is an infection. When you cut and tie blood vessels and ducts you risk spreading the infection further, even into the blood stream. In addition, it is less likely to heal and the cancer in the area may also affect healing. That is why surgeons either do gallbladder surgery early during an attack, before there is too much inflammation, or wait several days for the gallbladder to “cool off” before operating. It sounds like the patient is a high risk candidate and the best course of action in this case is to drain the infection, treat it with antibiotics, and remove the gallbladder (possibly with additional pancreas surgery) when he is more stable.

6

He’s a very well respected academic internist who was on the front line in the battle against SARS some years back. He’s a real asset to this board and to Medicine as a whole.

7

Qad is way, way too generous in his assessment and I will use this opportunity to say what I’ve posted here more than once (and meant it):

Dr. Qadgop is an amazingly well-informed and eclectic physician whose posts also show him to be supremely decent and humble. I can only hope the denizens of this board know how fortunate they are to have him around.

Now, with that out of the way, let me note:

Hmmm . . ., I think he added the following group of letters by mistake. Try removing them and you’ll get the real truth:

‘et to this board and to Medicine as a w’
:wink:

8

Yikes!

My sincerest apologies, KarlGauss.

9

I believe I understand now. In summary, the fact that an incision had been made in the abdominal wall (to remove the gangrene) did not make gallbladder excision less risky. And, in fact would probably have increased the risk. And generally, even with a healthy patient, removing the organ would not be done while in the midst of such a virulent infection.

If I’ve got that about right, I’ll sign off with my thanks once again.

10

Speaking in generalities, cholecystectomy on critically ill patients is a risky procedure. To remove the gallbladder, several things things must be done succesfully: the blood vessels serving the gallbladder must be tied or clipped and cut without cutting off the arterial blood supply to the liver. The duct from the gall bladder must be tied or clipped and divided without blocking off the bile duct from the liver to the gut. The gall bladder must be cut/burned off of the undersurface of the liver, leaving a raw area. Even if he did not have all of the other risk factors like the unstable diabetes, morbid obesity, respiratory failure, pancreatic cancer, and sepsis, there are cases where the swelling and fragility of the tissues around the gallbladder make it difficult or impossible to perform the needed tasks with a reasonable safety margin. Inflamed, swollen tissue does not hold sutures or clips well. Anatomical structures are difficult to identify when they are distorted and displaced. Raw surfaces weep and bleed rather than coagulating properly, especially if there is already liver dysfunction. It is the least-bad option in such cases to simply make sure that any infected material is able to drain away freely, either by placing a drain through the skin from the outside or by placing a drain into the area surgically. You then have to determine what the proper time is to go in and deal with things definitively, which is a matter of judgement.

11

These are all very interesting answers - I know taking out an organ isn’t nearly as simple as removing the butterflies from the stomach in Operation, but I kind of tend to forget that it goes way beyond “cut the thing out”.

12

Heh. You know how I mentioned in the OP that our direct link to the grapevine isn’t the most reliable of reporters? Well I decided to throw caution to the winds and call my sister-in-law yesterday evening, and not worry about whether any bridges get burned. She’s actually quite gracious and willing to speak with us. She set us straight on a couple of details.

One of them is that the entry into the abdominal cavity last week was NOT just removing gangrenous fluid; the gallbladder actually did come out. Another detail is that they discovered cancer on his liver. :frowning:

Not sure what the treatment options are going to be at this point, but they ARE hopeful that he’ll be able to be stabilized enough to be discharged home some time this week, at which point they’ll try to see how much he can be helped with chemotherapy and surgery.

Again, thanks to everyone for the input.

13

The docs on this board do an excellent job of shying away from giving medical advice or too detailed an opinion on what’s going on with an actual patient, since everything is not always as it seems, especially when one’s only exposure to the patient is two hundred words of second-hand text provided from an indeterminate distance in time and space.

That’s how I read the first part of post #2… a healthy application of skepticism to the practice of medicine-by-message-board.