Gall balls in the gall bag

We don't post much about clinical topics here, mainly because we haven't done much practice since our medical training days. I'm primarily a researcher and professor. But every once in a while I see papers on subjects that strike a nostalgic chord from those days and yesterday was one of those once-in-a-whiles. This was a report of a paper (DOI: 10.3748/wjg.14.5282) about what we used to call "gall balls in the gall bag," that is, gall bladder disease from gallstones. My medical school was located at a gigantic hospital with a very famous surgical program. And the chief surgeon there was most famous for fixing other surgeon's gall bladder surgery mistakes. In those days there was no "interventional radiology" or laparoscopic surgery. The surgeon just opened up the patient and took out the gall bladder. Sometimes he (rarely she) screwed up and cut or produced an obstruction of the common bile duct or did something else even more terrible. Then the patient was sent to this big shot surgeon to get fixed. The surgery department did a lot of this, and the operations were often very long. Everything took place in the bottom of very small hole just under the rib cage, a hole that had to be held open with right angled instruments called retractors. Someone had to hold the retractors to keep the hole open. This didn't take a lot of skill. It's usually what I did. Once I fell asleep holding a retractor and was awakened by the surgeon whacking my gloved knuckles with some instrument. He also said something very impolite through his surgical mask. I hope he strained his voice (that's a joke).

Anyway, back to the paper. One of the old fashioned things I learned in those days of yore was that the typical gall bladder patient was "fat, female and forty." We've learned a lot about gall bladder disease (GD) since those days:

. . . since the introduction of laparoscopic cholecystectomy into clinical practice at the end of 80s, a possible unjustified increase in surgical procedures has been observed, probably due to changes in the perceived risk-benefit ratio (for patients and physicians [sic!]) and changes in surgical indications. Therefore, there is the need for more knowledge of the epidemiological characteristics of GD in order to better identify therapeutic strategies.

A new research article addresses this question. The research team led by Prof. Davide Festi of the University of Bologna has performed the second phase of an epidemiological project (the MICOL project) which is a population-based, cross-sectional study carried out in 8 Italian regions by different operative units. (ScienceDaily)

The study looked at 5500 men and 4100 women first enrolled between 1985 and 1988. They were re-examined in 1995 to 1998 (after ten years). Gall bladder disease was diagnosed at the overall rate of .67%/ year, significantly higher in women (.81%) than men (.66%). Age was reported as a risk factor, although the odds ratios for age are around 3% per year. That doubles the odds in roughly 20 years, not a huge effect. These are results of a multiple logistic regression and no age specific rates are given, so we don't know if women in their forties are at special risk (it is the average value of the log odds that are being modeled as a linear increase with age, so it would be nice to see how well specified the relationship is, but alas we don't see the data). Women are indeed more prone than men to get GD. And Body Mass Index (BMI) is also a risk factor. So fat, female and at least forty probably still a good mnemonic (it was good enough for me to remember it for 40 years, anyway). The only symptom that was a decent sign of GD was pain in the pit of the stomach or under the right rib cage. Other symptoms often associated with GD were as likely to be other things.

Gall balls in the gall bag. Common. Painful. Expensive to society. And a part of my past I don't really miss. I hope they aren't part of my future.