Gallstones and Gallbladder Disease
Gallstones (cholelithiasis) and inflammation of the gallbladder (cholecystitis) affect over one million people in the US each year and 16-20 million Americans have gallstones. 500,000 surgeries are performed every year to remove gallbladders and stones. For the pilot and controller, this condition presents minor medical certification issues. Reporting to the FAA is usually rather straight forward.
Anatomy of the Gallbladder
The gallbladder is a large thumb sized sac that stores bile produced in the liver. A system of connecting tubes known as ducts direct transfer of the bile between the liver, the gall bladder and the small intestine, where the bile aids in the digestion of fats and cholesterol. This system is known as the bilary system. Think of the three ducts as forming a “Y”. Bile produced in the liver drains down one upper arm of the Y through the hepatic duct. It moves up the upper arm of the Y, called the cystic duct, to be stored in the gall bladder until it is needed for digestion. The gallbladder then squeezes bile through the cystic duct into the common bile duct which makes the lower leg of the Y. A muscle around the base of the common bile duct relaxes to allow bile to flow into the intestine for aid in digestion.
Stone Formation and Risk Factors
As long as there is unobstructed flow of bile through all three legs of the Y, problems rarely occur. If one or more of the legs are blocked, pressure can build as bile is continuously produced but not released. This can cause pain and inflammation. Bile may sometimes form into stones from the size of sand grains to nearly golf ball sized. The stones are composed primarily of cholesterol and tend to occur when cholesterol concentrations in the gall bladder increase compared to bile acid concentrations. These stones may get stuck in the cystic duct and block the outflow. Less commonly, they may get stuck in common bile duct and block flow of bile from both the liver and the gallbladder. This is very serious and a person quickly becomes ill and jaundiced. Ironically, the smaller granular stones tend to clog the ducts more frequently. The larger stones tend to sit in the gall bladder, rather than move down the ducts, because they are so large. They may not cause any symptoms at all.
Risk factors for gall stone formation include obesity, rapid weight loss by fasting, high fat diets, female hormones, increasing age, pregnancy, sludging in the gall bladder and some medications.
Gallbladder Disease Symptoms
Gallstones frequently manifest themselves by a cramping pain below the right rib cage after eating. Fatty meals may be particularly provocative. In more serious cases, the pain can be incapacitating and confused with ulcers, heart disease, kidney stones or pancreatitis. If associated with fever, the condition requires immediate medical attention to treat the cholecystitis. Sudden pain in the right upper quadrant of the abdomen that may radiate to the right shoulder blade is termed “bilary colic.” It may persist for 1-4 hours and is followed by a dull upper abdominal pain for about a day. The symptoms may be precipitated by a high fat meal (the FBO “special”) and relieved by limiting intake to non-fat liquids.
Initial treatment may include restricting oral intake to clear liquids or nothing at all. Intravenous fluids, restricting oral intake, and occasionally using a nasogastric tube to drain the stomach contents, will allow the gallbladder to calm down. Fever and an elevated white blood cell counts dictate the use of antibiotics. Surgeons are very reluctant to operate while someone has a fever as the complication rate rises dramatically. Many mild cases will not recur for extended periods, particularly if one is cautious with their diet. Forgetting about the diet may provide an uncomfortable reminder of the condition. Frequently, mild symptoms may be treated with dietary restriction and watchful waiting. This watchful waiting is an acceptable management technique. Many men will have asymptomatic, or “silent” gallstones and up to 80% may never have any symptoms nor require surgery. Asymptomatic gallstones are not disqualifying, but symptomatic stones result in grounding till the problem is corrected.
Diagnosis of Gallstones
The definitive test to verify the presence of gallstones is the gallbladder ultrasound, which gives a two dimensional picture using Doppler imaging techniques to show the location and size of the stones. Blood tests may lead to the suspicion of gall bladder disease with elevated liver function tests and bilirubin. Occasionally, the diagnosis is made by visualizing the stones during an x-ray or CT scan. Only 10-15% of stones contain enough calcium to be visible by x-ray. To evaluate inflammation and function of the gall bladder, scans using radioisotopes injected in the blood and visualized with a nuclear imaging camera are sometimes used. They are most useful in acute inflammation of the gall bladder. Finally, an Oral Cholecystogram (OCG), which was the primary diagnostic tool before ultrasound, is useful in assessing the function of the gall bladder and ducts in those people who are not surgical candidates.
For people with recurrent gall bladder symptoms, both medical and surgical techniques are available to treat the condition. Most commonly, surgery is used to remove the gallbladder and its stones. The bile no longer is stored in the gall bladder but is still produced in the liver and used for digestion. Again, very few people with asymptomatic gall stones have any need for treatment or surgery.
Two main surgical techniques are used. One is the traditional cholecystectomy where the abdomen is opened and the gall bladder and its duct are tied off and removed. This requires general anesthesia and leaves a significant scar under the right rib cage. President Lyndon Baines Johnson demonstrates his gall bladder scar in a famous photograph of the 1960’s. The recovery period for this is several weeks.
The alternative technique is much more popular today. It is called the laparoscopic cholecystectomy. This technique uses three or four probes inserted through tiny incisions in the abdominal wall to inflate the abdomen with carbon dioxide, view the gallbladder lying behind and underneath the liver, and remove the gallbladder and stones. The recovery period is usually only a few days and scarring is nearly invisible. Pilots/controllers undergoing these procedures may return to aviation duties when cleared by their surgeon for full activity and they are comfortable that they can perform all safety sensitive duties. Controllers must also obtain clearance from the Regional Flight Surgeon before returning to controlling. The operative report and discharge summary with the surgeon’s final note clearing the pilot/controller to return to activity should be attached on the FAA Form 8500-8 at the next physical. Follow up reporting is rarely required by the FAA.
Medical therapies to manage gallbladder disease are much less common than surgical treatment. Only 10% of patients requiring treatment for symptomatic gallbladder disease are candidates for medical treatment. One technique uses medications alone to attempt to dissolve the stones. These medications are called UDCA (ursodiol) and CDCA (chenodiol). They work very slowly by decreasing cholesterol production in the liver. The cholesterol in the stones is gradually diffused into the bile acid and excreted in the intestine. About 50-60% of stones will dissolve over two years. Use of these medications will require FAA review and approval before flying or controlling. Remember, the underlying condition of symptomatic gallstones may still be disqualifying, even if the medication is tolerated well.
A newer medical therapy uses extracorporal shock waves, similar to the technique used on kidney stones. The shock waves are focused on the stones and attempt to blast them apart. Stones reform in about 20% of patients and they generally are maintained on UDCA after treatment. Because of cost and chances for recurrence, this treatment is not used often.
FAA Policy for Pilots & Controllers with Gallstones
The FAA will allow a pilot and controllers to perform duty with gallstones that are not causing any symptoms. Frequently these stones are discovered incidentally during another study such as an ultrasound or x-ray. If the gallbladder is inflamed, a pilot or controller should not perform safety sensitive duty during this period. In many cases, symptoms will resolve in one to two weeks. They may then return to aviation duties and report the episode at the next physical, if it resolves. Controllers should clear through the Regional Flight Surgeons office before returning to work, however. Those with chronic inflammation of the gallbladder are at risk for recurrent attacks that may jeopardize flying safety. These individuals should not fly or control until the problem is definitively corrected.
Pilots may return to flying after surgery for gallstones once the healing is complete and their surgeon has released them to return to full activity. Again, this surgery should be reported on FAA Form 8500-8 at the time of the next physical examination. Reporting is not required for pilots prior to the next examination if medications are not required. The use of UDCA or CDCA for chronic treatment should be reported to the FAA prior to returning to fly.
For controllers, reporting on the medical application is also required. They must also clear through the Regional Flight Surgeon before returning to controlling duty. Remember, flying/controlling with active symptoms is not appropriate.
AMAS Aeromedical Assistance
For a more specific personal explanation to your questions or those concerning aeromedical certification, contact AMAS for a private consultation. For help in reporting treatment for and obtaining clearance from the FAA to fly or control with these conditions, refer to the AMAS FAA Confidential Questionnaire. If you are a AMAS Corporate Member, these services are FREE to you.