Gall Stones

[Ajc-fly]

Hi, Can someone could help and provide advice. Thanks in advance.

I went to my GPs recently, and to cut a long story short the GP requested an Ultra sound. The results were no problems found but they have found a number of small kidney stones. The specialist yesterday recommended keyhole surgery to remove my gall bladder.
I have looked at the medical section on the CAA but Il a bit confused. Can anyone tell me what I need to do and how I recover my Class 1 medical after (if i can) as I want to continue flying as a flying instructor and eventually join an airline.

Will this operation stop all my flying?

[Hydromet]

Kidney stones and gallstones are not the same thing. Which do you have?

[Ajc-fly]

sorry, my typo. Gall Stones

[Loose rivets]

I had one of the early keyhole operations for gall stone. They removed a stone the size of a small chicken egg and the bag out of a hole under my belly-button. There were three more holes for camera, tubes and- at a guess- inflation gas.

I was walking around in the foyer of the Oaks at Colchester within 36 hours. BUT - and yes, I'm shouting - I'd let it get bad before doing anything, and a couple of weeks before the op I was rushed to hospital as a blue light job. I felt like I'd got a spear in my belly that was coming out between my shoulder blades. I didn't know pain could reach those levels. I was stabilized with nothing but a drip and morphine for 3 days then sent home to wait for the surgery.

So, yes, get the bladder out of the way, you're so much better off without it.

Flying? No problem for me. Sensibly, about a month to make sure everything has settled down, but you'll have to see what the folks in the grey cube think. I had a class one for 15 years after that.

[Bearcat]

20% of the population have gallstones and they don't even know they have them. A symptomatic g/s are recommended to stay in situ. AMO may put a multi crew only stamp on your Licence.

If they are acting up, get them whipped out....8 weeks off I think

[obgraham]

Even if you've never had an attack of gallbladder trouble, a bunch of small gallstones is more of a problem than one or two big ones. They can lodge in the duct running from gallbladder to intestine (common bile duct), and then you have an acute problem, and treatment and/or surgery is more complicated. Could potentially incapacitate you while flying.

Big stones, not so much -- more time to discuss and decide.

So current advice for multiple small stones, even if no symptoms, is laparoscopic cholecystectomy (that keyhole bit). It's a pretty routine procedure nowadays, and I doubt that it would affect flying, once recovered. (I am not, however, an AME!)

[Loose rivets]

I smashed things in my bedroom as I reeled around with the pain. I'd taken 6 pethidine tablets during the night, given to me by a doctor who came to the house twice. He diagnosed a spasm of my sphincter. :ugh: in fact, double :ugh::ugh:

I was in a temporary okay state as I walked to the ambulance, but got bad on the 20 mile drive. They gave me some gas which made me drowsy.

I can remember being put on a gurney - for some reason in a kneeling position - must have done that myself - and then saying I felt sick. Someone bought a little cardboard hat-shaped thing, capacity, one tea cup at most. I emptied what looked like a gallon of bile onto the gurney and then slumped into it blissfully free of pain.

After thee days I was okay to go home. I'd lost 20 lbs. I was told 8 weeks for the operation.

I was commuting to Texas month-about-month then, and a surgeon phoned me from his car and said he was worried about me traveling. He'd do it privately in the Oaks in a week or so. I agreed. Twice they moved it forward, until I found myself packing for the next day. He'd got a team organized for a Saturday.

The anesthetist came in wearing a Canadian style shirt and everyone looked kind of relaxed. When the gall bag was removed, they told me it was covered in black patches. (that'll teach me not to act on early symptoms) I gather he had a lot to say to the night doctor and my GP. They were both kind of sheepish about it all. My GP blaming the 50 year in practice visiting GP cos of his experience. I made no criticism at all.

There was one big stone, and it undoubtedly blocked the duct or even the whole area near the outlet. What is significant is that it probably could have been coaxed out of the way by manipulation.

What is certain, anyone with an inflamed gall bag and a stone would have to be restrained on an aircraft, given the amount of the strong drug I'd taken still left me reeling about.

Slightest hint, get it diagnosed with absolute certainty. Multi-crewing? sheesh, they're working from books, no one who's really known that pain would want them on an airfield, let alone an aircraft.

Oh, BTW. I was an otherwise very fit 50 year old. Aggressive sports where I got a fair share of pain. Different league.

Another BTW. When I cut the stone in two, it was like rust on the outer layer, but inside, large white crystals were all pointing towards the centre. I felt disinclined to keep it for long.

[Hydromet]

Even if you've never had an attack of gallbladder trouble, a bunch of small gallstones is more of a problem than one or two big ones. They can lodge in the duct running from gallbladder to intestine (common bile duct),
I had two largish ones, one of which lodged in the duct. Funnily enough, I didn't have any of the pain that is common, but was nauseous and had some vomiting. I was sent in for an immediate 'minor' procedure to crush the stones, with planned later keyhole surgery to remove the gall bladder, after the surgeon returned from his holiday.
However, it all went wrong as the stone was too hard and damaged the 'crusher'. SWMBO received a call to get to the hospital immediately to sign the approval for me to have an op to remove the stones as they were now life-threatening. I finished up with a large scar under the ribs, a drain in my stomach and severe jaundice. Several weeks of antibiotics while in hospital, and a few more weeks at home with the drain saw me feeling pretty good. Went to the surgeon (not the one who went on holidays, the one who actually did the job) to have the drain removed, and collapsed in agony as soon as he did so. Back to hospital by ambulance - removing the drain had released a large infection - for another 3 weeks. By the end of this I felt well, and have never had any problems or limitation on diet. However, SWMBO and D2 have both also had gallstones, and now cannot face rich foods. Both their ops were keyhole surgery as described by LR, without any problems.

[gingernut]

What symptom's lead to the Ultrasound scan in the first place, and are they still bothering you, or have they resolved ?

[Ajc-fly]

Hi. Thanks for the replies and stories! No pain from them and the original reason for ultra sound was looking into what was thought to be an infection or more serious in the kidney/ bladder area which has long gone with some pills.

Just leaving the question about the gall stones. It seems sensible to get the key hole surgery done and seems doable to get medical back after(?). But it would hopefully still give me single crew to retain sep instruction.

[80-87]

There are many Chinese in this world. Having worked in Asia for a number of years, I've known a number of colleagues who have succumb to Gall Stones.

So, one of my friends went to the friendly Chinese herbalist and put him on an apple/apple juice diet.

I've known two people who have used this treatment. They are STONE FREE...no surgery...no drugs. Here is a link to a remedy. There are several and they are all basically the same. Good luck!

Apple Juice Remedy for Gallstones | eHow.co.uk (http://www.ehow.co.uk/way_5139430_apple-juice-remedy-gallstones.html)

[Loose rivets]

Keep your cholesterol under control. Excess cholesterol clumps together to form gallstones.

Well, there you go.:ugh:

[homonculus]

I presume your two friends have a picture of the stone on ultrasound before and a picture with no stone on ultrasound after

Unfortunately some stones get passed diet or no diet. Put 1000 patients on this diet and I doubt the surgeons will be out of a job

If the NHS could avoid such a common operation which costs such a relatively large amount of money by a bottle of apple juice........

Never mind

[YSSY]

Agree with bearcat - 10-20% of population at any one time will have gall stones.

But, even if you are asymptomatic JAA will require you to have the key hole operation (as they are small and thus pose a risk to in flight incapacitation). WRT how much time off - I'm unfamiliar with the CAA, but JAA say up-to 3 months - although this can be at the discretion of the medical examiner. If they are open to negotiation - point out: key hole surgery & they will have used CO2 for the surgery and thus would probably be fit to fly in reality within a month .... but whether the CAA will see it that way or not .. who knows.

We clear pax to fly within 10 days!

[Capt Chambo]

UK CAA.

Back in 1995 I was diagnosed as having numerous "small" gallstones. My symptoms had been incredible pain under my ribcage lasting almost exactly 4 hours.

Before I went for keyhole surgery the company doctor secured me 4 weeks leave in case I was one of the minority of people out there with a prolapsed gallbladder in which case major surgery would have been required. I had the surgery (keyhole) as an outpatient, walked out of the hospital that evening, and could have been back at work within a week. As it was i took the 4 weeks as it was over Christmas!

Post op. the most painful thing was an incredible ache in my right shoulder, apparently a by product of having your abdomen extended by CO2 gas, which presses on a nerve when you are subsequently deflated.

Small gall stones are the problem as they can pass done the bile duct, causing the pain. Large stones are to big to fit into the bile duct and will just remain in your gall bladder, and you may never know that they are there.

As ever seek professional advice.

[gingernut]

But, even if you are asymptomatic JAA will require you to have the key hole operation (as they are small and thus pose a risk to in flight incapacitation).

That's interesting. If we scanned all pilots, 1 in 5 of them would instantly be grounded.:uhoh:

[YSSY]

yes - sounds ridiculous! Who makes up these rules anyway?!

Thought I'd just check the stats though:


In the UK it has been estimated from autopsy studies that approximately 12% of men and 24% of women of all ages have gallstones present.(1) The prevalence in North America is comparable to that in the UK, and it is believed that 10–30% of gallstones become symptomatic.


(1) Garden, O. James. Hepatobiliary and Pancreatic Surgery: A Companion to Specialist Surgical Practice, 4th Edition. W.B. Saunders Company, 112009. <vbk:978-0-7020-3014-7#outline(10.1)>.

[gingernut]

yes - sounds ridiculous! Who makes up these rules anyway?!

Not heard of many planes crashing 'cos of gallstones.

(No doubt I'll be proved wrong!)

[80-87]

The stones are passed through the colon and into the stool. In these cases, small with a green hue. Want any more details. These people were told to have surgery and in one case, the doctor was quite adamant that she appear for the surgery.

A year later, both of these people are 'stone free'.

Believe the Chinese and their medicine....it works.

[homonculus]

80-87

You have just blown your argument

It is normal for small stones to pass into the guts and be eliminated. Nothing to do with apple juice, just a simple mechanical matter. Every time you eat the gall bladder 'contracts' and excretes bile - that is what it is for. And if the stone is small enough and in the right position and free out it goes.

The problem is when the stone gets stuck blocking the duct from the gall bladder to the gut. The gall bladder still contracts, the pressure goes up, and you get pain.

So what does the apple jouce do - scientific answers with evidence please, not anecdotal response.

Interestingly I can't find a single case of a pilot being forced to have surgery by a regulator. That doesn't mean the odd person didn't have surgery and I am sure there are some surgeons out there who are a bit knife happy and desperate to operate on anyone, but the operation is not risk free. Anthony Eden almost died from it albeit the non keyhole method. We not infrequently get patients with complications who have to go through years of corrective surgery and couldn't possibly fly.

So if you have asymptomatic gall stones, the usual advice applies: ensure you see a surgeon who does lots of these operations. See a surgeon your GP says is an expert ( as opposed to the surgeon saying it himself!!!), and if necessary get two opinions.

Neither of them from Pprune

[Level Attitude]

AJC Look on CAA website!
From memory: Single Gall Stone and no symptoms no problem.
Multiple Gall Stones then Medical is suspended (even if no symptoms)

Keyhole Gall Bladder removal is a commonplace, relatively minor operation.
Your medical will be suspended because you have to tell CAA if you undergo any operation. They will
probably advise you that the medical will be reinstated (with no limitations) once your surgeon writes
to advise them that you have fully recovered - probably 3 to 5 weeks post-op, with getting the surgeon's
letter taking longer than your actual physical recovery.

One point: Your surgeon will probably advise you to refrain from any
flying (inc Pax) for 48 hours to ensure any residual CO2 in your abdomen
has time to resorb and won't cause pain due to expansion as the pressure decreases with increasing altitude.

I am writing above only to suggest that if your problem is as "simple" as you indicate then you shouldn't be too concerned about regaining your Class 1.

However you should check with CAA, your AME and your surgeon (I am just an anonymous Poster)

[homonculus]

Thank you for this

But how would anyone know they had multiple gallstones if they were asymptomatic? I suppose the ultrasound probe could slip on a pregnant woman, but I don't go round Tesco waving my ultrasound at fit and healthy people

True it isn't the most major operation known, but I wouldn't call it minor, and complications can be significant.

Sorry to be a killjoy, but I worry about any pressure to take a risk....

And finally please don't fly 48 hours later or you may well be in agony as you depressurise - unpressurised aircraft are fine but commercial flights need at least 5 days and many airlines insist on 7 to 14

[Loose rivets]

AJC Look on CAA website!
From memory: Single Gall Stone and no symptoms no problem.
Multiple Gall Stones then Medical is suspended (even if no symptoms)


Do you think I'd get into trouble if I found the person that made that decision, and stuck a spear in their belly until it came out between their shoulder blades?

The gall bag is pliable, and can form around a large stone totally blocking the outlet. The sheer quantity of bile I dumped onto the hospital gurney evidenced just how much was squirted into the large intestine when the stone moved. Given that much of it probably went the other way, the bladder must have been a colossal size to have back-flowed so much.

I say again. One stone or a million stones, get the damn thing removed before you fly.

[Level Attitude]

From CAA website (just type in "gallstones")
MED.B.020 Digestive System

Class 1
(c) Gallstones
(1) Applicants with a single asymptomatic large gallstone discovered incidentally may be assessed as fit if not likely to cause incapacitation in flight.
(2) An applicant with asymptomatic multiple gallstones may be assessed as fit with a multi-pilot limitation.


Class 2
(c) Gallstones
(1) Applicants with a single asymptomatic large gallstone or asymptomatic multiple gallstones may be assessed as fit.
(2) Applicants with symptomatic single or multiple gallstones should be assessed as unfit. A fit assessment may be considered following gallstone removal.



Loose rivets, from what you have said, surely the above would not have applied in your case with your first sympton being as you describe.

[Loose rivets]

Certainly, it wouldn't have applied. but there had to be a first time, and the stone was already very large - based on the fact it took years to reach that size.

I recall two occasions of getting up in the night with a miserable pain in my upper back. Just a feeling of being ill. I leaned over the sofa with my back to the fire and let it cook for a while. In hindsight, it was probably the position and pressure that brought the relief.

Years went by before the big one.

So, if someone knows they have a stone, but carries on based on a legal/medical interpretation, then they stand the risk of finding themselves in hell in the middle of an ocean. Sure, a multi-crew would take care of the passengers, but the thought of being in that pain for hours is horrific. Remember, I'd swallowed about 4-5 days worth of Pethidine in one night and it was still beyond my endurance.

(My wife was in America, and it was my daughter that called the night service.)

However, I'm quite convinced that if the worst should happen, it is possible to manipulate or jar a large stone out of the way of the bladder's outlet - because it is not stuck in the duct. The position on the sofa and later, the position on the gurney may have done the trick, and indeed the reeling, drugged, about the bedroom might have done the same where the Pethidine failed. But people have to be aware before they'd make an attempt.

Now, here's a thing I hadn't intended sharing. I was about 8 years old, and my mother, a hefty woman who loved her fried food, became ill after a day at our beach hut. She'd been swimming many times, and when the neighbors finally called the doctor in the night, it was because her screams could be heard down the road. I have an enduring memory of her kneeling on the bed with her aunt offering a sheet end for her to bite on.

The doctor knocked her out with an injection. He diagnosed a chill round the heart. It satisfied everyone for a while.

For years, she described minor occurrences as 'My pain' and would beat herself on the back with her stick. Astonishingly, it often did the trick - or perhaps it was the raised arms, who knows. As medicine became more refined, they finally decided she'd got a gallstone, but was too aged to risk the anesthetic. She lived with it until she died of something else at 93.

It occurs to me on this night, that it may be just another reason I'm kind of passionate about getting that useless organ out of the way.

[Bearcat]

There's two trains of though here......re a symptomatic multiple gallstones....go to one surgeon, he'll whip them out....the next guy says if they are not bothering you leave them.

Glad previous poster can posted CAA /JAA dictate......you can fly easily with assymptomatic with a multi crew endorse ment class 1....it ok on class 2.

If you thinking of heading off to the sand or Asia.....you'll have to get them out. This is my predicament. For the sake of a week of hassle and 4 weeks off .....it might be worth it.

Gallbladder disease (http://www.drhoffman.com/page.cfm/140?Template=Default_Print)

[homonculus]

But Loose Rivets you DIDN'T have asymptomatic gallstones - you had had two episodes of pain. And to tell everyone to pop off and have them whipped out when in the next breath you say the operation is so dangerous it can't be undertaken on the basis of age........just keep taking apple juice and hanging up by your feet.

Back to my unanswered question

How would anyone know they had asymptomatic gallstones??????

[Hydromet]

How would anyone know they had asymptomatic gallstones??????
discovered incidentally...........

[homonculus]

OK let me rephrase my question

How would they be discovered incidentally

I am only a simple doctor, but I am struggling to think of a way anyone who does not already have medical issues that in effect make the holding of a license questionable could ever have an incidental discovery. You can only find the gallstones by ultrasound, MRI or XRays. I suppose virtual colonography is the only possibility but VC screening in the UK is almost unknown

[Level Attitude]

OK let me rephrase my question

How would they be discovered incidentally


You have a bad back - muscle spasm or whatever and go to your GP.
GP wishes to exclude more sinister causes (kidney disease) and refers you
for a blood test and ultrasound of kidneys

Or, because you have private health insurance GP sends you for MRI of spine

Plus original poster gives a real life example?

[Loose rivets]

when in the next breath you say the operation is so dangerous it can't be undertaken on the basis of age........just keep taking apple juice and hanging up by your feet.



It's the trouble with speaking emotionally. I'm putting in too much passion and not enough accuracy, but, I did say my mother was of a great age, and that it was miss-diagnosed when she - probably - had the 'big one' many years before, evidenced by the fact I was 8 or so.


It was the anesthetic that was deemed the risk.

By the time she had the stone spotted - while another problem was being investigated - it was too late for a safe general anesthetic.

Mind you, I've often wondered how the Queen Mother had a general at 90 odd.

[obgraham]

how the Queen Mother had a general at 90 odd. More likely a spinal -- often used for hip surgery in the frail and elderly.

[Loose rivets]

Quite so. My mother was heavily built and physically strong, but she wrecked her lungs with years of smoking. I suppose that's why they deemed it such a risk. Such a shame.








.

[homonculus]

I have to declare that I am .......

an anaesthetist

We do lots of 90 year olds under GA, and no the Queen mother had a GA not a spinal - my mentor anaesthetiassed her. Both are dead so this can be discussed.

The idea that it is the anaesthetic as opposed to the surgery that is the risk really hits the nail on the head, and is why I am so concerned at people being herded to major surgery for no good reason. Regulators need to be challenged on this

Oh, and a spinal MRI wont pick up gallstones in most cases.Ultrasound of the kidneys will often not look at the gall bladder. I agree some imaging of say the renal tract will pick up gallstones, but in this case the individual clearly has a medical problem - indeed it may be they have cholecystitis and the kidney issue is a misdiagnosis.

I accept people may have symptoms or other pathology leading to imaging that detects gallstones, but my question is how a fit asymptomatic pilot could end up being diagnosed. It is perhaps fortuitous that it is really very rare as otherwise 1 in 4 pilots might be sent for major surgery and be put at risk when there is scant evidence it is justified

[Loose rivets]

Indeed, the horns of a dilemma. But not for me. I'd have to come out on the side of using a chainsaw to get the damn thing out, so perhaps it's a good thing I'm not a doctor.


The two sessions of pain I had much earlier were odd. Doctor, a young locum, was all set to send me off for an x-ray, but I was so well and fit following that, it kind of got forgotten. My fault entirely, but the symptoms were like a bad chill, so anyone could go through that mild experience and not have a clue about the cause. I cost myself a lot of grief, but I suppose having got one of the first keyhole ops, I saved having open surgery, but . . .

[obgraham]

Homonculus:

I, of course, defer to your knowledge of the case regarding anesthetics. Certainly hereabouts, we use a lot of regional anesthesia.

However, as I many times advised, when asked "what should I have, general or spinal or epidural?", my standard answer was "speak to the anesthesiologist and go with what he/she thinks is best". Perhaps you agree, the worst thing is trying to tell the anesthetist what he/she should do!

[gingernut]

There's two trains of though here......re a symptomatic multiple gallstones....go to one surgeon, he'll whip them out....the next guy says if they are not bothering you leave them.

Ha Ha, remember when we were rolling out the concept of "Clinical Governance." Listened to the then director of clinical governance (?Aidan Hallerghan), who reckoned that if a pilot and co-pilot were as disparate as doctor's, then we'd never get on the plane.

We tend not to get these problems with nurses, 'cos they just do as they're told. (Although there are exceptions to the rule.):}

The trouble with these bloo+y tests, is that often, the findings don't often correlate with the symptoms, and sometimes, even less so with the cure.

How may cancers have we sparked off from ordering lumbar spine x-ray's ? And did it ever affect the management ? (Although we have moved on with the like's of MRI's.)

We're almost into the realms of screening here, and if the process doesn't satisfy Wilson's Criteria (Wilson's criteria for screening tests - General Practice Notebook (http://gpnotebook.com/simplepage.cfm?ID=1469710399)) then we shouldn't be using it.

PS homo, is it true that the job of anaesthetist is similar to that of pilot. Hour's and hours of tedium, punctuated by minutes of pure terror ?

[Level Attitude]

I accept people may have symptoms or other pathology leading to imaging that detects gallstones
You get treated (and cured) for the original pathology but you now know you also have gallstones.

but my question is how a fit asymptomatic pilot could end up being diagnosed.
Having been cured of original problem you are now a fit asymptomatic pilot.

It is perhaps fortuitous that it is really very rare as otherwise 1 in 4 pilots might be sent for major surgery and be put at risk when there is scant evidence it is justified
Exactly!! Which is why CAA says if you have asymptomatic gallstones then you can have a Class 1 or Class 2 Medical.

Risk of first sympton occuring whilst piloting an aircraft = Low
Risk of first ever sympton being incapacitating = Low
Consequences of incapacitation:
- Passenger Jet = Nil (That's what 2nd Pilot is for)
- Small GA = Person(s) on board only (Even a crash is highly unlikely to hit anything except open countryside)

[homonculus]

Obgraham you are an unusual doctor to say go with the anaesthetist. Actually more and more now we use epidurals as treatment as well as a method of eliminating pain. It would be 'suboptimal' (doctor speak for c***) to do for example removal of large bowel (colon) witout both an epidural and general. so more and more it is good practice not my preference

Gingernut - no there is a big difference between my two jobs. As an anaesthetist I always walk away from my accidents........

[Loose rivets]

A snippet about the subject.

BBC News - Nelson Mandela undergoes operation to remove gallstones (http://www.bbc.co.uk/news/world-africa-20739780)

[Bearcat]

Well there's the asymptotic gallstone conundrum put to bed.

[homonculus]

The BBC must have got it from the Daily M@@@

Tosh