It was a few days after Christmas when 16-year-old Amanda Custer and her mom made a rare stop for a takeout burger. The indulgence ended badly for Amanda.
Soon after, she said, "I felt real nauseous. Food was, like, gross. I got really bad cramps, a whole bunch of heartburn and an upset stomach."
And it didn't go away.
"I would feel OK and try to eat something, and then I'd regret it," she recalled. "The pain afterwards was horrible. A couple of hours after I ate, I'd be going to the bathroom, feeling nauseous."
After a series of tests, Amanda was diagnosed with gall bladder disease. And six weeks after her first attack, the Westminster teen had her gall bladder removed at St. Joseph Medical Center in Towson.
Her surgeon is Dr. Atena Rosak, who does a lot of adult gall bladder surgery. She says she's seeing more and more young people — especially young women — coming under her knife. Amanda, now 17, was her youngest.
"Since August 2010, I have done laparoscopic cholecystectomies on five women [aged] 16 to 25, and seven women 26 to 35," she said. "Only one male less than 35 in those few months."
That's surprising to her. The percentage of people aged 30 or younger among all patients having their gall bladders removed at St. Joseph has increased from 12.5 percent in fiscal year 2007 to 16.3 percent in the 10 months of the current fiscal year, hospital officials said. That's a 30 percent growth in the proportion of young people in the mix.
And it's easy to find comments on online medical sites from frightened teens facing gall bladder surgery and questions from their worried moms.
But what's not clear is whether there's been a real increase nationally in gall bladder disease among young people.
Dr. Anthony N. Kalloo, professor of gastroenterology at the Johns Hopkins University's School of Medicine, is not persuaded.
"The textbook description is an overweight woman in her 40s," he said. "We still see a lot of patients like that. Do we see more patients that are younger? I really do not think so."
"I have had a patient or two in their early 20s or late teens who needed gall bladder removal," Kalloo said. "But it's certainly not an epidemic." Nor could he find anything in the medical literature to support the notion of a trend.
"I'm not saying they're wrong," Kalloo said of the reports from St. Joseph. But he hasn't seen it in his practice. "There's an old saying, that one swallow doesn't make a summer."
At the University of Maryland Medical Center, Dr. Emanuele Lo Menzo said he had not checked his hospital's data for evidence of such a trend. "But I would not be surprised" to find it, he said. In an email message, Lo Menzo, an assistant professor of surgery at the university, said he sees several potential explanations.
"Certainly the change in diet [fattier, more preservatives, larger portions] plays a key role," he said. It's also possible that doctors are spotting incipient gall bladder disease earlier because they're doing more medical imaging.
Finally, Lo Menzo said, "more refined, minimally invasive techniques lead to a higher number of patients willing to undergo the procedure."
As many as 25 million Americans are said to suffer from gall bladder disease, with more than a half-million having their gall bladders removed each year.
The gall bladder is a thumb-sized pouch nestled in the liver, high on the right side of the abdomen. It collects digestive enzymes manufactured in the liver, and stores them as a fluid called bile. When called for by the digestive system, the gall bladder contracts and squeezes the bile through a duct system and into the small intestine.
Several things can go wrong with the gall bladder. Among the most common is the development of gallstones. When the bile is saturated with cholesterol, some of it will begin to crystallize. The crystals combine with calcium and other debris in the bile to form hard "stones."
"Roughly 20 percent of the people walking around out there have stones. They're a fairly common occurrence," said Dr. Richard A. Mackey, a biliary and pancreatic surgeon at St. Joseph.
In some patients, the gallstones grow and become an irritant to the gall bladder. Sometimes they move into the bile duct, causing pain as they pass through. Or they may block the duct, leading to pain, swelling, infection and a medical emergency.
The gall bladder may also become inflamed without the presence of stones. And in both situations its function declines. It is less able to squeeze bile into the digestive tract. That brings on digestive problems in addition to the pain, nausea and fever that typically come with the disease.
The causes aren't entirely clear, Rosak said. But a few things have been linked to a higher risk of developing gall bladder disease.
"We do know the development of … gallstones is related to the amount of fat or calcium in one's diet," she said. "We know that estrogen is related to it."
So the immediate suspects include overeating and a diet high in fats and highly refined foods. "Our diet in this country, particularly our youth, has deteriorated horribly in the last 20 years," she said.
More fat, more calories, more refined foods and less whole-grain foods, fruits and vegetables could all contribute to a rise of gall bladder disease among younger people.
Obesity continues to be associated with gall bladder disease. "I did have an 18-year-old who was obese, a very heavyset girl," Rosak recalled. Yet "she didn't see herself as obese."
"I think there's a perception that obesity is a social issue, and not a health issue," she said. "Not everyone appreciates the health effects of obesity."
The fact that some of her young patients have been skinny, she said, doesn't mean they're eating a healthful diet. Nor does it change the message: Without a change, Rosak said, "we should start to see [gall bladder disease] more and more."
The use of birth-control pills, which contain small amounts of estrogen, is also mentioned as a possible contributor to gall bladder disease, as is dehydration, which may contribute to the crystallization of cholesterol in the bile.
Teens, and especially their parents, are often surprised at the diagnosis, Rosak said. Gall bladder problems are still associated more with the middle-aged and older. But "most people are probably relieved, because it's simple and easy to do something about it."
Donna Custer took her daughter to a gastroenterologist, who soon zeroed in on her gall bladder, where X-rays showed an accumulation of debris called "sludge." A test called a HIDA scan revealed Amanda's gall bladder function was significantly degraded. It had to come out.
Rosak performed the out-patient surgery Feb.18. Amanda said she was sore afterward, and it was a week before she was up and moving around.
"It took probably about three weeks to a month for me to eat normal again," she said. "I guess I was timid to eat stuff till I knew how I'd feel."
She's still cautious about what she eats, but doctors say people generally do fine without their gall bladders.
"You no longer have a storage organ," Kalloo said, "so the liver simply compensates by increasing bile production at the time of a meal. It's adequate."
And patients today can heal with little if any scarring — an important consideration for young women concerned about their appearance in bathing suits.
Rosak said only 5 percent to 10 percent of her gall bladder surgeries are the traditional operations that open the abdomen. Eighty percent are now laparoscopic surgeries that leave three half-inch scars under the right ribs, and a fourth in the belly button.
Ten percent to 15 percent of her patients, especially younger women, are electing the newer "single port" surgery in which all the instruments — video camera, light, the device that grasps the gall bladder, scissors and the instrument that clips off the bile duct and arteries — are inserted through a hole in the bellybutton.
The surgery can take as little as a half-hour, depending on the patient, Rosak said. Patients go home the same day.
While the hope was that single-port surgeries would result in quicker, less complicated recoveries, she said, "most of the early studies are not noting much of a difference. But cosmetically, it looks fabulous."
Most patients still opt for the four-incision route. It's faster and cheaper. "A lot of people aren't fazed by the scarring," Rosak said. But she confessed her own vanity.
"I fully admit, I started doing it [single-incision gall bladder surgery] because I would want it for myself," she said.