Overview: Gallstones (Cholelithiasis)

• According to the third National Health and Nutrition Examination Survey, more than 20 million people in the United States have gallbladder disease. The occurrence of gallstones varies greatly, ranging from 2% to 70% among dif ferent populations. The highest incidence is among Pima Indian women older than 30 years of age.

• Bile aids in the digestion and absorption of lipids from the intestines. Made by the liver, bile is composed of bile acids, cholesterol, and phospholipids, and it is stored in the gallbladder until stimulation by cholecystokinin cases its release. Conditions that lead to gallstone formation include supersaturation of hile with cholesterol, decreased bile acids that dissolve cholesterol, excess mucus production, and gall bladder dysmotility and stasis (Fig. 43-1).

• Gallstones are classified as as e either cholesterol or pigment In industrialized countries, cholesterol stones account for up to 85%.

• Most people with gallstones remain asymptomatic. Approximately 20% will develop true biliary symptoms, such as severe pain in the right upper quadrant that can radiate to the back or shoulder, and d 1% 1% to 2% will develop a complication that requires surgery.

• Epidemiologic research has revealed many risk factors for gallstones. Some of these conditions are not modifiable: sex, age, and ethnicity.

• Many conditions can be changed, however, such as obesity, physical inactivity, medications, nutrition, and stress. Table 43-1 provides a list of condi tions that increase risk.

Important Points to Consider

• Foods associated with a reduced risk of gallstones include fiber-rich fruits and vegetables, whole grains, nuts, coffee, and moderate alcohol.

• Lifestyle is the key to treatment. Except for surgery, all treatments are associated with a high 5-year recurrence rate if lifestyle modifications are not made.

Prevention Prescription

Preventing gallstones is easier than treating them. The same principles of prevention apply to many common chronic diseases (diabetes, heart disease) for an added benefit.

• Maintain a healthy weight, with slow gradual weight loss if body mass index is elevated. Exercise. Get moving in a way that is enjoyable and sustainable for you, at least 30 minutes five times weekly.

• Find a stress-reducing practice.

• Encourage a diet high in fiber, vegetables, fruit, nuts, and omega-3 fatty acids.

• Maintain a low intake of saturated fats, refined sugars, and high-glycemic load foods.

• Remember hydration. Drink at least 6 to 8 cups of clean water daily. Consider coffee if you enjoy it, 2 to 3 cups daily. A moderate intake of alcohol may be suitable for some patients.

• Consider an elimination diet.

• Consider supplementation: vitamin C, 200 mg twice daily; magnesium, 300 mg/day; vitamin E, 400 units/day with meals; calcium, 1000 to 1500 mg/day; and lecithin, 500 to 1000 mg/day.

• Avoid medications associated with gallstone risk: estrogen, ceftriaxone, octreotide, and fibrates. Take precautionary measures if taking these medications, have excessive weight loss, or are receiving total parental nutrition (TPN).

Integrative therapeutics review

Immediate surgical referral is warranted in the setting of severe recurring symptoms, elevation in liver enzymes, amylase, or white blood cell count. In patients with asymptomatic or mild cases and normal liver function, proceed with the therapies listed here.

Lifestyle

• Maintain a healthy weight.

• Exercise at least 30 minutes a day, five times a week.

• Participate in stress-reducing activity.

Nutrition

• Diet should be high in fiber, fruits, and vegetables.

• Consider supplementing with fiber and flaxseed.

• Recommend diet low in saturated fat, rich in omega-3 fatty acids.

• Drink 6 to 8 cups of water daily.

• Avoid refined sugars.

• Avoid excess intake of legumes. Consider an elimination diet.

Supplements

• Vitamin C: 200 mg twice daily

• Calcium: 1000 to 1500 mg/day

• Vitamin E: 400 units/day

Botanicals

• Milk thistle (Silybum marianum) standardized to 70% silymarin extract: starting at 150 mg twice a day and increasing to three times/day if needed

• Dandelion (Taraxacum officinalis): 1:5 tincture, 5 to 10 mL three times/day

• Artichoke (Cynara scolymus): 1 to 4g of leaf. stem, or root three times/day

• Turmeric (Curcuma longa): 450-mg curcumin capsule, or 3g root daily

• Peppermint oil (Mentha piperita): one to two enteric-coated capsules three times/day between meals

Pharmaceuticals

• Ursodiol (ursodeoxycholic acid): 300 mg twice daily with meals

Surgery

• Laparascopic cholecystectomy

• Patients with common bile duct obstruction (elevation of liver enzymes, lipase, and bilirubin, right upper quadrant pain, jaundice, and common bile duct dilation on ultrasound) may need either endoscopic retrograde cholangiopancreatography for stone removal or surgical exploration.

Key Web Sources

• http://nccam.nih.gov.

• http://digestive.niddk.nih.gov.

• www.gastro.org.