Gallstones

WHAT ARE GALLSTONES?

Gallstones are solidified and hardened accumulations of cholesterol, calcium compounds, bilirubin, digestive fluids, and other particulates within the gallbladder. This gallbladder disease is also known as cholelithiasis, derived from the Greek terms “chole” which means bile, and “lithos” meaning, stone. Bile is a fluid made in the liver, stored in the gallbladder, and used to digest and absorb fats and remove wastes, among the many other functions it has.

Gallstone disease is a very common disorder, affecting a total of approximately 20.5 million men and women aged 20 to 74 in the United States alone based on the third National Health and Nutrition Examination Survey. Its prevalence makes it one of the top reasons for gastrointestinal-related hospitalizations. Although the mortality rate is much lower now, thanks to recent medical technology, gallstone disease is still something that must be taken seriously. Annually, gallstones account for a staggering total of ~$ 6.2 billion worth of financial burden for tests, treatment, research, and other medical procedures.

The most common type of gallstone is called cholesterol stone which makes up 90-95% of known gallstone cases. When there is too much cholesterol in the body, the bile can thicken and crystallization of the cholesterol may occur. A pigment stone, on the other hand, is caused by abnormally high levels of bilirubin and other minerals in the bile. Bilirubin is the dark yellowish waste substance produced during the breakdown of old red blood cells. It usually passes through the liver before it gets excreted by the body. Pigment stones also tend to develop in people who have liver cirrhosis, severe hemolytic anemia, or infections in the bile duct.

Oftentimes, gallstone formation is a long and complicated process. The particulates do not instantly form stones. Instead, it may start with a biliary sludge – a stagnant and concentrated bile residue. This sludge is known to be a precursor to gallstones. Once the bile fluid turns into sludge, the cells lining the gallbladder will also no longer be able to efficiently absorb fat and cholesterol.

WHAT CAUSES GALLSTONES?

Various reasons prompt the development of gallstones. Some of the common causes are:

• The imbalance of cholesterol and bile salts in the body may cause crystallization within the gallbladder which can turn into cholesterol stones.
• The presence of high levels of bilirubin over a long period of time may lead to pigment stones as it contributes to the formation of biliary sludge. Biliary sludge may be a mixture of different particulates including bilirubin, calcium compounds, cholesterol mucin, and other materials. This sludge can be a reason for the stagnation of bile within the gallbladder which eventually causes thickening and clumping together of particulates forming a gallstone.
• Other medical opinions also say that the use of some pharmaceutical drugs can cause gallstones. This includes medications containing estrogen, octreotide (used to treat certain kinds of tumors), and some types of cholesterol-lowering medications that lower the amount of cholesterol in the bloodstream but increase its presence in the bile.
• Weight issues – overweight, rapid weight loss, lack of physical activity
• Pre-existing gastrointestinal issues like leaky gut, constipation, chronic inflammatory bowel disease, or Chron’s disease
• Other diseases like metabolic syndromes, diabetes, and low thyroid
• Diet – an unhealthy diet that includes food with high triglycerides, high LDL cholesterol, non-fat diets, low-fat diets, low-fiber diets, excessive drinking of alcohol, and others. Even food intolerances or allergies can cause gallstones and gallbladder attacks. Refer to the section on the gallbladder diet for more details.

There are also certain unavoidable risk factors that increase your chance of developing gallstones:

• Family history – The likelihood of developing gallstones is hereditary. If any of your relatives have gallstone disease, there is a good chance you can also have it if the other controllable factors are not managed.
• Age – As one exceeds age 40, the risk of gallstones increases.
• Sex – Females, especially those who have had children, are more at risk for gallstones. The presence of extra estrogen during pregnancy contributes to cholesterol increase in the bile. Even after giving birth, too much of the female hormones can cause a higher propensity of the bile to aggregate. It also affects the normal functioning of gallbladder emptying. Aside from naturally existing hormones in the body, birth control pills and hormone replacement therapies may also cause the formation of gallstones.
• Ethnicity – American Indians and Mexican-Americans are most inclined to develop gallstones. In fact, almost 65 percent of women and 30 percent of men among American Indians have them.

WHAT ARE THE SYMPTOMS OF GALLSTONES?

It is not unusual for people to have gallstones and know nothing about them until it is discovered accidentally by some medical tests. This is because most of the time, the symptoms of gallstones are absent, thus the term “silent gallstones”. Of the known cases of gallstones, approximately 80% do not cause any pain, nor does it manifest through other symptoms. However, once a gallstone blocks a bile duct, it can cause sharp and severe abdominal/gallbladder pain is known as biliary colic. It is important to note though, that gallbladder pain is not automatically caused by gallstone blockage. A low-functioning gallbladder or disruption to the bile flow may also cause sudden and intense agony. To read more about bile duct blockage, inflammation and infection click here.

A few or all of the following may be experienced as symptoms of gallstones:

• Severe pain on the right side of the abdomen
• Pain may refer to the back, towards the right shoulder, or between the shoulder blades
• Symptoms often manifest at night, especially after having a fatty meal
• Pain may feel sharp and piercing like a knife. In acute cases, it may be cramp-like
• Chronic pain may be dull and colicky
• Bloating and gas that may cause distention
• Possibly belching or burping – often very deep
• Inhaling deeply can worsen the pain, making you double over
• Nausea and vomiting may be experienced
• Chills and fever may accompany other symptoms
• Gallbladder chest pain may be likened to a heart attack
• Yellowing of the skin and whites of eyes also known as jaundice may develop

Since chronic symptoms overlap with irritable bowel syndrome and non-ulcer dyspepsia, further medical testing is highly encouraged. This way, doctors may come up with an accurate diagnosis. Also, gallbladder symptoms can look and feel the same with or without stones.

GALLSTONE DIAGNOSIS AND TEST

If you have reason to believe that you may have gallstones, despite the absence of pain and other symptoms, it is best to seek professional medical help. Early detection is always a good way to prevent complications, shorten hospitalization and even lessen medical expenses.

During the consultation, a patient interview will most probably be conducted first. Through this, the patient’s health history, diet, and other related details may be gathered and factored in. Upon the doctor’s evaluation and recommendation, one or a few of the following tests may be conducted to confirm the presence of gallstones.

• Ultrasonography (US) – Most of the time, an ultrasonography test is enough to confirm if gallstones are indeed present. The US is usually an accurate detector, showing about 90% of gallstones on the first try. If some patients with strong clinical suspicion of gallstones yield negative results, then a more sensitive US test may be conducted. However, common bile duct stones may not appear in the imaging as these may be concealed by duodenal gas.
• Computed tomography (CT) scans – To get three-dimensional images of gallstones or their complications such as the blockage of the bile ducts or inflammation of the gallbladder, a CT scan may be performed on a patient. However, since more than 80% of gallstones are radiolucent, there is still a possibility that this test won’t be able to detect 100% of the gallstones present.
• Magnetic resonance cholangiopancreatography (MRCP)- Using magnets and radio waves, MCRP can produce detailed pictures of the body’s internal organs and soft tissues. This means that it can show images of gallstones blocking the bile duct and pancreatic duct if there are any. This test is a non-invasive alternative to endoscopic ultrasound. However, MRCP is less sensitive for stones smaller than 6mm.
• Endoscopic Ultrasound (EUS) – This particular test entails the insertion of a small tube to the mouth down to the stomach up to the first part of the small intestine. EUS is used to assess not just gastrointestinal diseases but it can also be used to check the lungs. Through the emission of high-frequency sound waves, EUS can show detailed images of the pancreas, liver, gallbladder, and other nearby organs.
• Endoscopic retrograde cholangiopancreatography (ERCP) – Similar to EUS, this test requires the insertion of a small tube through the mouth into the duodenum and bile ducts to help locate gallstones and affected bile ducts, if any. Because of its invasiveness, ERCP is not the usually recommended test in all cases of suspected acute cholangitis with a high probability of ductal stones.
• Biliary scintigraphy – This test is also called a hydroxyl iminodiacetic acid scan, HIDA scan, or hepatobiliary scan. Through the help of radioactive material, this procedure can produce pictures of the biliary system. It can even show the bile flow through the bile duct and how the gallbladder fills and empties. However, it can only provide indirect evidence of the presence (or absence) of gallstones.

GALLSTONE COMPLICATIONS

Though gallstones often do not cause pain or show symptoms, it may still cause a plethora of complications. Although some of these conditions are very rare, it is still important to know that these can happen if gallstones and other gallbladder diseases are not diagnosed early.

• Biliary colic – Generally speaking, biliary colic refers to the steady or intermittent pain experienced by patients with gallbladder diseases and possibly, other gastrointestinal issues. With gallstones, pain happens when the stones pass from the gallbladder into the cystic duct, common bile duct, or ampulla of Vater and block the duct. Biliary colic is also a term used to embody all of the symptoms during a gallbladder attack including pain or discomfort in the right upper quadrant, gas, bloating, and nausea.
• Cholecystitis – This condition is also called the inflammation of the gallbladder. This may happen when a gallstone becomes lodged in the neck of the gallbladder or when the abundance of gallstones erodes the gallbladder wall. If cholecystitis is not diagnosed early, it may result in a perforation of the gallbladder which may cause the leakage of bile, leading to peritonitis or severe inflammation. Patients suffering from cholecystitis may experience extreme pain.
• Blockage of the common bile duct – Gallstones may cause blockage along the bile pathways from the gallbladder or liver to the small intestine. This can result in the stagnation of bile, infection, and even jaundice.
• Blockage of the pancreatic duct – Aside from the bile duct, gallstones may also affect and block the pancreatic ducts causing pancreatitis (the inflammation of the pancreas). This may cause intense and constant abdominal pain to the patient. Immediate medical attention is imperative in the case of pancreatitis as it remains a life-threatening complication with mortality ranging from 3% to 20%.
• Empyema – When the gallbladder contently stagnates due to blockage or inflammation of the ducts, bacteria may proliferate, causing pus to fill the gallbladder. This is effectively an abscess within the gallbladder wall called empyema.
• Mucocele – This is a condition wherein the inflamed gallbladder mucosa, in the absence of bacterial infection, continues to absorb water from bile and excretes mucus despite gallstone blockage of the bile ducts. This complication leaves the gallbladder containing clear or bile-stained mucus. A patient with mucocele may also experience biliary colic.
• Porcelain gallbladder – Although gallstones are not the only cause for porcelain gallbladder, it is definitely the most common root for the development of such gallbladder disease. Porcelain gallbladder is the condition wherein the gallbladder becomes calcified. This may happen due to long-term gallstone blockage or the constant irritation of the gallbladder wall due to gallstones which can lead to swelling as well as the precipitation of calcium particulates in the bile. To know more about porcelain gallbladder, read here. 
• Cholecytoduodenal fistula (CDF) – CDF is a rare and serious complication of gallstone disease. Through an x-ray or ultrasound, an abnormal presence of gas within the biliary system may be detected. This is brought about by the erosion of the duodenum due to the presence of gallstone. To treat it, the CDF needs to be stapled and the gallbladder, removed.
• Gallstone ileus – This condition is a complication of acute cholecystitis that is responsible for over 25% of bowel obstruction cases in patients 65 years or older. It is typically caused by one gallstone that migrates through the gallbladder wall, through the wall of the small intestine, and lodges there, blocking the passage of food in the bowel. Usually, these stones are smaller than 2 cm in diameter.
• Gallbladder cancer – Although the probability of developing gallbladder cancer because of gallstones is very small, it can still happen. Due to chronic gallbladder inflammation brought about by gallstone blockage or irritation, bile release may be very slow. This exposes the gallbladder to the chemicals in bile for a longer time than usual. The reflux of pancreatic juices into the gallbladder and bile ducts due to gallstone blockage may inflame and stimulate the growth of cells lining the gallbladder, increasing the risk of cancer.

GALLSTONE TREATMENT

There are many different ways to treat gallstones. The most common and highly recommended measure is still surgery. However, non-invasive and natural alternatives are also an option.

Surgical

• Laparoscopic cholecystectomy – Since this technology has become available, laparoscopic cholecystectomy has been the gold standard in addressing gallstones and other gallbladder diseases. Since we can technically live without any gallbladder, many doctors implore this method at the onset rather than risking the recurrence of the gallstones or any other issues related to the organ. Successful laparoscopic cholecystectomy can be achieved in more than 95% of all gallstone patients.
• Open cholecystectomy – this type of surgical removal of the gallbladder may be used for certain patients such as those with cirrhosis, gallbladder mass, those with extensive upper abdominal surgery, and those with suspicion of malignancy.
• Percutaneous cholecystostomy – Percutaneous cholecystostomy is a method used to control acute cholecystitis in patients like the elderly who are prone to infective complications. Through this procedure, the gallbladder leakage is minimized and the causative gallstones will eventually be dealt with by laparoscopic cholecystectomy or percutaneous stone extraction along the drainage tract.
• Endoscopic sphincterotomy (ES) – This procedure, also called endoscopic papillotomy, is an operation that cuts the muscle between the common bile duct and the pancreatic duct. It requires the use of a catheter and a wire to remove gallstones or other blockages. It can sometimes also be used to drain the gallbladder and treat cholangitis (inflammation of the duct). ES, together with stone extraction, is also said to be effective in addressing obstructive jaundice. For patients unfit for surgery like the elderly, ES can be changed and used as long-term management.

Non-Surgical Approach

• Shock wave lithotripsy – Through a machine called a lithotripter, shock waves are directed to the body, breaking the gallstones into smaller pieces. Shock wave lithotripsy is sometimes used together with oral dissolution therapy. While this treatment is available in other countries, it is rarely performed in the United States.

Natural and Alternative Treatments

• Oral dissolution therapy – This method uses bile acids to dissolve gallstones. Medications like ursodiol (Actigall) and chenodiol (Chenix) may be prescribed to the patient. Oral dissolution therapy effectively dissolves small cholesterol stones but does not apply to everyone. Upon assessing the patient’s situation, the gallbladder condition, and the stone sizes, a doctor will be able to determine whether this non-surgical approach will solve the gallstone problem. However, even if this therapy works, there is still a huge probability that the gallstones will recur, especially without dietary and other lifestyle changes.
• Gallbladder and Liver Flush – This natural means of passing gallstones may be helpful with small stones. The gallbladder and liver flush helps cleanse stagnant waste from the organ and improve the bile flow as well as liver functioning. Products like the Phos Formula and enteric-coated Peppermint Oil can be taken while preparing for a flush. It is important to be able to prepare for this method for weeks or even months, coupled with a dietary change. If currently in pain, this method is not recommended. The gallbladder and liver flush can be used by those who have had gallbladder removal as well as by those who have not.

Sometimes, cholecystectomy is not the end of the story for those with gallstones. In some cases, even after the surgery, patients continue experiencing digestive issues. In this light, some medical practitioners recommend the use of complementary and alternative treatments together with a dramatic change in lifestyle and eating habits. Regular exercise, moderate eating, and maintaining the ideal weight are keys to maximizing the benefits of a gallbladder diet plan.

THE GALLBLADDER DIET – What to eat, which foods to avoid, and how to do it

• Drink at least 6-8 glasses of water per day
• Make sure that your diet is high in fiber – you need lots of vegetables!
• Avoid refined carbohydrates – this includes sugar and white flour
• Include Omega 3 oils such as fish oil and other polyunsaturated fats and monosaturated fats such as olive oil in your diet. Other sources include avocados, almonds, cashews, and peanuts.
• Eat moderate amounts of lean meats
• Avoid saturated and trans fats – foods with hydrogenated oils, butter, cream, and lard must be eliminated from your diet as much as possible. Fried and battered food, cake mixes, and frostings, as well as frozen or creamy beverages, are the most common examples.
• Eat more polyunsaturated fats – common sources are fish, soybean, sunflower oil, flaxseed and chia seeds, and certain types of nuts.
• Do an elimination diet for food allergies – cut out common allergens such as wheat and all other grains containing gluten, and dairy
• Take supplemental bile salts and bile thinning agents as found in the gallbladder products. In particular, The Starter Kit can be used, then afterward follow-up with Fos Formula and Peppermint Oil Capsules.
• Take care of health issues such as hypothyroidism, leaky gut, and food intolerances before they have a chance to cause gallstones.

The benefits of The Gallbladder Diet can go beyond just helping you with your gallstones. It can also aid in managing gallbladder attacks and lead you to improve your overall digestive health. If you want to get your energy back, end your recurring symptoms, and free yourself from gallbladder pain, this might just be the solution you are looking for. Get your Gallbladder Menu plans today or click here for recipes for your gallbladder pain.

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References:

(1)Torsoli A, Corazziari E, Habib FI, Cicala M. Scand J Gastroenterol Suppl. 1990;175:52-7.

(2) The physicochemical basis of cholesterol gallstone formation in man William H. Admirand and Donald M. Small 1Boston University Medical School, Department of Medicine, Section of Gastroenterology, Boston, Massachusetts 02118

(3) Friedman GD. Natural history of asymptomatic and symptomatic gallstones. Am J Surg 1993; 165: 399-404.

(4) Nagase M, Hikasa Y, Tanimura H, Setoyama M, Kamata T, Mukaihara S, Maruyama K., Etiology of cholesterol gallstones., Gastroenterol Jpn. 1979;14(1):40-7

(5) Ruppin DC, Dowling RH.Is recurrence inevitable after gallstone dissolution by bile-acid treatment? Lancet. 1982 Jan 23;1(8265):181-5.

(6) Weinstein S, Lipsitz EC, Addoniziol L, et al. Cholelithiasis in paediatric cardiac transplant patients on cyclosporin. J Pediatr Surg 1995;30:61-4.

(7) Carey MC.,Pathogenesis of gallstones.Recenti Prog Med. 1992 Jul-Aug;83(7-8):379-91

(8) M.M. Moga, Alternative treatment of gallbladder disease, Medical Hypothesis Volume 60, Issue 1, Pages 143-147 (January 2003)

(9)Igimi H, Tamura R, Toraishi K, Yamamoto F, Kataoka A, Ikejiri Y, Hisatsugu T, Shimura H. Dig Dis Sci. 1991 Feb;36(2):200-8 Medical dissolution of gallstones. Clinical experience of d-limonene as a simple, safe, and effective solvent. Shionogi Research Laboratories, Shionogi & Co., Ltd., Osaka, Japan

(10,12) Hiroshi Tanimura and Yorninori Hikasa, The Etiology and Pathophysiology of Cholelithiasis. Journal of Gastroenterology, Springer Japan ISSN0944-1174 (Print) 1435-5922 , Volume 10, Number 1 / March, 1975

(11)U. Leuschner, M. Leuschner, J. Sieratzki, W. Kurtz and K. Hübner,Gallstone dissolution with ursodeoxycholic acid in patients with chronic active hepatitis and two years follow-up. Springer Netherlands, Digestive Diseases and Sciences, Volume 30, Number 7 / July, 1985

(12)William A. Gracie, M.D., and David F. Ransohoff, M.D.,The Natural History of Silent Gallstones — The Innocent Gallstone is Not a Myth, N Engl J Med 1982; 307:798-800September 23, 1982