You would think gallstones are a normal part of the human anatomy with over 20 million people in the US harboring gallstones (15% of the US population).  As we get older these stones become even more common -- half of all women in the US over the age of 70 have gallstones.  The huge prevalence of this disease has the potential for big medical business.  Consider, even now there are 800,000 hospitalizations, and $2 billion spent annually on gallbladder disease. With more honest consumer information all of these figures could be cut to a fraction of the present figures.

Gallbladder Symptoms:

Fortunately, gallstones cause no symptoms in the vast majority of patients.  They may be discovered by a routine chest x-ray or other diagnostic tests looking for problems unrelated to the gallbladder.  The risk of people with gallstones developing mild symptoms is 1% to 3% annually.¹  Once diagnosed with gallstones, within the first five years 10% of patients develop symptoms, and within 20 years, 20% have symptoms.  This means someone with stones has an 80% chance of living without symptoms – that is, they remain asymptomatic.  Unfortunately, the greatest threat to an asymptomatic patient is the meddlesome doctor – trying to help patients who don't need help.

Simple pain, rather than serious complications, is the first symptom of gallbladder disease in over 90% of people with stones, therefore waiting has few serious consequences.   These facts: most people with gallstones remain asymptomatic and symptoms when they do occur are usually not life threatening, mean: "you should be allowed to die with your gallstones."

If doctors actually helped people by removing symptomatic gallstones, then the medical business would be actively trying to eradicate the "gallstone plague" upon our society by setting up x-ray booths and surgical units on every other corner in every town across the US.  This action would cause well-deserved criticism, because the scientific research clearly and consistently shows that your risk of death and disability is much greater if you take a course of immediate surgery upon discovery of gallstones, rather than "watchful waiting," until some symptoms develop.^2,3

Gallbladder Colic:

Most people who develop symptomatic gallbladder disease have pain in the mid-upper or right-upper section of the abdomen and it often radiates to the right shoulder blade.  This pain is caused by obstruction of the bile-carrying duct, called the cystic duct, which leads from the gallbladder to the small intestine.  The pain is sometimes referred to as "colic," which would indicate mild, transient pain.  However, this is a misnomer because the pain is usually severe, steady, and lasts from 15 minutes to 6 hours.  The pain is often at night and not related to meals.  Once the first pain has occurred, the probability of a second attack is between 50% and 70% within 2 years (if no change in diet is made).  Nausea and vomiting are also common.  Between attacks everything is usually normal.

When the obstruction is prolonged (more than 6 hours), then distention and inflammation can develop with secondary bacterial infection in about 50% of cases.  This is a serious complication that usually requires immediate medical attention.   Stones can also block the ducts draining the pancreas and cause pancreatitis.

The diagnosis of gallstones is usually made by an ultrasound examination (sound waves that penetrate the abdomen and find stones).  This test can painlessly detect 95% of stones larger than 2 mm (the size of a rice grain).

TREATMENT OPTIONS

Expectant Management Until Symptoms or Complications Develop:

"Expectant management," in other words, no treatment at all, is what I recommend for people with asymptomatic disease because the risk of attacks and complications is so small.  If you have had one attack, then you can likely change your condition to "asymptomatic" again by following the "time-honored" treatment for gallbladder attacks -- a low-fat diet.  Physical activity may also prevent progression of gallbladder disease.  One study found 34% of men with gallstones were able to prevent development of symptoms with 30 minutes of endurance exercise 5 times a week.⁴Therefore, by cost-free, pain-free diet and exercise practices you may be able to avoid surgery and in this way you can "die with your gallstones."  Patients with recurrent attacks that cannot be prevented are generally referred on to surgery.  However, after reading about surgery, there may be some other options you might want to consider.

Immediate Surgery:

Gallbladder removal for stones and disease is called a cholecystectomy.   The first such operation for symptomatic gallbladder disease was performed in 1882.  This surgery is preformed by cutting a 4 to 8 inch hole in the right upper quadrant of the abdomen.  The gallbladder is directly visualized and removed by the surgeon.

Laparoscopy cholecystectomy was introduced in 1987.  This technique is done using a small scope through which the gallbladder is removed.  Small incisions, leaving barely visible scars, are made and the patient has a much quicker recovery than with open surgery.  Because of the convenience of this procedure, the number of gallbladder surgeries has dramatically increased and more people with questionable indications – asymptomatic disease and those with symptoms not caused by the gallbladder – are undergoing gallbladder removal.  The number of surgeries in the US has increased from 500,000 annually in 1987 to 770,000 in 1996 – largely because of this new procedure.  Over half the operations these days are done on an elective basis and are done for symptoms of indigestion and dyspepsia (see the February 2002 newsletter for tips on relieving these common problems) that are not related to the gallbladder.  Laparoscopic cholecystectomy has a lower death rate than open cholecystectomy, but because of the increased number of cholecystectomies now performed, there may be no decrease in the total number of deaths associated with gallbladder removal.

Patient surveys, two to 24 months after both open and laparoscopic cholecystectomy, indicate that 40-50% of patients have one or two symptoms that continue, such as abdominal discomfort from excess bowel gas or dull pain, although 80-90% regard the operation as highly successful.

One of the most serious complications of gallbladder surgery is injury to the common bile duct.  Because of the limited visibility with laparoscopy surgery compared to open surgery, this injury is more common with laparoscopy surgery.  (Major bile duct injuries occur in about 0.33-0.5% of laparoscopic operations, compared with about 0.06% in open procedures.)

Reasons to Keep Your Gallbladder:

Long-term consequences of removal of your gallbladder are related to the lack of a storage sack for bile acids. Bile is continuously synthesized by the liver.  The purpose of the gallbladder is to store this greenish fluid between meals. When you eat, the gallbladder contracts, empting its contents into the small intestine, where the bile mixes with the food.  If there is no storage sack (gallbladder), then the bile constantly drips into the intestine, even when no food is present.  In this concentrated form, the bile acids are very irritating to the linings of the intestine.  Immediately, irritation of the large intestine by bile acids often causes diarrhea – and long-term the irritation can cause colon cancer.^5,6  This is the reason cancer of the right side of the colon is more common in people who have had their gallbladders removed.

These long-term side effects can be reduced or eliminated for people who have no gallbladder by eating a low-fat, high-fiber diet.  Fat is the primary stimulus for bile acid production.  On a low-fat diet much less bile acid is produced.  Dietary fiber (which is only present in plant foods) will combine and deactivate bile acids, thus protecting the bowel.  Therefore, after removal of the gallbladder it is doubly important to follow a healthy low-fat, plant-food based diet.  If this change in your diet fails to relieve diarrhea, then the next step in treatment is to use bile acid sequestering agents, such as activated charcoal or doctor-prescribed cholestyramine (Questran) or colestipol (Colestid).

Extracorporeal Shock Wave Lithotripsy (ESWL):

ESWL has been used for over 15 years to break up kidney stones.  During this treatment, shock waves generated outside the body are focused on gallstones in order to fracture them into smaller particles, the size of sand granules.   The success rate with small stones (<20 mm) is 77%, larger stones is 60%, and multiple stones is 41% -- success means complete disappearance in 6 months.⁷  The addition of bile acids (see below) to dissolve the small fragments may improve upon the success rate.⁷  This approach is of particular value for those patients who are poor surgical candidates and for those wanting to keep their gallbladders.

Bile Acid Treatment:

In the normal gallbladder, bile acids keep the cholesterol in solution, preventing stone formation.  Two bile acids, chenodeoxycholic acid (CDCA) and ursodeoxycholic acid (UDCA), when given as medications have been found to dissolve gallstones in people.  CDCA has significant side effects, like diarrhea and abnormal liver tests.  UDCA has few side effects.  Successful treatment is most commonly seen with noncalcified stones of less than 5 mm.   The rate of dissolving is about 1 mm per month.  A combination of CDCA with UDCA has about a 50% rate of complete dissolving of noncalcified stones with 6 months of therapy.⁸ The addition of cholesterol-lowering medications, known as "statins," like lovastatin (Mevacor) and simvastatin (Zocor), improve the effectiveness of UDCA therapy.^9,10   These cholesterol-lowering agents reduce both serum and bile cholesterol in humans, and also inhibit cholesterol gallstone formation in animals.  With the same cholesterol-lowering benefits, a healthy diet helps dissolve gallstones when used in combination with ursodeoxycholic acid.^11,12

Ursodeoxycholic acid (UDCA) is sold as Actigall, manufactured by Watson Pharmaceuticals, Inc.  A doctor's prescription is needed.

Drench Your Stones in a Gasoline Additive:

An ether, MTBE (methyl tert-butyl ether), which has been a popular gasoline additive, can be infused into the gallbladder onto the gallstones through a tube placed by an endoscope (from the mouth to the small intestine) or by sticking a needle through the skin into the gallbladder.  In properly selected patients, the stones dissolve in 95% of cases.  Unfortunately, they recur in 40% of patients with solitary stones and 70% with multiple stones in five years.¹³  Serious side effects are mostly related to the procedures for infusing the MTBE (endoscope and gallbladder puncture).  The MTBE can cause nausea and vomiting.

What to Do?

Try to keep your gallbladder – it has important functions that may be missed.  Many times removal of the gallbladder will not relieve symptoms and often times there are serious and troublesome side effects from treatments.  You may have not thought about this, but your gallbladder may save your life by screaming at you whenever you eat fatty foods.  In this manner, your suffering gallbladder can help you prevent heart disease, strokes, cancer, and may be the most effective weight-loss aid you could ever wish for.

References:

1)  Howard DE.  Nonsurgical management of gallstone disease.  Gastroenterol Clin North Am.1999 Mar;28(1):133-44.

2)  Aucott JN.  Management of gallstones in diabetic patients.  Arch Intern Med. 1993 May 10;153(9):1053-8.

3) Ransohoff DF.  Treatment of gallstones. Ann Intern Med. 1993 Oct 1;119(7 Pt 1):606-19.

4)  Leitzmann MF.  The relation of physical activity to risk for symptomatic gallstone disease in men. Ann Intern Med. 1998 Mar 15;128(6):417-25.

5) O'Donnell LJ.  Post-cholecystectomy diarrhoea: a running commentary.
Gut. 1999 Dec;45(6):796-7.

6)  Lagergren J.  Intestinal cancer after cholecystectomy: is bile involved in carcinogenesis?  Gastroenterology. 2001 Sep;121(3):542-7.

7)  Sauter G.  Safety and efficacy of repeated shockwave lithotripsy of gallstones with and without adjuvant bile acid therapy. Gastroenterology. 1997 May;112(5):1603-9.

8) Petroni ML. Ursodeoxycholic acid alone or with chenodeoxycholic acid for dissolution of cholesterol gallstones: a randomized multicentre trial. The British-Italian Gallstone Study group.  Aliment Pharmacol Ther. 2001 Jan;15(1):123-8.

9) Tazuma S.  A combination therapy with simvastatin and ursodeoxycholic acid is more effective for cholesterol gallstone dissolution than is ursodeoxycholic acid monotherapy. J Clin Gastroenterol. 1998 Jun;26(4):287-91.

10) Saunders KD.  Lovastatin and gallstone dissolution: a preliminary study.
Surgery. 1993 Jan;113(1):28-35.

11)  Moran S.  Effects of fiber administration in the prevention of gallstones in obese patients on a reducing diet. A clinical trial. Rev Gastroenterol Mex. 1997 Oct-Dec;62(4):266-72.

12)  Maudgal DP.  A practical guide to the nonsurgical treatment of gallstones.
Drugs. 1991 Feb;41(2):185-92.

13)  Hellstern A. Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey. Dig Dis Sci. 1998 May;43(5):911-20.