Gallbladder - Week 7

Question 1

What are four conditions that would be included in the differential diagnosis in acute cholecystitis?

Answer 1

• • Acute appendicitis
• • Renal stones/pain
• • Pneumonia/pleurisy
• IBS
• Pancreatitis
• Pancreatic cancer
• IBD
• Stomach ulcers
• GERD and HH
• Viral hepatitis
• UTI
• Diverticulosis/diverticulitis
• Pregnancy complications
• Heart attack

Question 2

What are the differences between the types of stones found in cholelithiasis?

Answer 2

Cholesterol stones

• 75% of stones in US
• Slow formation over years
• Increased cholesterol w/in bile salt micelles results in thickened sludge-like bile fluid

Pigment stones
- Composed of calcium bilirubinate, or calcified bilirubin
- Black stones
> Form in the gallbladder
> More common (20% of all US)
> Associated with hemolytic anemia or cirrhosis
- Brown stones
> Typically form in bile ducts
> More common in SE Asia
- Higher incidence overall in Asia and Africa
- More common in chronic cholecystitis
- May be infectious origin
- Might need aspiration of bile for culture
- Typically will be removed

Question 3

How does the etiology of the stones influence the treatment for cholelithiasis?

Answer 3

• Pigment stones typically get removed

- ??

Question 4

Which hydrotherapies are best for cholelithiasis, biliary dyskinesia, and cholecystitis? How do they differ? What are the precautions or contraindications?

Answer 4

Castor oil packs

• Add chaparral for more effectiveness in acute GB colic
• No heat with acute symptoms
• 30 minutes 3x/day

Vinegar packs
- Alternating hot and cold packs
> Non-acute only

Question 5

What dietary/lifestyle changes are appropriate for cholelithiasis and biliary dyskinesia?

Answer 5

Avoid
- Avoid saturated fats and high glycemic index foods
- Avoid food allergies/intolerances
- Elimination/challenge diet
- Avoid SAD diet
- Avoid animal proteins
     > Especially pork and eggs, casein
     > Beef must be grass-fed/finished
- Avoid hot sauces, fried foods, salty foods, dairy, sweets, shellfish
- Avoid large quantities of alcohol

Increase
- Eat liver cleansing foods
> Beets, radishes, burdock root, carrots, artichokes, lemons, parsnips, dandelion greens, watercress, horseradish, mustard greens
- Increase water-soluble fiber foods (30-50g)
> Flax seeds, guar gum, oat bran, pectin, mucilage
> Not legumes
- Increase vegetable and fruit intake (increases fiber)
- Eat foods high in omega-3, especially fish
- Eat foods high in vitamins C and E
- Increase fluids (water) intake

Other
- Exercise (30 mins 5x/wk)
- Tobacco cessation
- Coffee conundrum
> If have stones, might make it worse
> If don’t have stones, might inhibit formation

Question 6

What is the role of food allergies, and which ones are commonly seen, in cholelithiasis, biliary dyskinesia, and cholecystitis?

Answer 6

• Egg and pork allergies are commonly seen

- Study showed patients symptom-free when on elimination diet

Question 7

What are the primary etiologies for cholelithiasis?

Answer 7

Non-modifiable risk factors for cholesterol stones
- Female
> Higher estrogen levels/events
- Over 40
- Family history
- Genetics
- Ethnic background (Latino, Native American, Northern European)

Modifiable risk factors for cholesterol stones
- NAFLD/NASH
- Insulin-related conditions
     > DM/metabolic syndrome
     > Obesity or rapid weight loss
- Biliary stasis
- Total parenteral nutrition
     > Lack of fiber
     > High omega-6 intake
     > High sugar diet
- Lifestyle
     > Tobacco use
     > Sedentary
     > SAD diet
          ^ High refined carbs, high caloric intake, low fiber
- Hypothyroidism

Iagtrogenic causes

• HRT
• Oral birth control (mild risk)
• Thiazide diuretics (moderate risk) (cholesterol-lowering drug)
• Fibric acid derivatives (Tricor) (drug to correct cholesterol levels)
• Ceftriaxone (lowers biliary motility)
• Somatostatin and analogs
• Tamoxifen
• Bariatric surgery (not lap band)

Risk factors for pigment stones

• Advancing age
• Hepatic cirrhosis
• Hemolytic anemia
• Total parenteral nutrition
• Intestinal resection or bypass
• Biliary infection (parasitic)
• Duodenal diverticula

Other Risks

• Prolonged IV feeding
• Crohn’s
• Organ transplants
• Cystic fibrosis
• Pancreatic insufficiency
• Vagotomy

Fair, fat, forty, female, fertile

Question 8

Why isn’t lithotripsy used more often as a therapy for cholelithiasis?

Answer 8

• ??

- Often asx and can resolve naturally?

Question 9

What is the role of exercise (or lack thereof) in gallbladder conditions?

Answer 9

• Exercising 30 minutes/day 5x/wk eliminated 34% of cases of symptomatic gallstones
• Reduces obesity
• Reduces cholesterol levels in the biliary tract
• Breathing exercises can stimulate bile secretion
• Exercise, even without weight loss, lowers risk

Question 10

What are the appropriate herbal therapies for cholelithiasis, biliary dyskinesia, and cholecystitis? How do they differ?

Answer 10

Spasmolytics
- Fumaria officinalis
     > Mildly bitter, balancing effect on GB
     > Not strong enough for acute cholecystitis/colic
- Dioscorea villosa
     > Well-paired with Fumaria
     > Best for short-term use
- Ammi visnaga
     > Best in acute GB conditions
- Atropa belladonna
     > Excellent for acute biliary colic
     > Toxic
- Lobelia inflata
- Piscidia piscipula (Jamaican dogwood)
- Corydalis niger
- Hyoscyamus niger
- Gelsemium sempervirens

• Yarnell’s Acute Cholecystitis Tincture
• So many others listed in GB document…