GALLSTONES:WHEN IN DOUBT, CUT IT OUT

We’ve been trying to make gallstones disappear for several thousand years, yet the magic act still hasn’t been perfected. Although gallstones can occur at any time, the average “sufferer” is between 40 and 50 years old. The likelihood of you sufferin

Gallstones (which can be detected easily radiologically, or by using ultrasonography to check whether they are harmless or not) are regarded as the most common, and at $5 billion each year, the most costly to treat, of the digestive diseases in the US. Around 10 per cent to 15 per cent of the adult population, or more than 20 million people there suffer from gallstone attacks, and have opted for surgery to remove the gall bladder which contains the stones.

In the elderly, 50 per cent of stones lie in the bile duct (Brit J of Clin Practice, 1993; 47 [3]: 164-165). It’s thought that around a million new sufferers are diagnosed every year (JAMA, 1993; Vol 269, No 8: 1018; Ann Clin Lab Sci, 1984; 14: 243-251).

Women are more likely to suffer from gallstones, especially older women, and those who have had multiple pregnancies, who may be obese, or who may have been on crash diets (Ann Clin Lab Sci, 1984; 14: 243-251). In fact, anything that increases a woman’s estrogen levels, greatly increases the incidence of gallstones, including HRT and the Pill.

Bile, made by the liver, is stored in the gallbladder. From there, it’s eventually transferred into the intestines, so that it can assist in the process of digestion. Gallstones are actually chunks of cholesterol and other minerals which grow in size for a couple of years within the gallbladder and then stabilize.

Gallstones can block the route of bile from the liver to the intestines, and can irritate the gallbladder’s lining, causing inflammation (cholecystitis).

Around 85 per cent of all gallstones measure less than 2 cm across. They’re formed when bile in the gall bladder becomes saturated and the bile’s substances that can’t be absorbed, harden. Typically, symptoms occur eight years after the stones’ formation (Scientific American Medicine, Rubenstein E and Federman DD, Scientific American, 1986; 4: VI-I-10).

Much of gallstone prevention has to do with diet and processing of food. According to Dr Melvyn Werbach (Healing Through Nutrition) gallstone formation appears to be associated with the backward movement of bile and pancreatic juices into the stomach. These juices can destroy the gastric acid producing cells, causing flatulent dyspepsia (gas and indigestion), as well as other symptoms of hydrochloric acid deficiency (HCl). About half of all people with gallstones are deficient in HCl.

Stomach acid is necessary, so that the body can properly utilize nutrients. A deficiency also increases both the susceptibility to, and severity of, bacterial infections of the intestines. Therefore, in addition to its possible value in reducing symptoms, Werbach suggests that an HCl, supplement would be appropriate for anyone who is found on testing to be deficient.

One silent villain in the gallstone saga is certain cholesterol lowering drugs. Clofibrate and some other cholesterol lowering drugs lower blood fats but greatly increases the development of gallstones by increasing the amount of cholesterol that is secreted into the bile. Octretide (Sandostatin), one of the new generation “statin” drugs, prevents the gall bladder from emptying after a fatty meal. It has been suggested that a reduction in gallbladder emptying may well play a role in stone formation (BMJ, 1992; 305: 313; Gut, 1996; 38 [5]: 775-83). Short term doses (for up to a month) of octreotide pose a minimal risk, but the risk increases with longer treatments (Am J of Gastroent, 1995; 90 [7]: 1042-52). In fact gall bladder stones have been found in up to 50 per cent of patients receiving octreotide (Metabolism: Clin & Experimental, 1992; 41 [9 Suppl 2]: 22-33). The manufacturer recommends that ultrasound examination of the gallbladder be conducted before and at six to 12 month intervals during long term therapy. And of course, in today’s hysterical anti cholesterol climate, many patients with slightly elevated cholesterol are being placed on statin drugs for life.

The other big culprit may be thiazides (water pills), usually used for high blood pressure, which may increase the risk of acute cholecystitis developing in a patient with gallstones (BMJ, 1984; 289: 654-655). Although gallstones rarely occur in children, they are more likely to develop after taking furosemide (J of Perinatology, 1992; 12 [2]: 107-111).

Despite the clear association with diet in most cases, medicine persists with a barbaric solution to gallbladder disease. In 1991, 600,000 people decided to “solve” the gallstone problem by having their gall bladder removed altogether (cholecystectomy). This can be done in two ways: either through traditional “open” surgery (open cholecystectomy, or minilaparotomy); or through keyhole (minimally invasive) surgery, where the gall bladder is literally pulled though a small incision in the abdomen. Endoscopic sphincteroscopy is commonly used to remove stones in the bile duct.

An open cholecystectomy may be required if a keyhole operation runs into trouble, and may be considered the treatment of choice for severe infection, perforation of the gall bladder or severe, acute cholecystitis.

However, the so called surgical alternatives carry with them their fair share of risk, which can aggravate the condition rather than cure it. Laparoscopy, or keyhole surgery, has attracted much publicity and criticism.

In the late eighties the modern era of laparoscopic surgery was ushered in when a miniature video camera was attached to the eyepiece of a laparoscope, so that the surgeon could operate via the video screen. Both doctors and patients immediately pressed for a revolution in keyhole gall bladder operations without a single clinical trial confirming its benefits (J Royal College Surg Edinburgh, 1993; 38: 353).

Since then, many surgeons have whipped out gallbladders using the technique, citing its advantages over an open cholecystectomy, or laparotomy patients experience much less pain, spend less time in hospital and recover much more quickly (Surg Endosc, 1989; 3: 131-3; Surg Gynecol Obstet, 1992; 174: 114-8).

However such claimed benefits have been disputed. For instance, a speedier return to work, where it happens, may be due to several influences; and social class, cultural factors, and even a patient’s occupation also contribute to this highly variable outcome (Lancet, 1994; 343: 308-9; Am J Surg, 191; 161: 396-8).

As many as 80 per cent of cholecystectomies are now performed laparoscopically in the US (JAMA, 1993; 269: 1018-24 and 270: 1429-32).

However, the operation does have its risks, and the widespread adoption of laparoscopic cholecystectomy has aroused concern about how safe the new procedure really is (New Eng J of Med, 1994; 330: 403; WDDTY, vol 4, no 12). Studies carried out in Maryland hospitals between 1985 and 1992 show that the overall number of deaths has decreased by 33 per cent since keyhole gall bladder surgery was introduced. However, the total number of gall bladder related deaths has not fallen because of a 28 per cent increase in the total number of gallbladder operations being performed.

Thus, the attraction of “band aid” surgery has appeared simply to convince more patients to rush into an operative solution (New Eng J of Med, 1994; 330: 403; JAMA, 1994; 271: 500-1).

The supposed fall in the death rate also masks the dangers of the operation, and its technical difficulties. The success of an endoscopic sphincterotomy, for example, depends on the proper training, skills and experience of the endoscopist. A recent study found that complications can occur around 10 per cent of operations, including haemorrhage, pancreatitis inflammation of the pancreas, a potentially fatal condition perforation of the duodenal wall, and cholangitis being the most frequent (New Engl J Med, 1996; 335: 961). About one in a hundred patients can die from this kind of operation (Gastrointest Endosc, 1991; 37: 383-93).

Most surgeons now accept that injuries to the bile duct occur more commonly with laparoscopic cholecystectomy than with the old style, open operation. And because the injuries occur higher up in the bile duct, they may be harder to repair (BMJ, 1996; 308: 928).

In Ontario, Canada, where 86 per cent of gall bladder operations are performed laparoscopically, the number of bile duct injuries has increased by 305 per cent (Lancet, February 24, 1996).

Besides bile duct injuries, there is also the, admitedly rare, possibility that some gallstones “leak” out and are retained in the tissue after surgery, as happened in one case (J Royal College Surg Edinburgh, 1993; 38: 353). Patients have also been pierced by surgical instruments (Surgery, 1991; 110: 769-77). There also may be an increased risk of thromboembolism in patients undergoing laparoscopic gall bladder operations (BMJ, 1993; 306: 518-9), and spreading cancer, if it is present (N Eng J Med, 1991; 325: 1316-7).

The popularity of laparoscopy operations is also having another effect. Surgeons in Bristol, reviewing the gall bladder operations they’d done in the three years up to April 1994, saw they’d carried out 578 laparoscopic cholecystectomies and 35 open operations. Fourteen trainee surgeons had performed only 16 open cholecystectomies and assisted at nineteen. Trainee surgeons rarely see an open operation, let alone become familiar with the different techniques required (Ann Royal Coll of Surg Eng, 1995; 77: 256-8).

This is devastating news. The obvious disadvantage of laparoscopic cholecysectomy therefore is that its wide adoption could lead to a new generation of surgeons emerging who are not experienced in open surgery to use it when needed (BMJ, 1992; 304: 559-60).

Extracorporeal shockwave lithotripsy (ESWL), the much ballyhooed alternative to surgery, where the gallstones are literally pounded into submission by a series of sound waves, has also been criticized because it can result in kidney damage and raises blood pressure, which is more pronounced if stones are close to, or in, the kidney (Lancet, 1993; 341: 1151-2).

The procedure also leaves gallstone residue in the bile duct which then provides a home for bacteria (JAMA, 1994; 272: 1643).

Over the last 10 years, ESWL has been hailed as a technique that would revolutionize the medical management of kidney stones, as well as gallstones. However, recent studies show that most patients experience internal bleeding, ranging from tiny hemorrhage to major bleeding that requires transfusion.

This bleeding also seems to change the dynamics of the blood in the kidney, causing hypertension in up to 8 per cent of patients (RH Heptinstall, Pathology of the Kidney; Little, Brown, 1992). The extent of damage appears dependent upon the dose of shock waves used (see also WDDTY; vol 5 no 11).

But in most cases, you shouldn’t have to resort to surgery. According to WDDTY Alternative columnist Harald Gaier, gallstones can be made up from, very rarely, either pure cholesterol; pure pigment (calcium bilirubinate); a mixture of cholesterol and its derivatives, along with varying amounts of bile salts, bile pigments and inorganic salts of calcium; and stones which are composed entirely of minerals.

Recent studies have shown that nearly 80 per cent of sufferers have stones of the mixed variety. The remaining 20 per cent of the stones are made up entirely of minerals, mainly calcium salts (Ann Clin Lab Sci, 1984; 14: 243-51). This is good news because only the solid mineral variety require surgery. An x-ray of the gall bladder can tell you the type of stone (only the mineral ones will show up as solid).

If you are having no symptoms (and the majority of gallstones are “silent”), and your stones are not made up entirely of minerals, you can consider alternatives to breaking up stones and preventing new ones. Only if you have mineral stones or are suffering acute attacks due to severe blockage should surgery be a first option.

If about four fifths the operations should not be done at all, whether by open or laparoscopic techniques, the discussions about one less day in hospital, or half an hour longer in the operating theatre, pale into insignificance.