TRUTH – dissolving stones works but DR’s won’t go the extra mile and diagnose root cause issues to prevent a recurrence. Why – Fraud -$$$$$
I took a long history from her and performed a physical exam, which included examining her abdomen. When I pushed on her right upper quadrant, she all but yelped and grabbed at my wrist. At that point in my medical education, I knew just enough to be dangerous, so I excused myself, left the exam room and presented this lady’s case to the medical resident running the clinic that day.
He asked me a few questions, which, I, in my ignorance, had failed to ask the patient. A couple of the questions he asked, however, I did know the answers to. The patient was in her forties, she was blond, overweight, and had three children.
The resident then told me she fit the description of the four Fs of gallbladder disease: Fat, fair, forty and fertile. (As I was to learn later, there is actually a fifth F, which is female, and my patient fit that description as well.)
Woman suffering the cholic
etching by G. Cruikshank, 1819
Courtesy of the Wellcome Library
I never saw this patient again, so I don’t know how her case ended up. I did, however, ask the resident what this non-surgical treatment was. He told me it was some sort of drug that dissolved gallstones. I asked him if the drug really worked. He said he thought it did. I then asked why taking the drug wouldn’t be better than fairly major abdominal surgery.
He replied that although the drug did dissolve gallstones, it didn’t treat whatever the underlying problem was causing the gallstones in the first place. Patients who took the drug, got rid of their stones, but as soon as they went off the drug, the stones redeveloped. He said the only effective permanent treatment of gallstones was to remove the gallbladder.
Over the next few years of my medical education, I learned this was the common wisdom on dissolving gallstones. It can be done, but what’s the point? The stones will simply come back.
Turns out, however, that there may well be a way to avoid surgery, get rid of gallstones and, most importantly, keep them gone. I’m going to lay out the approach I would take myself, should I ever develop gallstones, or would recommend to any family member with the same problem.
Before we get into the nuts and bolts, let’s briefly discuss what gallstones are and why they develop. The gallbladder is a little sack tucked up under the liver that acts as a bile reservoir. Bile is a thick yellowish- green liquid, made in the liver, stored in the gallbladder, and used to help break down or emulsify fat. A duct system runs between the liver and the gallbladder and the gallbladder and the upper end of the small intestine. Whenever fat leaves the stomach and enters the small intestine, the gallbladder contracts and squirts out a measure of bile that then mixes with the fat and starts breaking it up, so the fat can be more easily digested.
One of the major components of bile is cholesterol. Under certain circumstances, if bile sits around in the gallbladder, the cholesterol becomes supersaturated and can form stones called, appropriately enough, cholesterol stones. There is another type of gallstone called a pigment stone, but these kinds of stones are rare in non-Asian countries.
There are a number of conditions that lead to the formation of cholesterol stones in the gallbladder. You can read about them in more detail in this brief article about gallstones and gallbladder disease.
Risk factors for developing gallstones
- Hormone replacement therapy and birth control pills. Estrogens tend to increase the amount of cholesterol in the bile and reduce the contracting movement of the gallbladder.
- Some cholesterol lowering drugs. Typically not statins. There is some evidence that treatment with statins might actually lower the risk of forming gallstones, but the jury is out until more research comes in. Certainly not a reason to start a statin.
- Female. During the reproductive years, women produce plenty of estrogen. Women suffer gallbladder disease at more than three times the rate as men. As many as 20 percent of women have gallstones by the time they are 60 years old.
- Obesity. Obesity, especially abdominal obesity, leads to increased levels of cholesterol in the bile. At higher concentrations the cholesterol will be more prone to precipitate out into gallstones.
- Pregnancy. The extra estrogen from pregnancy can, as with HRT or birth control pills, increase the cholesterol in bile and reduce the activity of the gallbladder.
- Weight loss, especially rapid weight loss. Lack of fat intake allows the bile a chance to sit in the gallbladder and form stones. This last risk we shall cover in more detail.
Low-carb versus low-fat and gallstone formation.
About 15 years ago, MD and I ran the largest study group in the world looking at a drug called orlistat (Xenical, now Alli) as a weight loss maintenance drug. We recruited a large number of subjects, put them through thorough physical exams and an exhaustive battery of tests; those who passed, we entered into the rigid study protocol.
Here’s how the study worked.
The drug company insisted that all subjects go on low-fat, calorie-restricted diets, which they were to follow for six months. If the subjects lost four percent of their body weight after six months, they were then to be randomized into one of three doses of orlistat or placebo.
Most of the subjects recruited were in the 200 pound range weight-wise. Which meant each had to lose at least eight pounds (4% of body weight) over the six months of low-fat, calorically-restricted dieting. It was amazing to MD and me how many patients could not lose even that small amount over six months on a low fat diet and had to be dropped from the study.
The other thing we found amazing was the number of subjects who developed gallstones over the six month period. One of the battery of tests the subjects had to go through to get into the study was a gallbladder ultrasound, a test that determines the presence of gallstones. Any recruits who were found to have gallstones were rejected. So we started the study with a large group of subjects we knew were free from gallstones, put them on the low-fat diet, low-calorie diet and followed them for six months.Those who lost the requisite four percent of body weight then went through another round of testing including another gallbladder ultrasound.
We were stunned. I don’t remember the exact figure, but somewhere in the range of 15 percent of these subjects who were gallstone free at the start of the study had developed gallstones within six months.
That’s what a low-fat diet can do for you. I’ve seen it up close and personal. In the many years MD and I have treated countless obese patients with low-carb diets, we’ve never had a case of gallbladder disease. I’ve often wondered if our patients had stones but just no symptoms. Now in the light of a new study in press, it appears that dieters who lose weight on higher fat diets do not develop gallstones. So I feel on more stable ground when I say our low-carb, high-fat dieting patients probably didn’t have gallstones.