Counseling Sheet

Agatha M. Thrash, M.D.
Preventive Medicine

The crucial factor in the development of gallstones is the presence of over-nutrition. Refined carbohydrates are a prominent culprit. Refined carbohydrates are abundant in semisynthetic diets, a product of civilization, as are gallstones. In countries taking their food in a natural state, people do not produce gallstones. When fiber is removed from food and it is rendered less bulky, less chewy, sweeter, and more fattening, it is prone to cause saturation of the bile. When the bile becomes saturated it may crystallize certain of the solid materials dissolved in bile, forming a tiny grain on which other crystals develop to form gallstones.

The use of refined fats is as instrumental in the production of gallstones as are refined carbohydrates. The more fat in a meal the more bile is released, and the more concentrated it is with cholesterol and bile salts. Generally people eat much more fat than can be taken care of by the one to two ounces of bile stored in the gallbladder. Therefore, more bile must be produced in order to emulsify the fats and accompany them through the wall of the intestine into the bloodstream. The liver is overworked, as the operation of this cycle is quite energy consuming.

About 20% of the population of the United States has gallstones. The typical patient has the three F's: fat, female, and forty. In the early days of my medical training, a fourth F was included: fair, since gallstones were seldom seen in the black race. Now, however, blacks eat the same diet and lead the same sedentary lives that whites do, and the incidence of gallstones is virtually the same in both races. Each generation we are producing gallstones younger and younger because of the richness and refinement of the diet. Decreased exercise, a national disease in America, is also instrumental in the formation of saturated bile.

Symptoms of gallstones include belching, regurgitation of food, and finally obstructive symptoms including pain in the right upper abdominal quadrant with nausea and vomiting. The pain is of a colicky nature, and is often intense and accompanied by severe nausea with active vomiting.

When fiber in the diet is low, cholesterol in the bile goes up. Fiber tends to bind bile salts. It decreases intestinal transit time of food wastes, and interrupts the enterohepatic circulation of bile as it is brought from the intestine to the blood, to the liver, to the gallbladder, and back to the intestine, increasing the excretion of bile acid with cholesterol bound to the bile acids.

In order to treat gallstones, one should immediately reduce the weight and maintain normal weight. One can calculate normal weight by allowing 100 pounds for the first 5 feet, and 5 pounds per inch of height thereafter for a woman and 6 to 7 pounds for men, depending on how muscular he is. Since losing weight can slightly increase the ratio of cholesterol to lecithin in the bile, the person losing weight must drink quite a lot of water to keep the bile thin to prevent precipitation of cholesterol in the first few days of beginning a weight-loss program. Especially one should avoid alternately gaining and losing weight as this significantly increases the risk of forming stones. The more meals eaten per day the greater the likelihood of getting stones in the gallbladder (The New England Journal of Medicine 288:24-27, 1973). Any kind of surgical procedure can also increase one's likelihood of getting gallstones. Spicy foods irritate the gallbladder and thereby increase the likelihood of gallstones.The first dietary measure should be to remove free fats from the diet and decrease the number of rich foods served. One may eat freely of fruits and vegetables prepared in a simple way without sugar or fat. One should reduce one's salt intake since salt is dehydrating to many body fluids, including the bile. All heavy foods such as meat, milk, eggs, cheese, nuts, wheat germ, margarine, cooking oil, sugar, and salt should be removed immediately, until symptoms subside. If one is overweight, sugar, oil, and margarine should be permanently omitted.

Avoid gas-forming foods such as radishes, Brussels sprouts, cucumbers, dried beans, sauerkraut, and so forth. Coffee and candy should be avoided. Use no fresh breads except for quick breads, as they increase the likelihood of forming gas. Eating between meals should be forbidden, as well as large meals. Stay away from drugs that are reported to reduce gallstones as they have unwanted side effects. Oral contraceptives have been reported to increase the likelihood of developing gallstones. Vitamin C has been reported to reduce the incidence of gallstones. To insure plenty of vitamin C, something raw should be eaten in each meal. Physical exercise tends to prevent gallstones. One should bear in mind that a number of other diseases are also associated with gallstones - cancer of the colon, hiatus hernia, angina pectoris, and coronary heart disease, most of which are benefited or prevented by exercise and a proper diet.

A hot fomentation over the upper abdomen in persons who have symptoms from gallstones can greatly reduce the pain. The use of catnip tea can quiet the gastrointestinal tract and the gallbladder. An ice rub over the area of pain can be of great relief. Swelling and inflammation around the bile duct may produce a large portion of the pain, and both heat and cold can help to reduce swelling and promote drainage. They both increase the concentration of white blood cells which move into the area to help eliminate products of inflammation. An enema is sometimes helpful to relieve gallbladder pain.

The question always arises as to whether a person with "silent gallstones," those not causing any symptoms, should have them removed surgically. I feel that it is better to leave silent gallstones in place. While it is said that there is an increased incidence of cancer of the gallbladder in those who have gallstones, it must be exceedingly rare. Cancer of the gallbladder is unusual and more often not associated with stones. A group of surgeons were asked if they would recommend surgery to their patients who had silent gallstones. About 80% responded that they would. However, when asked if they themselves would have surgery to remove silent gallstones only 20% responded that they would. I agree with the 80% who would leave them alone. My advice is usually similar for my patients.