Feature

Getting Gallstone Relief

by David Wolfson, N.D.

Maybe you've had this scenario described to you by a customer: About an hour after dinner she begins to notice an uncomfortable sensation in her abdomen. She says the pain is cramplike, builds in intensity and shoots back toward her right shoulder blade. Nausea follows. She takes an antacid but wonders whether she has symptoms of appendicitis, food poisoning or an ulcer. A visit to her doctor reveals that she is actually suffering from complications of cholelithiasis, also known as gallstones.

The presence of stones, or calculi, in the gallbladder and adjacent ducts (collectively called the biliary tract) is a common phenomenon but does not always cause such painful symptoms. In fact, most people with gallstones remain asymptomatic for long periods of time—frequently for life.¹ Symptoms, such as those described above, usually arise when a stone passes from the gallbladder into one of the ducts leading to the intestinal tract. Stones can irritate the lining of these sensitive ducts, causing pain, or may completely block a duct, causing bile fluids to build up behind the stone. Bile buildup leads to irritation and inflammation.

Gallstones affect roughly 20 million Americans, ² most commonly women and members of ethnic groups such as Native Americans. Predisposing factors include aging, obesity, family history, pregnancy, estrogen use, and eating a Western diet. Many nutritionists believe diet is the most important factor—gallstones rarely develop in populations that eat a more traditional, unrefined diet.³

To understand how gallstones form, it is necessary to understand how the biliary tract functions. Bile serves two purposes: making dietary lipids more digestible, and excreting cholesterol and other unwanted materials from the body. Bile is formed in the liver from bile acids (lipid-dissolving agents), cholesterol, minerals and phospholipids such as phosphatidylcholine or lecithin. Once formed, bile is transported to the gallbladder, where it is concentrated and stored until needed.

A fatty meal stimulates gallbladder contraction and bile flow into the small intestine where it combines with food to emulsify the fatty elements. It also enables digestive enzymes to break fats down into their elementary components—fatty acids, monoglycerides, cholesterol and fat-soluble vitamins. Bile salts then corral these substances into minute complexes, called micelles, and herd them to the lining of the intestinal tract for absorption.

Under normal circumstances, bile components remain in solution as a liquid. But when bile becomes cholesterol-heavy, the cholesterol may crystallize and start to form a stone. Cholesterol can also crystallize when bile flow is slowed. Less commonly, other elements of bile, such as bilirubin, may precipitate out, causing bilirubin stones—also called pigment stones.

The standard medical approach to treating gallstones depends on whether the stones are painful. Asymptomatic, or silent, stones are commonly found during a medical evaluation for another condition. In such cases, the doctor may suggest elective surgery, or the patient may simply be monitored for symptom onset. If gallstones are painful, gallbladder removal—a procedure known as cholecystectomy—is usually recommended. More than 500,000 cholecystectomies are performed yearly in the United States and are becoming even more common with the advent of less invasive laparoscopic techniques. The rationale for removing the gallbladder is that gallstone symptoms, once they occur, tend to recur at a rate of 30 to 50 percent within one to two years.² Left untreated, gallstone disease may also cause peritonitis (inflammation of the membrane that lines the abdominal cavity and covers the viscera), pancreatitis (inflammation of the pancreas), and an increased risk of gallbladder cancer.

Even though nonsurgical options for treating gallstones exist, doctors rarely recommend them. There are, however, three effective nonsurgical procedures: bile acid therapy, contact solvent therapy and lithotripsy (see sidebar above). There is also ample evidence that gallstone disease can be treated with dietary, nutritional and herbal interventions. And while it is easier to prevent than to treat gallstones, even people with symptomatic stones can benefit from natural therapies.

Dietary Factors
Some dietary modifications can make a big difference in managing gallstones.

Dietary fats have been linked with gallstone formation, though evidence is somewhat conflicting. Most studies cite saturated fats (i.e., butter and margarine) as a contributing factor vs. monounsaturated fats (i.e., olive oil), which appear to play a protective role. ⁴ The majority of polyunsaturated fats (i.e., safflower oil) seem neither to cause nor prevent gallstones, although some animal experiments indicate that the omega-3 class of polyunsaturates (i.e., flaxseed oil) may prevent gallstones.⁵

Paradoxically, some studies have shown fats in the form of cholesterol actually protect against stone formation in humans. In one study, a majority of test subjects fed five to 10 eggs a day for six weeks experienced a decrease in their cholesterol/bile acid ratio.⁶ This occurred despite a slight increase in serum cholesterol levels. In a more recent population-based study, risk of gallstone formation decreased when cholesterol consumption increased.⁴ The explanation for this paradox may be that the liver synthesizes less cholesterol as dietary cholesterol increases.

Fiber may prevent gallstone formation. Dietary fiber appears to deter the synthesis and absorption of secondary bile acids (SBAs), which are unhealthy bile metabolites that form in the intestinal tract. Certain SBAs have been linked with increased cholesterol saturation of bile and thus gallstone formation.⁷ Fiber not only allows less time for SBAs to form in the gut by improving intestinal motility, it may also bind SBAs and escort them out of the body. Population research has confirmed that low-fiber diets predispose toward gallstone formation.⁴

Food allergies may have a connection to gallbladder symptoms. In vitro and animal experiments from the 1920s showed pathological changes in gallbladder tissue following exposure to certain food antigens. More recent research by J.C. Breneman, M.D., a pioneer in food allergy research, found that allergy-elimination diets dramatically improved gallbladder symptoms in 100 percent of his test subjects. The foods most likely to cause symptoms were eggs, followed by pork, onions, poultry, milk, coffee, oranges, corn, beans and nuts.⁸ Breneman postulated that allergenic substances induce inflammation of the biliary ducts, causing pain and possibly impairing bile flow.⁹

Sugar consumption may also pose a risk for gallstone development. Sugar promotes insulin secretion, which increases cholesterol synthesis in the liver—a condition favoring stone formation. Eating sugar is also related to elevated serum triglyceride levels, which, in turn, are associated with cholesterol saturation of bile. Studies have consistently reported a higher prevalence of gallstones in people with a sugary diet.^2,4,10

Nutritional Support
A supplements plan for those with gallstones should include antioxidants, fiber and lecithin.

Antioxidant intake may, in fact, be more important than other dietary considerations. A recent study suggests micronutrients such as vitamins and minerals may play a more important role in the development of gallstones than macronutrients such as carbohydrates and fats. Researchers found that subjects with a lower antioxidant intake— especially of vitamin E, manganese and methionine—had a greater incidence of gallbladder disease. A weaker association was found for the antioxidants beta-carotene, cysteine, selenium, vitamin C and zinc. The researchers theorize that oxidant stress within the liver leads to unfavorable changes in bile composition that promote precipitation of both cholesterol and bilirubin (thus favoring the formation of both cholesterol and pigment stones).^11,12 These findings corroborate earlier studies showing that antioxidant deficiencies can induce gallstone formation in animals.^13,14

Supplemental Fiber has beneficial effects on bile acid composition and intestinal motility. Fiber supplements are a good idea for people who do not eat a lot of fruits, vegetables and whole grains. I recommend products with psyllium husks or oat bran, but not those with ground flaxseeds because the oils in these seeds tend to go rancid rapidly (freshly ground flaxseeds are fine).

Lecithin is a natural component of fatty foods, especially eggs and organ meats, but low-fat diet trends have reduced our lecithin consumption. Aside from bile acids, phospholipids such as lecithin are the principal bile components that keep cholesterol in solution. In light of Breneman's findings, one might be reluctant to increase egg consumption, but research suggests that egg lecithin may be superior to other types such as soy lecithin in preventing cholesterol precipitation in the bile.¹⁵ I believe eggs from free-range chickens fed a healthy diet are such an excellent source of phospholipids, essential fats and other nutrients that they should be included in the diet unless they provoke undesirable symptoms. For people who cannot eat eggs, I recommend lecithin supplements. Studies show as little as 300 mg of lecithin per day can raise lecithin levels in the bile.¹⁶

Herbal Remedies
Herbs have been used for centuries to treat the symptoms associated with gallstones. Traditional choleretics and cholagogues, herbs intended to increase the production and flow of bile, include barberry (Berberis vulgaris), burdock (Arctium lappa), dandelion root (Taraxacum officinale), fumitory (Fumaria officinalis), globe artichoke (Cynara scolymus), goldenseal (Hydrastis canadensis), greater celandine (Chelidonium majus), milk thistle (Silybum marianum), Oregon grape (Berberis aquifolium) and peppermint (Mentha x piperita).

Of these, only a few have received attention in the medical literature. Milk thistle, for example, has been found to have beneficial effects on the gallbladder. A recent study found that 420 mg/day of silymarin—the active flavonoid compounds in milk thistle—given for 30 days, lowered biliary concentrations of cholesterol in a group of 10 subjects. The researchers believe silymarin may inhibit HMG-CoA reductase, the enzyme responsible for cholesterol synthesis in the liver.¹⁷

Perhaps the most widely studied herb for gallstone treatment is peppermint and its menthol component. Menthol belongs to a class of compounds called terpenes that, for decades, has been studied for the treatment of gallstones. Studies suggest that terpenes keep cholesterol crystals from forming in bile¹⁸ and may even dissolve existing stones.¹⁹ A terpene mixture derived from purified plant essential oils, known as Rowachol, has been used in Europe since the mid-1950s for treating gallstones. Although Rowachol is unavailable in the United States, health care practitioners can request a generic form from a compounding pharmacist. Michael Murray, N.D., in the Encyclopedia of Natural Medicine (Prima Publishing, 1998), suggests that enteric-coated peppermint oil might also act as a suitable substitute.²⁰

Exercise Matters
Many diseases associated with a Western diet also appear connected to a sedentary lifestyle, and gallstones are no exception. Although some early studies failed to find a direct connection, recent evidence indicates lack of physical activity is a significant risk factor for gallstone development. In one prospective trial, the most active people had 30 percent less risk of developing gallstones than the least active. ²¹ Researchers think exercise protects against gallstone disease by reducing known risk factors such as obesity, insulin resistance and serum triglyceride levels.

The good news is you can educate your customers on proper food choices and recommend nutritional and herbal supplements that may help reduce their risk of developing gallstones.

Sidebars:
Nonsurgical Gallstone Treatments
Summary of Recommendations

David Wolfson, N.D., is a naturopathic physician, nutrition educator and writer, as well as a consultant to the natural products industry.

References

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3. Heaton KW. The role of diet in the aetiology of cholelithiasis, Capocaccia L, Editor. In: Epidemiology and prevention of gallstone disease. Lancaster (PA): MTP Press Limited; 1983. p 129-43.

4. Misciagna G, et al. Diet, physical activity and gallstones—a population-based, case-control study in southern Italy. Amer J Clin Nutr 1999;69:120-6.

5. Magnuson TH, et al. Dietary fish oil inhibits cholesterol monohydrate crystal nucleation and gallstone formation in the prairie dog. Surgery 1995;118:517-23.

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7. Hussaini SH, et al. The roles of biliary deoxycholic acid (DCA) and vesicular cholesterol (CH) in the pathogenesis of CH gallbladder stones (GBS). Gut 1992;33(2):S57.

8. Breneman JC. Basics of food allergy, 2nd ed. Springfield (IL): Charles C. Thomas; 1984. p 920.

9. Breneman JC. Allergy elimination diet as the most effective gallbladder diet. Ann Allergy 1968;26:83-7.

10. Moerman C, et al. Dietary risk factors for clinically diagnosed gallstones in middle-aged men: a 25-year follow-up study (the Zutphen study). Ann Epidemiol 1994;4:248-54.

11. Worthington HV, et al. A pilot study of antioxidant intake in patients with cholesterol gallstones. Nutrition 1997;13(2):118-27.

12. Braganza JM. A radical view of gallstone aetiogenesis. Med Hypoth 1995;45:510-6.

13. Jenkins SA. Hypovitaminosis C and cholelithiasis in guinea pigs. Biochem Biophys Res Comm 1977;77:1030.

14. Malet PF. Animal models of gallstone formation. In: Cohen S, Editor. Gallstones. Edinburgh: Churchill Livingstone; 1985. p 309-33.

15. Hidenori O, et al. Lecithin hydrophobicity modulates the process of cholesterol crystal nucleation and growth in supersaturated model bile systems. Biochem J 1996;318:139-44.

16. Tuzhilin S, et al. The treatment of patients with gallstones by lecithin. Amer J Gastroent 1976;65:231-5.

17. Nassuato G, et al. Effect of silibinin on biliary lipid composition: experimental and clinical study. J Hepatol 1991;12:290-5.

18. von Bergmann K, et al. Administration of a terpene mixture inhibits cholesterol nucleation in bile from patients with cholesterol gallstones. Klin Wochenschr 1987;65:458-62.

19. Somerville KW, et al. Stones in the common bile duct: experience with medical dissolution therapy. Postgrad Med J 1985;61:313-6.

20. Murray M, Pizzorno J. Encyclopedia of natural medicine, 2nd ed. Rocklin (CA):Prima Publishing; 1998. p 483.

21. Kato I, et al. Prospective study of clinical gallbladder disease and its association with obesity, physical activity, and other factors. Dig Dis Sci 1992;37(5):784-90.