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Overview |
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Definition |
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Cholecystitis (gallbladder inflammation) or symptomatic gallbladder disease
is associated with cholelithiasis (formation of gallstones) in 98% of cases. It
affects about 20 million people or about 10% of the U.S. population. Most people
with gallstones never develop symptoms. Types of gallstones include pigmented
(20% to 30% prevalence, composed of calcium bilirubinate), cholesterol (70% to
80% prevalence, at least 70% cholesterol by weight), and rarely, calcium
carbonate stone (chalky, white paste). |
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Etiology |
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Development of gallstones is a complicated process, and is not completely
understood.
- Imbalance in the relative amounts of cholesterol, phospholipids, and
bile salts
- Increased biliary secretion of cholesterol (e.g., from obesity,
estrogen therapy, age)
- Decreased hepatic secretion of bile salts and phospholipids (e.g.,
from resection, ileal disease, long-term total parenteral nutrition)
- Nucleation of cholesterol monohydrate initiates the process of stone
formation
- Stone formation requires cholesterol saturation, biliary stasis
within the gallbladder, and a nucleating agent (either pronucleating or
antinucleating), such as bacteria, calcium salts, proteins, pigments, or other
substances
- First liquid then solid crystals form, then stones
- Biliary sludge
- Precursor to gallbladder disease
- Thick mucous material composed of bile containing cholesterol
crystals, calcium bilirubinate, and mucoproteins forms in the
gallbladder
- Gallbladder motor functioning
impairment—delayed stasis and emptying
- Pigmented stones—excess of unconjugated
bilirubin
- Black stones—associated with hemolysis and
cirrhosis
- Brown stones—associated with biliary tract
infection, bacteria (especially E. coli), or
parasites
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Risk Factors |
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- Demographic features, may relate largely to diet
- Obesity and extremely low-calorie diets
- Complications and incidence increase with age
- Female (2:1)
- Estrogen therapy
- Diabetes
- Crohn's disease
- Cystic fibrosis
- Ileal disease or resection
- Biliary parasites
- Cirrhosis
- Total parenteral nutrition
- Hemolytic disorders
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Signs and Symptoms |
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Symptoms usually occur following cystic duct obstruction by a
stone.
- Upper right quadrant epigastric pain radiating around mid-torso to
infrascapular region
- Biliary colic
- Fluctuating intensity
- Pain following meals, intolerance of fatty foods
- Nausea, vomiting,
anorexia
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Differential
Diagnosis |
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- Peptic ulcer
- Appendicitis
- Pneumonia
- Myocardial infarction
- Hepatitis
- Pancreatitis
- Gallbladder cancer
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Diagnosis |
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Physical Examination |
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Physical findings are present during an acute attack and include upper right
quadrant epigastric tenderness and guarding (indicates peritoneal involvement)
to palpation. Murphy's sign may be evident. There may be fever, tachycardia, and
tachypnea from inflammation. Jaundice occurs with concurrent bile duct
obstruction in 10% to 30% of cases. |
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Laboratory Tests |
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Leukocytosis is usually present. |
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Pathology/Pathophysiology |
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- Acute cholecystitis
- Gallbladder wall edema
- Mucosal necrosis
- Subserosal hemorrhaging
- Week 1—granuloma formation
- Week 2—collagen formation, fibroblast
proliferation
- Chronic cholecystitis
- Gallbladder—distended
- Gallbladder walls are edematous, ischemic, and inflamed
- Deconjugated bile salts produce mucosal damage
- Leukocytic infiltration
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Imaging |
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- Ultrasound—98% sensitivity and specificity
for diagnosis
- Oral cholecystography—iopanoic acid
(Telepaque) is administered before X ray; less accurate than ultrasound; used to
confirm a negative ultrasound
- Computed tomography scan—results similar to
ultrasound
- Hepatobiliary isotopic scan—better
sensitivity for acute cystic duct obstruction
- Cholescintigraphy with technetium 99m-iminodiacetic acid (99mTc
IDA)
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Other Diagnostic
Procedures |
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Cholecystokinin is administered; samples of gallbladder bile examined for
crystal; diagnostic for cholecystitis |
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Treatment Options |
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Treatment Strategy |
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Only patients with symptomatic stones are treated. |
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Drug Therapies |
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- Parenteral narcotic administration—relieves
pain, relaxes gallbladder
- Nasogastric aspiration
- Intravenous fluid replacement
- Antibiotics
- Oral bile acids are used primarily for cholesterol stones; stone must
be radiolucent, float on oral cholecystogram, and be <15 mm in diameter; 40%
effective in 2 years; used when laparoscopic surgery is not an
option.
- Chenodeoxycholic acid—250 mg bid for two
weeks, then increase dose by 250 mg/day until 13 to 16 mg/kg/day is reached;
side effects include diarrhea and possible liver damage.
- Ursodeoxycholic acid—8 to 10 mg/kg bid to
tid; few side effects
- Methyl tert-butyl ether—strong lipid
solvent; 95% of mass is dissolved in 12.5
hours
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Surgical Procedures |
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The following surgical methods are performed when the patient's condition
deteriorates or there is a perforated gallbladder or serious
complication.
- Laparoscopic cholecystectomy
- Comparable mortality (0% to 0.3%) and morbidity (1.3% to 11.2%)
rates, less pain, and shorter hospital stays than open
cholecystectomy
- Rate of common bile duct injury is slightly greater (0.4% to 0.5%
compared to 0.1% to 0.2%) than open cholecystectomy
- Open cholecystectomy
- About 5% of cases convert to open
technique—unclear anatomy, bleeding, bile
leakage
- Asymptomatic cholecystectomy—can be
preventive; controversial
- Cholecystostomy—planned alternative when
biliary anatomy is obscured by inflammation; done under local
anesthesia
- Lithotripsy shock wave procedure—not
approved by the Food and Drug Administration; not effective for large or
multiple stones
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Complementary and Alternative
Therapies |
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Imaging is imperative before beginning any alternative treatment. Herbs that
are stimulating to the gallbladder may induce contraction triggering acute
cholecystitis with a stone too large to pass. Follow dietary guidelines and
consider herbs if indicated. |
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Nutrition |
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- Decrease total fat intake, especially saturated fats (meat and dairy
products).
- Eliminate food allergens. Eggs, in particular, may be irritating to
the gallbladder and exacerbate spasm.
- Increase dietary fiber in order to promote secretion of bile acids
and reduce bile saturation.
- Consider fiber supplements such as flaxmeal (1 tsp., one to three
times a day). Combine 1 heaping tsp. of flaxmeal in 8 oz. of apple juice for a
drink high in fiber and pectin.
- Lecithin (1,000 to 5,000 mg/day) emulsifies cholesterol and
facilitates its excretion.
- Lipotropic agents such as choline (1,000 mg/day) and lipase (10,000
NF units with meals) stimulate gallbladder function.
- Vitamin E (400 to 800 IU/day) and vitamin C (1,000 mg bid to tid)
promote bile production.
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Herbs |
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Herbs are generally a safe way to strengthen and tone the body's systems. As
with any therapy, it is important to ascertain a diagnosis before pursuing
treatment. Herbs may be used as dried extracts (capsules, powders, teas),
glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless
otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water.
Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for
roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as
noted.
Choleretic herbs stimulate bile production and increase bile solubility.
Especially useful are milk thistle (Silybum marianum), dandelion root
(Taraxacum officinale), greater celandine (Chelidonium majus),
globe artichoke (Cynara scolymus), and turmeric (Curcuma longa).
Use these herbs singly or in combination as a tea or tincture (15 to 20
drops), bid to tid before meals.
Enteric-coated peppermint oil (Mentha piperita) may help to dissolve
stones (0.2 to 0.4 ml tid between meals). |
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every 1 to 4 hours until
acute symptoms resolve.
- Colocynthis for colicky abdominal pains that are ameliorated by
pressure or bending double.
- Chelidonium for abdominal pain that radiates to right scapular
region.
- Lycopodium for abdominal pain that is worse with deep
inhalation.
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Physical Medicine |
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Castor oil pack. Used externally, castor oil is a powerful anti-inflammatory.
Apply oil directly to skin, cover with a clean soft cloth (e.g., flannel) and
plastic wrap. Place a heat source (hot water bottle or heating pad) over the
pack and let sit for 30 to 60 minutes. For best results, use for three
consecutive days. Apply to abdomen, especially the gallbladder area to help
reduce inflammation. |
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Acupuncture |
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Acupuncture may prove especially beneficial in pain relief, reducing spasm,
and facilitating bile flow and proper liver and gallbladder
function. |
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Patient Monitoring |
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- Patients on oral therapy need to have liver enzymes
monitored.
- Complications generally indicate need for immediate
treatment.
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Other
Considerations |
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Prevention |
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- A vegetarian low-fat, high-fiber diet reduces absorption of
deoxycholic acid and aids prevention.
- Patients should drink 6 to 8 glasses of water a day.
- Chenodeoxycholic acid naturally occurs in cereal fiber.
- Patients should avoid refined sugars, simple carbohydrates, fried
foods, animal proteins, coffee, food that causes allergic symptoms, and high
calorie intake.
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Complications/Sequelae |
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- With previous biliary colic, complications after cholecystectomy
increase.
- Cholangitis or common bile duct stone obstruction (with
jaundice)
- Pneumocholecystitis (Emphysematous
cholecystitis)—secondary infection by gas-forming
organisms
- Gallbladder cancer—90% of patients who have
gallbladder cancer have gallstones
- Diabetes—20% of patients with diabetes have
perforation or gangrene of the gallbladder; elective cholecystectomy is highly
recommended.
- Gallstone ileus—gallbladder forms a
fistulous connection with adjacent bowel (usually duodenum), and a large
gallstone passes into the small intestine, creating an acute obstruction in the
terminal small bowel.
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Prognosis |
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- Patients with asymptomatic stones may remain symptom-free by
controlling their risks.
- Can take two years for stone to dissolve.
- Early cholecystectomy usually ends symptoms and recurrence; however,
stones may recur in the bile duct.
- Mortality (0% to 0.3%) and morbidity (1.3% to 11.2%) rates are lower
for elective surgery than for emergency
surgery.
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Pregnancy |
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- It is difficult to diagnose any intra-abdominal disease during
pregnancy.
- Ultrasound is a safe diagnostic tool.
- Surgery is indicated if more conservative treatments fail.
- Choleretic herbs must be used with caution in pregnancy. Milk thistle
and dandelion root are generally safe in pregnancy.
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References |
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Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:422, 427, 465
Fauci AS, Braunwald E, Isselbacher KJ, et al., eds. Harrison's Principles
of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.
Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms.
Albany, Calif: Hahnemann Clinic Publishing; 1993:118, 139, 230.
Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed.
Rocklin, Calif: Prima Publishing, 1998.
Sabiston DC, Lyerly HK. Textbook of Surgery. 15th ed. Philadelphia,
Pa: WB Saunders Co, 1998
Weiss RF; Meuss AR, trans. Herbal Medicine. Medicina Biologica; 82-89,
94-97. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |