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).

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

• 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

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

• Peptic ulcer
• Appendicitis
• Pneumonia
• Myocardial infarction
• Hepatitis
• Pancreatitis
• Gallbladder cancer

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.

Leukocytosis is usually present.

• 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

• 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)

Cholecystokinin is administered; samples of gallbladder bile examined for crystal; diagnostic for cholecystitis

Only patients with symptomatic stones are treated.

• 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

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

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.

• 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.

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).

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.

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.

Acupuncture may prove especially beneficial in pain relief, reducing spasm, and facilitating bile flow and proper liver and gallbladder function.

• Patients on oral therapy need to have liver enzymes monitored.
• Complications generally indicate need for immediate treatment.

• 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.

• 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.

• 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.

• 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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