The Gallbladder In The Modern Age

The upper intestinal tract is so well programmed that bile enters the duodenum just at the time it is needed to help digest the fats of our diet. Since the liver is manufacturing bile all the time, this exact timing is carried out by the gallbladder, which is the receptacle for the temporary storage of bile.

When the fats in the diet enter the duodenum, they release the hor­mone known as cholecystokinin that causes the gallbladder to contract and empty its bile content just at the time and place where it is needed to facilitate the next step of fat digestion. Fats consist of long chains of fatty acids that are attached to glycerol; these are known as the triglycerides. These fatty sub­stances do not dissolve in water; as we all know, oil and water do not mix. To be absorbed, the triglycerides undergo a complex chemical rearrangement. The triglyceride is split into small components, the fatty acids, by the pancreatic fat-splitting en­zymes, the lipases, and the particles are then enclosed in bile salts secreted in the liver bile. The reorganized particles are called micelles, and these can now be transported across the lining cells in the intestine and thus be absorbed.

The main problem associated with the gallbladder when things go wrong is that it can produce stones, which can cause serious difficulties and episodes of pain.

What about the Things the Gallbladder Is Blamed for?

The gallbladder is blamed unfairly for any discomfort in the right upper portion of the abdomen whenever there may be burping, bloating, or belching, or whenever there is any indi­gestion at all connected with fatty foods. This is understandable since gallstones and disease of the gallbladder are so common. It is estimated that between 10 and 20 percent of the world’s population has stones. A recent estimate suggested the majority of individuals above sixty years of age have gallstones as well.

Who Is Likely to Get Gallstones?

In approaching the problem of preventing gallstones, we must first consider who is most at risk. First, there are some families who have the genetic predisposition to form stones. The Pima Indians in southwestern United States, for example, have a very high incidence: 85 to 90 percent of the women and 70 to 80 percent of the men are affected with gallstones.

Women are more likely than men to have stones and this susceptibility increases with each pregnancy. While young peo­ple can develop stones, the incidence of gallstones increases with age, especially as we approach middle age. Those that are overweight suffer more. It is important to know that the obese individual who attempts to drop pounds by trying a crash diet can precipitate stones in the gallbladder. While one might sup­pose that individuals with higher levels of cholesterol in their blood or bile will have more cholesterol stones, this is not the case. However, some individuals with unusually high levels of triglycerides in the blood do have a greater chance of forming stones. The older forms of contraceptive pills with high estrogen levels seem to have played a part in the problem of stone for­mation, but this is rarely seen nowadays with the improved low-estrogen pill.

What Causes Gallstones?

About 70 percent of stones are cholesterol stones. The other type of gallbladder stone is the pigment stone found when the bile contains excessive amounts of bilirubin, the breakdown product of hemoglobin, which is an element of red blood cells. The pigment stones form in the individual whose red blood cells are destroyed more rapidly than normal. This includes in­dividuals suffering from chronic hemolytic anemia, sickle cell disease, or malaria.

The cholesterol stones result from a defect in the liver that forms an abnormal bile. This bile is over-saturated with choles­terol and under saturated with bile acid, which dissolves bile cholesterol._ The stones are formed from this imbalance of over­production of cholesterol by the liver and the concomitant un­der secretion of bile acids.

But Surely One Needs to Have Trouble in the Gallbladder Itself?

Irregular meal patterns may lead to longer storage time for bile in the gallbladder, in some individuals, but this does not nec­essarily lead to stones. Infection in the gallbladder wall does interfere with that organ’s ability to absorb cholesterol and thus reduce its super saturation. Finally, bile, is recycled by mecha­nisms in the ileum. The bile salt pool can be reduced by disease or by surgical removal of parts of the ileum, as in Crohn’s dis­ease.

How Can Dietary- Manipulation or Changes in Eating Habits Prevent or Treat Gallstones or Disease of the Gallbladder?

For those without stones, more regular eating patterns without skipping meals will prevent too long a period of storage of bile in the gallbladder. Reduction of triglycerides in the blood seems the rational thing to do, and some would favor the idea of a high-fiber, low-fat diet.

Many individuals have been discovered by accident in the course of other investigations to have asymptomatic gallstones of the cholesterol variety stones that are silent and produce no discomfort. For these individuals, it may be prudent to avoid obesity and to reduce any overweight by very small steps over a long period of time, to avoid a rapid weight loss that can very easily precipitate attacks of gallstones. Rapid weight loss may precipitate gallstones by mobilizing large amounts of choles­terol from the fat deposits of the body.

For those whose stones have been discovered because of episodes of biliary colic, which is an attack of severe right upper abdominal pain due to a stone or stones attempting to get out of the gallbladder, there is now a medical program that will help dissolve these stones.

For those with cholesterol stones, especially small stones, the bile salts have been in use for a long time. Chenodeoxy­cholic acid and more recently ursodecolic acid, or a combination of these two, may dissolve about 23 percent of stones. But with the presence of the gallbladder, there is a tendency for these stones to reform. In fact, about one-third of stones will reappear within three and a half years to seven years. This method of bile salts dissolving cholesterol stones probably has a limited role to play in those too sick for the conventional or the newer forms of laparoscopic-assisted cho­lecystectomy. In this procedure, the surgeon views the interior of the abdomen through videoscopic cameras and removes the gallbladder through a very small abdominal incision. The result is a more rapid recovery and a shorter hospital stay.

For those with stones who have suffered at least one episode of gallbladder colic and elect to continue to live with their stones, it would be prudent to reduce the fat intake of the diet, not to dissolve the stones, but instead to prevent a fatty meal from releasing large amounts of cholecystokinin, stimulating the gallbladder to contract vigorously and thus precipitate a colic attack. While this appears prudent and I think rational, it has never been proven scientifically. I have observed many pa­tients who have had only one episode of colic and have never had another that the patient ascribes to improved eating habits, especially the reduction of fat intake. It is impossible for the normal individual to reduce the intake of fat so much so the gallbladder fails to contract at all. The gallbladder, after all, plays an important role in breaking down fat in the diet fat which seems a mainstay in the American diet.

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