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Gall Bladder, Cholesterol,


thinking about eating-->CCK release-->gall bladder constriction and duct relaxation

up to a liter of bile produced/day

ETIO OF HIGH CHOL
20% from diet
80% made by us
(how much variation is there in chol manufacturing???)
he doesn't like to see chol under 140 because it hurts cell walls, hormone production
find chol in arteries which get inflam dt free radicals
plaques are patches on damage to arteries
stress pt for 1/2 day and then test blood-->will find high chol
high cortisol --> raises LDL levels (LDL is patching up tiger bites)
chronic stress raises cholesterol

CHOLESTEROL STONES
a balance of bile salts, cholesterol, lecithin
lecithin = emulsifier
chol stones mc in this culture dt diet, dehydration, and stress
high # of peeps have stones on autopsy, were ASx
stones can get stuck in cystic or common bile duct or at outlet
size of gall stone doesn't concern Dr Thom much

PIGMENT STONES
high bilirubin dt RBC metabolism
hemolysis?

RISK FACTORS FOR CHOLELITHIASIS
est
preg
dieting
high chol
obese
OCPs
genetics: white, hispanic, native
CF
IV bag, what does it symbolize???

PT HAS HAD GALL ATTACK
allopathic medicine steers to surgery
some are told you can dissolve it: can you? not really, it's quite difficult
no lithotripsy done on gall bladders, not very successful procedure, easier to take it out

PATHOLOGIES
cholelithiasis = calculi
cholecystitis = inflam of gall bladder
cholangitis = inflam of biliary ducts

CHOLELITHIASIS
most pts ASx
found on US or autopsy
3 typical presentations: ASx, biliary colic, acute cholecystitis
management overlaps
3% of pts with stones/year-->symptomatic
3-5%-->complications: acute cholecystitis, choledocholithiasis, cholangitis, pancreatitis, cholecystocholedochal fisutla, cholecystoenteric fistula, gall bladder cancer
*you'll never get gall bladder cancer if you take it out
if have one attack and no more-->this is the pt who might get cancer

LAB WORK
CBC: WBC's high in some
LFT incr w/ infx, obstrx
bilirubin: conjugated is elevated with duct obstrux
serum amylase and lipase if common bile duct obstrx

IMAGING
ultrasound
inexpensive, noninvasive, good info if operator is skilled
want to know thickness of gall bladder wall (risk factor for CA)
has thickness changed? if thickening-->aggressive intervention incl removal
if inflamed will see pericholecystic fluid (this doesn't necc mean rupture)

HIDA TEST
aka hida scan aka nuclear hepatobiliary scan aka cholescintigraphy
radionuclide imino diacetic acid (IDA) is injx IV
detected in liver within 10 min, accumulates in gall bladder as liver processes it
gall bladders shows up white on screen
then you get another injx this one makes your gall bladder think
that you just ate a cheeseburger
you can see the white radionuclide pushing out of the gall bladder,
into and along the duodenum, if there is good fx
GB ducts and duodenum are visualized continuously for up to an hour
these notes as much on my experience (I had this test) as from Dr T
acute cholecystitis-->nonvisualized GB (95% s&s)????what does that mean?
to eval biliary leak or hypomotility

CT
to define biliary tree and nearby structure
test of choice to eval for malig

MRI
to see ducts

ERCP
sedate pt
visualize ampullary region and direct access to distal CBD

DDX
acute/chronic choly, CBD stone, cholangitis
inflamed or perforated duodenal ulcer
hepatitis
appendicitis
renal colic
pneumonia, pleurisy
pancreatitis
IBD: esp Crohn's
GERD

CHOLELITHIASIS SX
ASX or
intermittent RUQ pain dt transient cystic duct obstrx
no fever/WBC, normal LFT

case 1
ACUTE CHOLELITHIASIS
stone is blocking a tube but it hasn't been there long
RUQ pain after fatty meal, initial attacks mb short but can become persistent
pain may radiate to R scap
most have N/V
some have fever, incr WBCs, some LFT elevation
palpable tender distended gallbladder, guarding
+Murphy's w/ inspiratory arrest
pericholecystic fluid and wall thickening and stones on US
TX: analgesic/antispasmodic tincture, vinegar packs, homeopathy
want to pass stone, heal infx, inflam will subside
if stone won't pass in 12 hours-->surgery

ACALCULOUS CHOLECYSTITIS
GB inflam dt biliary stasis (5%) and not stones
seen in critically ill pts
vagotomy, trauma, GI stasis

CONVENTIONAL TX OPTIONS
laparoscopic cholecystectomy
minimally invasive, low risk of complications
hospital stay under 24 hours
if surgery inappropriate: antispasmodics such as Bentyl, analgesics ie Demerol, ABX for infx

TWO NATUROPATHIC TREATMENT PLANS
acute and chronic

TREATMENTS: ACUTE RUQ DISTRESS
appears to be gall bladder colic
needs pain relief and antispasmodic
herb options: kava, dioscorrea, viburnum, tincture, 2 droppers/15 min
vinegar packs work really well for acute spasm
50/50 w/ water, heat on top, quick relief
homeopathic specifics: mc chelidonium
these 3 things are what Dr Thom does: tincture, vinegar, homeopathy
send for US, labs, work it up to be sure it's gallbladder

TREATMENTS: CHRONIC RUQ DISTRESS

DIET CHANGES
1) incr fiber (flax, chia, pumpkin seeds)
2) decr sat fat
3) eat hypoallergenic foods
avoid: eggs, pork, onions, chicken, other common foods

SUPPLEMENTS
1) bile salts (cholocol, ichol) **in medicinary
vit C (esp w/ chol gallstones)
vit E 400-800 IU qd esp w/ chol stones
2) EFA's
HCl and digestive enzymes lipase)
lecithin: 100mg tid up to 4-6g qd
methionine 1gm
taurine 2-4gm
antioxidants
3) lipotropics (choline, carnitine, inositol, 300mg tid)
peppermint oil (metharil)

LONG TERM TX
avoiding exogenous estrogens
weight loss, gradual
castor oil packs
modulate risk factors

TINCTURE to strengthen liver
berberis aquafolium & vulgaris
chionanthus
chelidonium
chelone glabra
colocynthis 2-5 drops q 1-3 hours
cynara scolymus
dioscorea villosa
Euonymus atropurpureus
taraxicum
lots more

HOMEOP: chelidonium, cholesterinum, fel tauri 8x (ox bile) are his top 3
carduus marianum, chionanthus, leptandra, myrica, podophyllum

I USED TO HAVE TROUBLE WITH MY GALL BLADDER
AND I DIDN'T HAVE IT OUT, IT GOT ALL BETTER
if biliary pt is asx
will revert to old behavior
most will remain asx
still needs longterm management
get US if they had a problem 10+ years ago
to be sure no CA
Dr Thom has seen 3 pts that presented this way with CA
UNTIL I FOUND OUT I HAD CANCER OF MY GALL BLADDER

case 2
15yo female
RUQ pain x 3hrs increasing
epigastric rad to R shoulder
now disappearing
RUQ TTP
N/V
2 episodes in past 3 mo
WBC 7,000 no infx of inflam, also no fluid around gall bladder
hct 25% PLT normal
LFT normeal except indirect dili 2mg/dl
US shows 3 stones, no pericholecystic fluid, no edema of gall bladder
4mm bile duct
risk factors: female, fertile, est, diet, preg, ocps, famhx
want more hx: what's her race/genetics, activity/running?, menses/est/ocps/preg
hemolysis dt low HCT
DDX: gastric or duodenal ulcer, crohn's, preg, hepatitis (prob not), sickle cell or some other reason for hemolysis
consider preg test, endoscopy
lab results suggest: hemolysis
DX: biliary colic, probably pigment stones, high bili condition dt hemolytic anemia
TX: analgesic/antispasmodic tincture, vinegar pack, homeopathy for colic, plus long term management: address the anemia

case 3
jaundiced 46yo female with hx of cholelithiasis
liver enzymes normal, neg for hepatitis
US shows CBD dilated to 1cm, gallstones, CBD stone
dx: choledolithiasis of common bile duct
tx: try acute care x12 hours to see if stone will pass with antispasmodics
smooth muscle relaxers
backup tx: ERCP, go in via duct and remove stone
ERCP is sticking a tube in though the mouth, I think, all the way up the tubes to the gall bladder. Lots more invasive and risky than US, involves total sedation.

case 4
54yo white man, HTN, DM
L flank pain, hematuria
LFTs normal
US 2 stones L kidney, 3 stones 1x1cm in gall bladder
no gall sx
dx: chol stones, Asx
tx: really good diet

case 5
thickened GB wall
no inflam or infx or perycholecystic fluid
hx of biliary colic, many attacks
very common presentation
discuss risk of gallbladder CA, consider removal
TX for chronic choledolithiasis and CA prevention
attacks may resolve but cancer could still happen
must followup with US every 5 yrs of so
difficulty is motivation to stay on tx plan after pain is resolved
dx: chronic choledolithiasis
tx: monitoring gall bladder wall thickness via US
if no sx check now, then at 2 years and again at 5
want to be sure no CA, esp if pt is eating old diet, smoking, drinking, other risks

ND TX FOR CHOLELITHIASIS per Siebert
bile acids 1000-1500 mg qd
choelgogue herbs esp milk thislte 210-420 mg qd
fiber
L-methionine 1000mg qd
choline 1000mg qd
lecithin (phosphatidylcholine) 100mg tid
vit C 500-1000 mg tid
vit E 200-400 IU

CHRONIC ND TX (Siebert)
don't reduce fat too much: dieting can trigger more attacks
eat small frequent meals
watch for food intolerances, bloating/flatulence
may need enyzme supps if stool is bulky or greasy
30,000 IU lipase with each meal
avoid larg emeals, high fat and etoh overload

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