Therapies For Gallstone Problems by Dr. JB Lim



Choletithiasis

The blogger’s cousin brother has recently suffered from cholelithiasis (i.e. presence of gallstones in the gall bladder) and acute pancreatitis.  He requested the blogger to seek the expert advice from the most-learned Great Sifu Dr. JB Lim whether a surgical operation to remove the gall bladder is inevitably necessary.

The blogger is deeply indebted to the kindest Dr. Lim for having promptly responded with the following two emails, the contents of which are so informative and educational that the blogger wishes to share with the world for the benefit of all concerned readers of this blog.  Dr. Lim believes in the Bible’s beatitude that says “It is more blessed to give than to receive” and he practices it regularly to the utmost admiration and respect of all his friends and e-buddies.     

  

Wednesday, 4 June, 2014 9:30 PM

From: Lim Juboo

Dear Sifu Ir. Lau,

It looks like from the CT scan done on your cousin brother on 29 May, he had an inflamed bile duct, and inflamed pancreas due to stones in the bile duct and possibly gallstones in the gall bladder blocking the flow of bile into the small intestines.

However another non-invasive imaging done at Ramsay Sime Darby Hospital 4 days later on 2 June (probably after his stones were taken out from the bile duct) showed there were several other stones remaining in the gall bladder as well. Why was these not taken out during the first surgery?

The gall bladder is a reservoir for bile connected to the bile duct from which bile is then drained into the intestines. If you remove stones only from the bile duct, the chances is that stones from the gall bladder may pour back into the bile duct and block it again.

Gallbladder removal

Hence his surgeon was right in that, the ‘only solution’ is to remove the gall bladder. That is just one way.

The reason I used the word ‘only solution’ is that his surgeon did not tell him about other alternatives methods that can also break up the stones in the gall bladder into smaller pieces and then let the smaller fragments easily drain out through the duct straight into the intestines. Maybe he wanted to do another surgery on your cousin brother?

I suggest he discuss with his surgeon once again other options below:

•Using shock wave (extracorporeal shockwave lithotripsy) to break up the stones into small bits (probably the best other than surgery).

•Use ursodeoxycholic acid as a bile salt therapy to dissolve the stones if they are cholesterol in nature. But this method may take a longer time and may not also be successful if the stones are too large. The second radiology did not tell us how big were the stones in the gall bladder?

•Use contact dissolution procedure to dissolve the stones. But there may be risk and complications, and the stones may return.

•Herbal medicines include milk thistle (Silybum marianum), dandelion, and a local herb called Phyllantus amarus or Phyllanthus niruri can also soften stones and prevent stones from forming in the gall bladder as well as in the kidneys.

•Add apple cider vinegar, lecithin, and olive oil in the diet. These adjunct therapies are also useful.

Of course if he can have the reservoir that collects the stones surgically removed then of course it is probably the best and “the only way” as the above may be ‘troublesome’ as it involves change of lifestyle, food and eating habits etc.

Whichever method, care is still needed to be taken from preventing stones from blocking the duct again even if the gall bladder has been removed.

To prevent future reoccurrences, the following need to be observed:

•·         Reduce obesity if overweight

•·         Increase intake of high fibre foods like fruits and vegetables

•·     Exercise, or at least do housework instead of watching Astro or e-mailing to ‘buddies’ all day long (joking)

•·         Manage blood cholesterol if high

•·         Drink adequate fluid (water) daily – at least 2 litres

•·     Reduce intake of foods rich in cholesterol, calcium and oxalates (example bayam) and all foods rich in animal fat, lard, ghee, roti canai, Hokkien mee, (Penang) char kuih teow, roasted pork with the fat, etc

•·         Do not over eat. Eat just sufficient to prevent hunger

•·         Nutritional supplement with lecithin may be useful

•·       Use olive oil for cooking, or at least 1-2 tablespoonful added into dressing for salad 

I can go on and on, but I need to stop to do other work as “a male slave in my own house” as ordered by a Speaker in “Parliament”.

regards

jb lim

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Thursday, 5 June, 2014 9:23 PM

From: Lim Juboo

Dear Sifu Ir. Lau TO,

You and your cousin brother are most welcomed.

CBD

In order to understand a little more about gallbladder and gallstones on what I wrote earlier, concentrated bile from the gall bladder is drained into a duct called the cystic duct which then joins up with the hepatic duct from the liver to form the common bile duct (CBD).

The gall bladder is a sac placed there quite apart from the liver except it is joined by these two ducts, and at the lower end before it enters the small intestine, it is joined by the pancreatic duct from the pancreas which pours its exocrine digestive juices to further break up the carbohydrates, proteins and fats (lipids) in the chime.

The pancreas also acts as an endocrine organ that produces insulin by the beta cells of the islets of Langerhans, but insulin is delivered directly into the blood stream and is not poured into the small intestine like bile from the liver and the pancreatic juices.

At the neck of the gallbladder there is a fold of mucosa (Hartmann's pouch), where gallstones commonly get lodged either by cholesterol or bilirubin that concentrate there.

If bile stones block the gallbladder or any of the ducts, it may cause pain, jaundice or fever if the ducts, the gallbladder or pancreas get infected

The only function of the gall bladder is to store the bile from the liver, concentrate the bile, store it there, and release it into the small intestine.

It can actually be surgically removed by a procedure called cholecystectomy just like in appendectomy for the removal of the appendix. Both have little use physiologically.

Cholecystitis

If the gallbladder is inflamed because of stones or due to an infection, it is called cholecystitis, and if there is an obstruction, it is called cholelithiasis.

If bile is blocked, it accumulates, and pressure on the gallbladder wall may build up. This will cause substances like phospholipase to be released.

The accumulated bile may also dam back into the blood stream causing yellowness of the white of eyes and skin (jaundice or icterus). The bilirubin (bile pigment) in the blood will then rise. This can easily be detected by blood test (liver function tests).

If the pancreatic duct is blocked, the pancreas will be inflamed (pancreatitis) when pancreatic juice cannot enter the small intestine. There may also be risk of infection in the gall bladder, pancreas or in the ducts.

In all cases there will be pain, fever, tenderness in the upper, right quadrant of the abdomen, and during a clinical examination, there may be tenderness on palpation during breathing in and out  (Murphy's sign maybe positive).

Cholecystitis due to infection is usually treated often with rest and antibiotics such as cephalosporins or with metronidazole

Most people do get stones lodge in their gallbladder and they do not cause any pain or problems. As such we normally leave them alone instead of going for unnecessary surgery.

If surgery is chosen, normally it is just elective surgery – meaning it is not so important and can be postponed to another date unless there is pain, jaundice or fever or severe infections.

If surgery is chosen, it is best to choose a minimally-invasive procedure called “key hole surgery” (laparoscopic procedure) rather an open one.

Key hole surgery

However, you need to find a surgeon who is well-trained and experienced in laparoscopic procedures rather than looking for a general surgeon who may not be too familiar with key-hole surgery.

There are a lot of advantages of opting for laparoscopic surgery done by a good gastroenterology surgeon rather than by convention open surgery.

What if I were to have gallstones in my gall bladder, and if it is not troubling me?

I will just leave them alone as a lot of people do have stones in their bladders, and they remain healthy and asymptomatic (no symptoms) for the rest of their lives.

The bladder in some way is meant to store these stones and deposit them there instead of sending them to the much smaller excretory ducts and the chances of them blocking there.

However, if the stones are present, and even if they do not cause pain, I would regularly, say once every 6 months or longer go for a liver function test, especially for bilirubin levels to ensure I do not have sub-clinical jaundice that may be undetected clinically due to blockage of the ducts, and dam back into the blood. This is what I would do.  I would not even want to think of unnecessary elective surgery.

I will not even go to a private hospital or even a GP to do a liver function test as this can easily be done so cheaply in any private pathological lab. I think it cost less than RM 25 to do the entire liver function tests that includes bilirubin levels. It also gives the other liver enzymic profiles.  Why spend thousands of ringgit for such simple screening tests in private hospitals?

What I would do, is to practice preventive medicine by leading a healthy lifestyle with lot of fruits and vegetables, cut down on fatty and meat-based foods, managed my body weight within the desirable BMI, exercise regularly, drink a lot of fluid (less sweet fruit juices – carrot, tomatoes, apple, etc), plain tea without sugar or milk, or plain water, or add about 20 ml of apple cider vinegar per litre into the drinking water.

I may add at least 10 -15 ml of olive oil into my daily diet.  I have mentioned some of these earlier.

These measures could be preventive, and may even flush out any existing small gallstones or even kidney stone lodged in the body.

Potassium citrate

A urine alkalinizer (example 15 ml Potassium citrate) may help to prevent most stones from forming and clears up urinary tract infections.

Fruit juices low in oxalates and salicylates (aspirin) may prevent uric acid stones formation.  It is best to avoid aspirin for those with gouty arthritis as salicylates may block uric acid excretion and cause hyperuricemia (high blood uric acid).

So are asparagus, cauliflower, spinach, and mushrooms high in purines.

Hence, it is advisable to avoid these vegetables if you have gout or high blood uric acid.

Regards

Jb lim