Prevention of cholelithiasis: intervention on risk factors
Prevention of cholelithiasis is in its infancy and depends largely on a clear understanding of events during pathogenesis. Nucleation and stone growth-inhibiting factors are new areas. Abnormal bile composition resulting in excess cholesterol in bile is believed to be the precursor of cholesterol gallstone formation and intervention is directed against this hypothesis. Several populations have been identified with a high prevalence of gallstones and a high prevalence of cholesterol-saturated bile. Lithogenic bile is associated with (a) obesity, morbid or mild; (b) Crohn’s disease, iIeal resection or bypass and cystic fibrosis with pancreatic insufficiency; (c) Clofibrate or oral contraceptives; (d) female relatives of patients with gallstones; (e) becoming worse on fasting in women compared to men. The factors documented for cholesterol saturation are also associated with an increased prevalence of cholesterol gallstones. Dietary constituents have been proposed as risk factors. We have performed prevalence studies, looked at dietary factors and with age-controlled discriminant stepwise analysis have found obesity; the presence of relatives with gallstones; reduced intakes of dietary fibre and iron as significant risk factors in patients who were found to have gallstones at the time of study and had not yet had time to change their diet. This is contrasted with the usual group of reported patients (which includes prior cholecystec-tomy, presence of gallstones in functioning gallbladders or otherwise), where obesity; relatives with cholecystectomy; reduced calcium or protein intake and duration of oral contraceptive use are significant factors.
We have tested these prospectively and find that (a) a high-protein diet protects against cholesterol-saturated bile, (b) a diet high in carbohydrate and high in refined carbohydrate promotes lithogenic bile and (c) duration of fasting and obesity are associated with lithogenic bile; we have established a modified diet, based on these findings. This modified diet includes reducing to ideal body weight and maintaining this; regular meals with a late-night snack with sufficient protein or fat to contract the gallbladder; a reduced duration of overnight fast; more protein (20–25%); less carbohydrate (<50%); less refined carbohydrate (<30%); and 30% dietary fibre.
Using this diet compared to the regular diet, and chenodeoxycholic acid to dissolve cholesterol gallstones, we have found that patients taking a modified diet dissolve gallstones quicker and more of them do so. On follow-up of these patients with 6-monthly bile analysis and repeated gallbladder ultrasounds, recurrences are predominantly in the second year of follow-up; lithogenic bile is seen more frequently in those maintaining their regular diet during the follow-up period.
There are several general measures we can take to prevent cholesterol gallstone disease; reduce and maintain ideal body weight, avoid repetitive and prolonged fasting, use an oral contraceptive of low oestrogen content or an alternative method of birth control, and reduce bile cholesterol saturation by diet changes. In addition, we may add cholelithic agents, such as chenodeoxycholic acid or ursodeoxycholic acid, particularly for ileal resection or bypass or where Clofibrate is necessary. Diet should be of benefit in the most common form of gallstones; that seen in the situation of mild to moderate obesity and in the situation where ethnic groups are predisposed to gallstone formation.
KeywordsUrsodeoxycholic Acid Ideal Body Weight Gallstone Disease Chenodeoxycholic Acid Regular Diet
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