Advertisement

Prevention of cholelithiasis: intervention on risk factors

  • C. N. Williams

Abstract

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.

Keywords

Ursodeoxycholic Acid Ideal Body Weight Gallstone Disease Chenodeoxycholic Acid Regular Diet 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Bennion, L. J. and Grundy, S. M. (1978). Risk factors for the development of cholelithiasis in man (two parts). N. Engl. J. Med., 299, 1161–1221PubMedCrossRefGoogle Scholar
  2. 2.
    Williams, C. N., Morse, J. W. I., Kotoor, R., Park-dincsoy, H. and Macdonald, I. A. (1976). Biliary pain, cholecystokinin cholecystography and lithogenic bile. J. Gen., 31, 91–100Google Scholar
  3. 3.
    Reid, J. M., Fullmer, S. D., Pettigrew, K. D. et al. (1971). Nutrient intake of Pima Indian women: relationships to diabetes mellitus and gallbladder disease. Am. J. Clin. Nutr., 24, 1281PubMedGoogle Scholar
  4. 4.
    Sampliner, R. E., Bennet, P. H., Comess, L. T. et al. Gallbladder disease in Pima Indians. N. Engl. J. Med. 283, 1358Google Scholar
  5. 5.
    Brown, J. E. and Christensen, C. (1967). Biliary tract disease amongst the Navajos. J. Am. Med. Assoc., 202, 138CrossRefGoogle Scholar
  6. 6.
    Williams, C. N., Johnston, J. L. and Weldon, K. L. M. (1977). Prevalence of gallstones and gallbladder disease in Canadian Micmac Indian women. Can. Med. Assoc. J., 16, 1356Google Scholar
  7. 7.
    Williams, C. N., Johnston, J. L., McCarthy, S. and Field, C. A. (1981). Biliary lipid bile acid composition and dietary correlations in Micmac Indian women. Am. J. Dig. Dis., 26, 42 - 49CrossRefGoogle Scholar
  8. 8.
    Danzinger, R. G., Gordon, H., Schoenfield, L. J. and Thistle, J. L. (1972). Lithogenic bile in siblings of young women with cholelithiasis. Mayo Clin. Proc., 47, 762–766PubMedGoogle Scholar
  9. 9.
    Bennion, L. J. and Grundy, S. M. (1975). Effects of obesity and caloric intake on biliary lipid metabolism in man. J. Clin. Invest., 56, 996–1011PubMedCrossRefGoogle Scholar
  10. 10.
    Freeman, J. B., Meyer, P. D., Printen, K. J., Mason, E. E. and DenBesten, L. (1975). Analysis of gallbladder bile in morbid obesity. Am. J. Surg., 129, 163–166PubMedCrossRefGoogle Scholar
  11. 11.
    Cohen, S., Kaplan, M., Gottlieb, L. and Patterson, J. (1971). Liver disease and gallstones in regional enteritis. Gastroentewlogy, 60, 237–244Google Scholar
  12. 12.
    Dowling, R. H., Bell, G. D. and White, J. (1972). Lithogenic bile in patients with ileal dysfunction. Gut, 13, 415–420PubMedCrossRefGoogle Scholar
  13. 13.
    Roy, C. C., Weber, A. M., Morin, C. L., et al. (1977). Abnormal biliary lipid composition in cystic fibrosis: effect of pancreatic enzymes. N. Engl. J. Med., 297, 1301–1305PubMedCrossRefGoogle Scholar
  14. 14.
    Pertsemlidis, D., Panveliwalla, D. and Ahrens, E. H., Jr. (1971). Effects of Clofibrate and of an estrogen-progestin combination on fasting biliary lipids and cholic acid kinetics in man. Gastroentewlogy, 61, 488–496Google Scholar
  15. 15.
    Bennion, L. J., Ginsberg, R. L., Garnick, M. D. et al. (1976). Effects of oral contraceptives on the gallbladder bile of normal women. N. Engl. J. Med., 294, 189–192PubMedCrossRefGoogle Scholar
  16. 16.
    Wood, P. D., Shioda, R., Estrich, El. et al. (1972). Effect of Colestyramine on composition of duodenal bile in obese human subjects. Metabolism, 21, 107–116PubMedCrossRefGoogle Scholar
  17. 17.
    Thornton, J. R., Emmet, P. M. and Heaton, K. W. (1973). Diet and gallstones: effect of refined and unrefined carbohydrate diets on bile cholesterol saturation and bile acid metabolisms. Gut, 24, 2–6CrossRefGoogle Scholar
  18. 18.
    DenBesten, L., Connor, W. C. and Bell, S. (1973). The effect of dietary cholesterol on the composition of human bile. Surgery, 73, 266–273PubMedGoogle Scholar
  19. 19.
    McDougall, R. M., Yakymyshyn, L., Walker, K. and Thurston, O. G. (1978). Effect of wheat bran on serum lipoproteins and biliary lipids. Can. J. Surg., 21, 433–435PubMedGoogle Scholar
  20. 20.
    Metzger, A. L., Adler, R., Heymsfield, S. and Grundy, S. M. (1973). Diurnal variation in biliary lipid composition. N. Engl. J. Med., 288, 333–336PubMedCrossRefGoogle Scholar
  21. 21.
    Williams, C. N., Morse, J. W. I., Macdonald, I. A., Katoor, R. and Riding, M. D. (1977). Increased lithogenicity of bile on fasting in normal subjects. Am. J. Dig. Dis., 22, 189–194PubMedCrossRefGoogle Scholar
  22. 22.
    Johnston, J. L., Williams, C. N. and Weldon, K. L. M. (1977). Nutrient intake and meal patterns of Micmac Indian and Caucasian women in Shubenacadie, NS. Can. Med. Assoc. J., 116, 1356PubMedGoogle Scholar
  23. 23.
    Williams, C. N. and Johnston, J. L. (1980). Prevalence of gallstones and risk factors in Caucasian women in a rual Canadian community. Can. Med. Assoc. J., 122, 664–668PubMedGoogle Scholar
  24. 24.
    Williams, C. N. (1982). Diet changes enhance cholesterol gallstone dissolution. In Paumgarter, G., Stiehl, A. and Gerok, W. (eds.) Bile Acids and Cholesterol in Health and Disease. ( Lancaster: MTP Press )Google Scholar
  25. 25.
    Williams, C. N. and Scallion-George, S. M. (1982). Prevalence of gallstones in urban Canadian Caucasian women: comparison with rural Caucasian and Indian women. Ann. Roy. Coll. Phys. Surg. Can., 15, 296AGoogle Scholar
  26. 26.
    Hesse, F. G. (1959). A dietary study of the Pima Indian. Am. J. Clin. Nutr., 7, 532–537PubMedGoogle Scholar
  27. 27.
    Sarles, H., Gerolami, A. and Cross, R. C. (1978). Diet and cholesterol gallstones, a multicentre study. Digestion, 17, 121–127PubMedCrossRefGoogle Scholar
  28. 28.
    Sarles, H., Gerolami, A. and Bord, A. (19 78). Diet and cholesterol, a further study. Digestion, 17, 128–134Google Scholar

Copyright information

© MTP Press Limited 1984

Authors and Affiliations

  • C. N. Williams

There are no affiliations available

Personalised recommendations