The Gallstone Elimination Report

Gallstone Natural Solutions by David Smith

The Gallstone Elimination Report is a new program developed by David Smith, who has many years of experience in the health industry. The program provides people with step-by-step strategies on how to remove their gallstones quickly and effectively. With the program, people will find out the top 3 digestive conditions related to gallbladder disease and how to relieve them easily. Besides, the program guides people on how to prevent gallstones from coming back. Users will also know how to boost their energy levels and how to slow down the aging process. Using this step-by-step and comprehensive guide, users will get to know how to get rid of gallstones in 24 hours or less, without drugs, surgery, or pain. This method is safe and very affordable also. Continue reading...

The Gallstone Elimination Report Overview

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Gallstones

Gallstones are common, and are estimated to be present in 20-30 of people in developed countries. Only 20-30 of these people will develop problems related to their stones, and it is important to try and differentiate between symptomatic and asymptomatic stones. Gallstones contain cholesterol, bile pigments, or a mixture of these compounds, and it is clear that their aetiology is multi-factoral. Obesity, ileal resection, and haemolytic anaemia have all been linked to gallstone formation, the only certain factors about their formation is that they are twice as common in women as men, and become increasingly common with age. Gallstones may cause a variety of symptoms depending on which part of the body they are in. The commonest problems arise from stones in the gallbladder, and present as biliary colic or cholecystitis. Biliary colic is a self-limiting condition characterised by right upper quadrant pain, often severe, caused by temporary cystic duct obstruction. The pain is associated...

Gallbladder Disease

Ultrasound is generally accepted to be the modality of choice in the evaluation of biliary disease. 4 Greater than 90 percent of biliary disease is calculous in origin, and, regardless of composition, even the smallest of gallstones are visible sonographically. Conversely, only 15 percent of gallstones are visible with standard radiographs. The primary sonographic finding in biliary disease is gallstones. Gallstones appear as bright, echogenic foci within the gallbladder and move with changes in position unless impacted (Fig 29.5-8). A minority of gallstones float within the bile. Symptomatic gallstones may be very small in relation to the volume of the gallbladder, and a thorough search of the organ is mandatory. In order to ensure this, the patient should be instructed to halt inspiration when the gallbladder is well visualized. During this breath holding, the entire gallbladder should be visualized in one axis, sweeping from one side of the gallbladder to the other. This should be...

Right Upper Quadrant Pain

Right upper quadrant pain can be caused by gallbladder disease including acute cholecystitis, biliary colic, biliary dyskinesia, cholangitis, and bile duct obstruction. Other sources of right upper quadrant pain include hepatic dysfunction or abscess, leaking duodenal ulcer, as well as processes outside of the peritoneal cavity, such as a right lower lobe pneumonia. Hepatobiliary disease and gallbladder disease, depending on the severity, require different degrees of intervention. Emergent surgical intervention is rarely required. Most patients who present to the ED or doctor's office complaining of right upper quadrant pain can receive an outpatient workup for symptomatic cholelithiasis. If required, cholecystectomy can be elective in these patients. If, however, they have fever or unrelenting pain they may have acute cholecystitis requiring more urgent care. They usually require admission and cholecystectomy during that hospitalization. Cholangitis requires an inpatient admission...

Extra Articular Conditions

The efficacy of arthroscopy in treating pathologic conditions in encapsulated environments (joints, bladder, etc) has spawned interest in further applications. Advancements in general surgery to endoscope soft tissue cavities have allowed treatment of inguinal hernias and gallbladder disease. Similarly, orthopedic arthroscopic procedures have begun to extend to extra-articular areas. As mentioned above, post-traumatic periarticular impinging ossification has been resected via the arthroscope. Glick has also reported his experience with this technique for iliopsoas and iliotibial band release.15 It should be emphasized that the results are preliminary the recovery can be protracted, especially for the il-iopsoas, and further study is necessary.

TABLE 771 Extraintestinal Manifestations of Inflammatory Bowel Disease

Hepatobiliary disease is common in patients with inflammatory bowel disease and includes pericholangitis, chronic active hepatitis, primary sclerosing cholangitis, and cholangiocarcinoma. Gallstones are detected in up to 33 percent of patients with Crohn's disease. Ihe incidence of acute and chronic pancreatitis is increased in patients with Crohn's disease and ulcerative colitis.

TABLE 801 Causes of Jaundice

If the liver can produce but not normally excrete conjugated bilirubin because of a metabolic defect or intra- or extrahepatic obstruction, conjugated hyperbilirubinemia and cholestasis results. Intrahepatic cholestasis is caused by decreased excretion of conjugated bilirubin, hepatocellular damage, or damage to the biliary endothelium. Obstruction of biliary outflow by a congenital defect, inflammation, a mass lesion, or gallstones produces extrahepatic cholestasis.

Diagnostic Studies

Additional studies in patients with biliary colic may be performed to support the diagnosis and rule out other causes of upper abdominal pain with nausea. Plain film radiographs of the abdomen demonstrate gallstones in only 10 to 20 percent of cases. The majority of stones are cholesterol and therefore radiolucent. Pigment and mixed stones containing at least 4 percent calcium by weight are radiopaque. Abdominal films are more useful in excluding other causes of pain. A chest radiograph should be obtained to identify right lower lobe pneumonia or pleural effusions. A 12-lead electrocardiogram should be obtained in all older patients to exclude myocardial ischemia or infarction.

Chapter References

Gracie WA, Ransohoff DF The natural history of silent gallstones The innocent gallstone is not a myth. N Engl J Med 307 798, 1982. 2. Ikard RW Gallstones, cholecystitis, and diabetes. Surg Gynecol Obstet 171 528, 1990. 3. Jorgenson T Abdominal symptoms and gallstone disease An epidemiological investigation. Hepatology 9 856, 1989. 9. Diehl AK, Sugarek NJ, Todd K Clinical evaluation for gallstone disease Usefulness of symptoms and signs in diagnosis. Am J Med 89 29, 1990.

Clinical Features

Clinical presentation of acute liver disease is variable. Symptoms of hepatocellular necrosis accompanying viral hepatitis include anorexia, nausea, vomiting, and low-grade fever. Cholestatic disease is accompanied by jaundice of varying degree, pruritus, clay-colored stools, and dark urine. Biliary colic implies acute obstructive cholestasis of extrahepatic or mechanical etiology, as in common duct gallstones or rapidly growing tumors. Cholestasis resulting from intrahepatic processes and infiltrative disease presents more insidiously with the slow development of jaundice and few other constitutional complaints.

Gallbladder and Biliary Tract Disease

Gallstones are the most common cause of biliary tract disease in the United States. Gallstones occur in 20 to 35 percent of the population by age 75 years but in the majority are asymptomatic. Acute colicky pain localizing to the right upper quadrant accompanied by nausea and vomiting, sometimes with a finding of a palpable and tender gallbladder, characterizes gallstone obstruction of the cholecystic duct. The acutely ill patient frequently will give a history of past episodes of postprandial pain, although less severe or prolonged. Typically, pain is of rapid onset and slow resolution with a pattern of radiation to the right lower scapula or right shoulder. Fever and toxicity suggest infection and cholecystitis. Gallstone obstruction of the common bile duct produces pain, frequently mild jaundice, and serologies suggesting biliary obstruction, hepatocellular injury, and pancreatitis. Fever and toxicity suggest infection and cholangitis. The diagnosis usually can be made by clinical...

TABLE 833 Laboratory Utilization in Suspected Acute Pancreatitis

Ultrasonography is most helpful in the identification of gallstones or dilatation of the biliary tree, which has both diagnostic and therapeutic implications in pancreatic disease. Although pancreatic edema and associated pseudocysts may be visualized on ultrasound, it is generally an insensitive test for the diagnosis of acute pancreatitis, particularly in nonbiliary etiologies. Overlying bowel gas or adipose tissue and the retroperitoneal location of the pancreas frequently impair adequate

Fats And Oils Substitutes

At 9 kcal g, fat is the most concentrated source of energy among the macronutrients. According to the Surgeon General's Report on Diet and Health, high intake of dietary fat is associated with increased risk for obesity, some types of cancer, and possibly gallbladder disease. Epidemiologic, clinical and animal studies provide strong and consistent evidence for the relationship between saturated fat intake, high blood cholesterol, and increased risk for coronary heart disease. Excessive saturated fat consumption is the major dietary contributor to total blood cholesterol levels (4). Reflecting national health policy, the Surgeon General, the National Academy of Sciences, the American Dietetic Association, the American Heart Association, the National Cholesterol Education Project, the American Cancer Society, the National Institutes of Health, the USDA, and the U.S. Department of Health and Human Services are among the many health and government authorities that recommend limiting...

Gastrointestinal System

Pregnancy-induced changes in the gastrointestinal system are due to both progressive displacement of the abdominal viscera and hormone-mediated functional alterations. Gastric reflux commonly occurs as a result of delayed gastric emptying, decreased intestinal motility, and decreased lower esophageal sphincter tone. The size and morphologic characteristics of the liver are not altered by pregnancy, but the presence of placental alkaline phosphatase may produce the increased alkaline phosphatase activity observed on analytical evaluation of maternal liver function. Bilirubin concentration and aspartate aminotransferase and alanine aminotransferase activities are unaltered. Hepatic enzyme systems are induced during pregnancy. Gallbladder emptying is delayed and less efficient, and pregnancy therefore increases the risk of cholesterol gallstones.

Upper Gi Emergencies Acute cholecystitis

For more details see also the section Gallstones. Acute cholecystitis is an inflammatory condition of the gallbladder, often, but not always, associated with the presence of gallstones. It is a common surgical cause of emergency admission to hospital, and is more common in women than men in keeping with the distribution of stone disease. The symptoms will initially resemble biliary colic, with right upper quadrant pain, and nausea, but symptoms persist and patients become systemically unwell. Fever, tachycardia, and mild jaundice may develop, and the pain may radiate to the scapula. An initial chemical inflammation is often superceded by bacterial infection with a deterioration in systemic symptoms. Clinical examination demonstrates localised tenderness in the right upper quadrant over the fundus of the gallbladder. Pain on inspiration while palpating in the right Trans-abdominal ultrasound scanning is the investigation of choice for suspected acute cholecystitis, and should ideally...

Pathology and dysfunction

One of the more common causes of stasis and thus infection in the United States is gallstone disease. Bile salts, cholesterol, and calcium salts usually are found in perfect solution in bile however, when an imbalance occurs, the bile salts come out of solution and precipitate into sludge or stones. Hemolytic states, such as due to sickle cell disease, results in the formation of pigmented stones, whereas high cholesterol states result in cholesterol stones, the most common form of gallstones. Mostly, these stones are formed where natural stasis of bile occurs in the gallbladder. Stones are, however, rarely formed in the bile ducts or intrahepatically. Stones are generally asymptomatic until they cause obstruction. Biliary pain can be caused by contraction of the gallbladder, but severe disease typically does not appear until a stone occludes the bladder or a duct. A gallbladder with stones is called cholelithiasis. Obstruction of the outflow of the gallbladder by a stone, results in...

Pathophysiology of Stone Formation

There are three kinds of gall stone cholesterol, black pigment, or brown pigment stones. Cholesterol stones constitute 75-90 of all gall stones. They are composed purely of cholesterol or have cholesterol as the major chemical constituent. Most cholesterol gall stones are of mixed composition. Pigmented stones get their color and their name from precipitated bilirubin. Increased production of unconjugated bilirubin causes black pigmentation. Formation of black pigment stones is typically associated with chronic hemolysis, cirrhosis, and pancreatitis. Brown pigment stones are usually associated with infection. Cytoskeletons of bacteria can be seen microscopically in brown pigment stones, Major risk factors predisposing to gall stones are age, sex, genetic profile, nutritional status (including the route of nutrition), hormones, drugs, and some other diseases such as diseases of the terminal ileum. A summary of these elements is provided in Table 1. body mass index and the reported...

Interventions and operations

Gallstones and their related complications are one of the most common hepatobiliary abnormalities seen in the clinical wards. As previously discussed, all symptomatic cholelithiasis and asymptomatic cholelithiasis in high-risk groups such as the elderly and diabetics, should be surgically addressed. However, in case of a common duct stone, choledocholithiasis, endoscopic retrograde pancreatography (ERCP), or interventional radiology techniques (percutaneous transhepatic cholangiogram PTC with percutaneous biliary drainage PBD catheter placement) are favored as first-line therapy for duct drainage and stone retrieval over surgical bile duct exploration. Open common duct exploration has been associated with much higher morbidity and mortality than ERCP for common duct stones. Surgery is strongly indicated for removal of the gallbladder once the common duct stone has been addressed. In the case of cholangitis in the presence of chole-docholithiasis, immediate bile duct drainage is...

Treatment recommendations

Because the trials have failed to show benefit for secondary prevention, and there are no published trial data for primary prevention, in both instances decisions about hormone therapy should be based on established non-cardiovascular risks and benefits.64 The major proven benefits of estrogen are relief of the symptoms accompanying the menopause, urogenital atrophy, and prevention of osteoporosis. Known risks include endometrial cancer, venous thromboembolism, pancreatitis (in women with high blood triglycerides), and gallbladder disease. At the average age of menopause, the risk for cardiovascular and non-cardiovascular disease conditions is low, and therefore, the short-term use of estrogens to manage the menopause is not at issue.65 If there is no benefit from reductions in CHD, the potential harm from breast cancer, endometrial cancer, venous thromboembolism, gallbladder disease, and pancreatitis may exceed the benefit from reduced fracture risk.

TABLE 2132 Clinical Emergencies in Patients with Sickle Cell Anemia

Bilirubin gallstones are found in up to 75 percent of patients with SCD. Hepatomegaly and liver function test abnormalities are common. Splenomegaly is seen in children with SCD however, by adulthood, the spleen is usually small as a result of recurrent infarction. Renal abnormalities including isosthenuria (inability to concentrate urine) and papillary necrosis occur commonly because of sickling phenomena in the hypertonic, acidic renal medulla. Bony abnormalities, resulting from expansion of the marrow space, and bony infarcts are typical. Radiographs of the bones show thinning of the cortices and sparseness of the trabecular pattern the biconcave fishmouth changes in the vertebrae are pathognomonic of SCD. Skin ulcerations occur over the distal lower extremities. Ophthalmologic problems primarily involving the retinae are common. Chronic disabilities resulting from central nervous system vasoocclusive events are seen. Abdominal Pain This is the second most common type of...

Hereditary Spherocytosis

Hereditary spherocytosis (HS) is the most prevalent hereditary hemolytic anemia among people of northern European descent. An estmated 1 in 4500 persons is affected. The disease is typically inherited in an autosomal dominant pattern, but in up to 20 percent of patients it is the result of an apparent spontaneous mutation. The abnormal shape of the RBCs results from molecular abnormalities in the cytoskeleton of the RBC membrane, most commonly with the proteins spectrin and ankyrin. Because of their abnormal shape, the RBCs are caught in the spleen and destroyed. As a result of the typically mild symptoms, the diagnosis may not be established until adulthood. Clinically, HS is characterized by a hemolytic anemia that is usually mild (a small minority of patients have severe anemia), splenomegaly, and intermittent jaundice from indirect bilirubin (due to hemolysis). Pigment gallstones are common.

Autonomic Dysreflexia

A variety of stimuli can produce an acute episode of autonomic dysreflexia. The commonest causes usually involve the urinary system bladder distention, urinary tract infection, and kidney stones. The second commonest reasons involve the colon fecal impaction or bowel distention. However, any noxious stimulus below the level of injury can lead to autonomic dysreflexia, including other abdominal problems, such as ulcers, appendicitis, and gallstones. Other causes may be fractures, deep venous thrombosis (DVT), pressure ulcers, ingrown toenails, tight-fitting clothing, sunburns, blisters, heterotopic ossification, sexual intercourse, pregnancy, and labor and delivery.

Detailed Anatomy of the Right Upper Quadrant

Paravertebral Groove

Morison, an English surgeon, is best known for the pouch that he described in The Anatomy of the Right Hypochondrium Relating Especially to Operations for Gallstones in 1894. He emphasized that bile leaks drain into this area but the external drain must extend to the very depths of the pouch. Morison, an English surgeon, is best known for the pouch that he described in The Anatomy of the Right Hypochondrium Relating Especially to Operations for Gallstones in 1894. He emphasized that bile leaks drain into this area but the external drain must extend to the very depths of the pouch.

Fibric acid derivatives Table 132

Rarely are these sufficient to warrant discontinuation of the medication. The increased incidence of hepatobiliary disease (particularly gallstones) occurs with all agents in this class.68 Minor alterations in several plasma biochemical values may occur, but these are dose-dependent and usually transient. The effective non-toxic dose-range is narrow, and at high doses fibrates cause myositis. They may potentiate the effects of oral anticoagulants and oral hypoglycemics and might also interact with statins to raise the risk of rhabdomyolysis.

Differential Diagnosis

Gallstone pain can be very similar to that of renal colic and should generally be considered in all patients with any right upper quadrant abdominal tenderness. Unlike the symptoms of renal colic, biliary colic symptoms are often associated with oral intake, last for several hours before remitting, and include vomiting. Pancreatitis is suggested by left upper quadrant or midepigastric pain, especially in the presence of risk factors (e.g., alcohol consumption or cholelithiasis). A perforated peptic ulcer may present with severe pain in the midepigastrum or either upper quadrant. However, these patients have marked tenderness on examination and develop peritoneal signs over time. Appendicitis shares the unilateral presentation with renal colic, but the subacute prodrome usually excludes urolithiasis. Ventral hernias should also be considered in the differential diagnosis and sought on physical examination. Diverticulitis usually causes pain in lower quadrants, more commonly the left,...

TABLE 751 Common Causes of Intestinal Obstruction

Tables Bowel Obstruction

Other causes of SBO are much less common and are generally due to intraluminal or intramural processes. Primary small bowel lesions include polyps, lymphoma, or adenocarcinoma. An unusual cause of intraluminal obstruction is gallstone ileus. In this situation, a gallstone has eroded from the gallbladder through the bowel wall and can cause obstruction at the ileocecal valve. Besides the findings of bowel obstruction, one may note air in the biliary tree on abdominal radiographs. Lymphomas may be the leading point of intussusception and present as SBO.

General Considerations

Acalculous cholecystitis is of particular concern in the postoperative period. While it may occur in any age group, it seems to be more common in elderly males. Signs and symptoms are similar to those for calculous cholecystitis, but ultrasound studies fail to reveal gallstones. Liver function studies and the neutrophil count may be normal. Important findings on ultrasonography include gallbladder enlargement, wall thickening, and pericholecystic fluid collection. Hepatobiliary scintigraphy may be helpful. Early diagnosis is critical because early operative intervention can reduce morbidity and mortality rates.

Laboratory Evaluation

A direct-reacting fraction of at least 30 percent (and usually much higher) is present with conjugated hyperbilirubinemia. Conjugated bilirubin is water soluble and appears in the urine at very low serum concentrations. Urobilinogen will be absent from the urine if significant cholestasis is present. If liver enzyme levels are normal, the jaundice is caused by sepsis or recent systemic infection, in-born errors of bilirubin metabolism (such as Rotor syndrome or Dubin-Johnson syndrome), or pregnancy rather than by primary hepatic disease. If liver enzyme levels are abnormal, which is much more common, the pattern of abnormality suggests the cause. Predominance of aminotransferase elevation is more suggestive of hepatocellular disease, such as viral or toxic hepatitis or cirrhosis, while marked elevations of alkaline phosphatase (two to three times normal) and g-glutamyl transpeptidase suggest intra- or extrahepatic obstruction, such as malignancy or gallstones. If the clinical...

Clinical Manifestations and Diagnosis of Gall Stone Disease

Approximately 80 of people with gall stones are asymptomatic. The presentation of gall bladder disease can be episodic pain when a brief cystic duct obstruction occurs or acute cholecystitis when the obstruction lasts longer and results in local and relatively extensive inflammation and edema. The complications include infection of the biliary system (cholangitis) and pancreatitis.

Surgery Of Hepatobiliary Malignancies

Gallbladder cancer is notoriously difficult to diagnose and is frequently only discovered at laparotomy, or incidentally following laparoscopic cholecystectomy for symptomatic gallstones.11,12 Gallbladder cancer is very aggressive and is frequently incurable due to local extension, hepatic lymph node involvement and early peritoneal spread.

TABLE 846 Complications of Laparoscopy

Patients presenting soon after cholecystectomy with pain, pancreatitis, and or jaundice may have retained common duct stones. If the CT scan does not reveal an intraabdominal collection of fluid, an ERCP should be performed. Endoscopic sphincterotomy is usually an effective means of dealing with retained stones. Patients presenting late after cholecystectomy with fever, pain, and jaundice may have bile duct stricture. Diagnosis requires ERCP. While stents are usually tried at first, surgical repair may be necessary. A more recent concern has been the spillage of gallstones into the peritoneal cavity at the time of surgery. Initially, such stones were thought to be innocuous. However, they have been linked to abdominal pain, pelvic pain, dysmenorrhea, intraabdominal abscess, colocutaneous fistula, and implantation into the ovary with subsequent infertility.14

Cholecystitis And Biliary Colic

Biliary tract emergencies result primarily from obstruction by biliary calculi in the gallbladder and bile ducts. The four major biliary tract emergencies related to gallstones include biliary colic, cholecystitis, gallstone pancreatitis, and ascending cholangitis. While gallstones are common, most are asymptomatic. The incidence of new-onset biliary pain among patients with previously asymptomatic gallstones is about 2 percent per year for the first 5 years and 15 percent at 10 years. 1 Although the classic patient with symptomatic biliary tract disease is an obese female aged 20 to 40 years, the disease occurs in all age groups and must be especially considered in diabetics and the elderly. 2 In both men and women, age over 60, right upper quadrant (RUQ) pain has the highest positive predictive value (11 to 16 percent) for gallstones.3

Obesity

The adipose fat cell is not only a passive storage site but an endocrinologically active secretor of many substances like leptin, adiponectin, and cyto-kines, which participate in an inflammatory response and may mediate a host of adverse consequences, including insulin resistance and diabetes. Obesity is related to an increased risk of developing type 2 insulin-resistance diabetes mellitus, hyper-lipidemia, heart disease, obstructive sleep apnea, asthma and other respiratory problems, back pain and orthopedic problems, fatty liver (nonalcoholic steato-hepatitis or NASH), gallstones, and depression. The increasing incidence of type 2 diabetes in obese adolescents is already being noticed, with estimates of 200 000 diabetics under age 20 years in the US predicted to rise to a lifetime risk of developing diabetes of 33-39 for those born in the year 2000.

Analytical Studies

The use of cohort studies can be advantageous in many ways when studying the relationship between diet and cancer. A cohort study allows the assessment of multiple effects of a given dietary exposure. Dietary data can be updated during follow-up and the temporal relation between diet and cancer can be addressed. For example, the beneficial effects of alcohol in reducing the risk of gallstone formation and coronary heart disease, and the potentially deleterious effects of alcohol on cancer and hemorrhagic stroke, can be weighed against each other in a cohort study. It is also possible to measure the absolute rates of disease according to the level of food or nutrient intake.

Cohort study

Subject selection is especially important in a cohort study. The probability of the endpoint occurring may be determined by the population under study. If a study is to be undertaken of the long-term sequelae of gallstones, it is likely that a different result will be obtained if the patients studied are those who have been admitted to hospital with an attack of acute cholecystitis rather than all the people in a defined community who are found to have gallstones in a population screening exercise. The answer obtained might still be clinically important but the conclusions drawn should be limited to the type of patient studied. Failure to differentiate the type of patients who had been studied led in the past to the recommendation that all patients with gallstones should undergo cholecystectomy because patients with symptomatic gallstones have a high rate of developing complications. A specific difficulty of the cohort study is loss to follow-up. There may be many reasons for this and...

Etiology

Mechanical small bowel obstruction (SBO) is one of the most common problems for which the general surgeon is consulted. Although incarcerated groin hernias were the most common cause of SBO in the past, the increase in elective hernia repairs as well as laparotomies over the last several decades have led to adhesions being by far the most common cause of SBO in adults. Hernias are still a common cause of SBO as are Crohn's disease, small bowel neoplasms, radiation enteritis, and miscellaneous other causes such as volvulus, foreign bodies, and gallstone ileus4 (Table 10-1). Ileus, or functional bowel obstruction, is also in the differential diagnosis of many patients. In addition to dehydration and electrolyte abnormalities from fluid losses, the most important complication of SBO is small bowel strangulation due to closed loop obstruction.

Acute pancreatitis

Acute pancreatitis is an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems. It includes a spectrum of disease from a mild, self-limiting event, through to a severe, potentially fatal condition with associated multi-organ failure. There are 20-40 cases per 100 000 population per year in the UK, and the mortality rate remains unchanged at 10 . The majority of cases (80-90 ) are caused by gallstones or alcohol ingestion other rarer causes are listed in Table 12.1. The number of genuine idiopathic cases decreases as other possible causes are investigated. The classic presentation is a sudden onset of severe epigastric pain, radiating to the back, associated with profuse vomiting. The patient will often be unable to keep still with the pain, in contrast to the immobile patient with peritonitis. A history of previously diagnosed gallstones, or alcohol consumption, is helpful, but not conclusive. Hypotension, tachycardia,...

Pancreatic carcinoma

The majority of cases present with jaundice, which is classically painless, secondary to obstruction of the CBD by a tumour in the pancreatic head. In this situation the gallbladder is often palpable, in keeping with Courvoisier's law, which states that jaundice in a patient with a palpable gallbladder is unlikely to be due to gallstones. Pale stools, dark urine, and severe pruritus are common complaints, and as the tumour progresses pain may develop in the epigastrium, radiating to the back in advanced disease. Cachexia, nausea and vomiting are also seen in advanced disease, especially if gastric outlet obstruction occurs. Upper GI bleeding, acute pancreatitis, and thrombophlebitis are also recognised features of pancreatic cancer.

Jaundice

Patients with obstructive jaundice may give a history of pain in the epigastrium and right upper quadrant suggestive of symptomatic gallstones, or may have painless jaundice, which is always suspicious of malignant biliary obstruction. Inflammatory changes from stones in the gallbladder cause fibrosis, so the finding of a palpable, distended gallbladder on examination suggests that gallstones are not the cause (Courvoisier's law), raising the possibility of malignancy. Blood tests do not diagnose obstructive jaundice, and the definitive investigation is an ultrasound scan of the abdomen. This must document whether the bile ducts (intra- and extra-hepatic) are dilated or not, and if dilated a search for the cause attempted. Ultrasound is the best imaging for showing gallstones, but visualisation of the CBD, especially the distal portion, is difficult with overlying bowel, and stones here are often missed. Large tumours in the pancreatic head may be obvious on ultrasound, but smaller...

Management

The decision about the treatment of gall stones will depend strongly on the presentation of the patient. Asymptomatic gall stones should not be treated surgically. This recommendation is based on multiple studies, including several prospective studies, that showed that patients with asymptomatic gall stones, observed over many years, develop symptoms or biliary complications only on rare occasions. In one study of 123 people with asymptomatic gall stones followed for 11-24 years, biliary pain developed in 2 during each of the first 5 years, followed by a decreasing incidence thereafter. Complications were seen in only 3 people and were preceded by warning signs of pain in all cases. Prophylactic cholecystectomy has been performed in diabetic patients because of concern of higher rates of complications from acute cholecystitis and also in patients with sickle cell disease. In the latter group, the main reason for prophylactic cholecys-tectomy is that the pain of sickle crises is not...

Summary

In summary, patients without indications for temporary drainage procedures can be definitively treated at presentation. In the majority of cases, this urgent management is comparable to management of symptomatic stone patients with partial obstructing stones who are not candidates for conservative treatment protocols. In this setting, all endourologic treatments have been used to treat stone disease. With improvements in ur-eteroscope design and instrumentation, however, we have increased utilization of ureteroscopy for these stones. Favorable results can be expected with urete-roscopy. In addition, direct stone manipulation provides an opportunity to alter treatment in the setting of an unrecognized infection. Despite favorable early results with the use of ureteroscopic treatment of stones in pregnancy, we have continued to favor retrograde stenting in symptomatic patients failing conservative treatment.

Arya M Sharma

In 1998 the American Heart Association reclassified obesity as a major modifiable risk factor for coronary heart disease.4 This is a step forward from the earlier notion that obesity contributes to heart disease primarily through covari-ates related to obesity, including hypertension, dyslipidemia, and impaired glucose tolerance or type 2 (non-insulin dependent) diabetes mellitus. Overweight and obesity are now also recognized as important risk factors for stroke, renal dysfunction, gallbladder disease, certain types of cancer, osteoarthri-tis, sleep apnea and a host of other disorders.5 Importantly, increased body weight is also an important determinant of impaired quality of life.6

Chronic Pancreatitis

IabJe.83-6 lists the causes of chronic pancreatitis. Of these, alcohol abuse is the most important, accounting for 70 to 80 percent of cases. 17 Most of the remaining cases are idiopathic. Ihe mean ages of onset and death in chronic pancreatitis are 42 and 52 years, respectively. 18 Because the disease can be undiagnosed, the true prevalence is unknown, with estimates ranging from 0.04 to 5 percent.19 As with alcohol abuse, chronic pancreatitis is most common in men. Gallstones are not a cause of chronic pancreatitis, despite their role in the acute form of the disease.2021 It is believed that acute pancreatitis does not progress to chronic disease unless complications such as pseudocysts or ductal strictures are present.19

Digestive System

Gallbladder disease The risk of gallbladder disease, particularly gallstone formation, is increased in obesity and occurs with greater frequency in women. The prevalence of gallbladder disease in obese individuals increases with age, body weight, and parity. The etiology of increased gallstones is unclear, but genetic factors play a role. Increased cholesterol production, which leads to increased excretion of cholesterol in bile, is known to occur in obesity and correlates with increases in body weight. Many obese people skip meals and the reduced number of meals may result in less frequent emptying of the gallbladder. The resulting bile stasis may contribute to gallstone formation. Although long-term weight loss and maintenance may reduce the occurrence of gallbladder disease, the risk of gallstone formation actually increases during the active weight loss phase. The etiology of this increase is thought to be the mobilization of cholesterol from adipose tissue during rapid weight...

Radiation Enteritis

Radiation damage to the small bowel and previous resections may cause decreased absorptive surfaces, bile salt malabsorption, and increased intestinal transit and hence nutritional deficiencies. Late radiation damage may cause ileal dysfunction with increased gallstones secondary to hyperoxaluria. Radiation-induced strictures and fistulas may cause stasis of bowel contents resulting in bacterial overgrowth and malabsorption.

Orientation

The transmission of ultrasound waves is blocked by highly echogenic structures (e.g., gallstones), resulting in a relatively anechoic area distal to the echogenic structure. This effect is known as acoustic shadowing. Acoustic enhancement occurs distal to an anechoic, fluid-filled structure, such as the gallbladder. The area distal to the anechoic structure has increased echogenicity due to the greater number of ultrasound waves reaching this area through the anechoic structure. Examples of these phenomena are present in almost every ultrasound image. However, the many other technical factors that influence the creation of ultrasound images and artifacts are beyond the scope of this discussion. Two of the most common and useful are illustrated in Fig QS-S.

Somatostatinoma

The classic somatostatinoma syndrome is characterized by the triad of mild diabetes, diarrhea steatorrhea, and gallstones.5 Other symptoms of patients with a somatostatinoma include most commonly, weight loss identified in 39 of patients, abdominal pain in 28 of patients, nausea vomiting in 26 of patients, and jaundice in 20 of patients (Table 29.1). Diarrhea and or steatorrhea occurred in only slightly more than one-third of patients. While diarrhea results from an increase in the stool osmolarity secondary to malabsorption, steatorrhea results from decreased pancreatic secretion and resultant impairment of fat absorption. Cholelithiasis also appeared in approximately one-third of patients. It is related both to the direct inhibition of gallbladder contractility by somatostatin as well as to the somatostatin-mediated inhibition of cholecystokinin release. While cholelithiasis led to jaundice from common duct involvement in some patients, jaundice was more often secondary to the tumor...

Midepigastric Pain

Midepigastric pain is associated with early stages of acute appendicitis, acute small bowel obstruction, peptic ulcer disease, and acute pancreatitis. Pancreatitis, depending on the etiology of the inflammation, including gallstones, alcohol or idiopathic causes, requires different types of intervention. Gallstone pancreatitis is one of the few types of pancreatitis that require early surgical intervention. It occurs when gallstones become lodged in the pancreatic duct causing obstruction and inflammation. Treatment involves admission for bowel rest and intravenous fluid hydration until the obstructing stone passes and the pancreatitis resolves. This is seen with cessation of clinical symptoms of pancreatitis and normalization of amylase and lipase serum levels. After resolution of the acute pancreatitic flare, the patient should undergo cholecystectomy during the same hospital admission as he or she will be at increased risk of having recurrent pancreatitis until the source of the...

Glucagonoma

Somatostatin is a naturally occurring hormone produced by the D cells of the islets of Langerhans and mucosa of the GI tract. It is a potent inhibitor of peptide release, and has been successfully used to control hormone secretion and clinical symptoms of glucagonomas, gastrinomas, vipomas, insulinomas, carcinoid and other neuroendocrine tumors. Octreotide is a long-acting analogue of somatostatin that can be self-administered subcutaneously. Octreotide has no reliable effect on tumor growth, but often induces a long-lasting remission of clinical symptoms. The most dramatic improvement is the rapid resolution of NME. The insulin requirements to control blood glucose may be reduced, but diabetes only rarely improves with soma-tostatin therapy. The hemoglobin concentration can also normalize with somatosta-tin analogue therapy. Side effects, including occasional abdominal pain, distension and diarrhea are uncommon and usually mild. Chronic administration of octreotide increases the...

Carcinoid Tumors

For carcinoid syndrome, somatostatin analogs have replaced most pharmaco-logic agents previously mentioned for the relief of hormone-mediated symptoms. Octreotide can improve or normalize diarrhea and flushing at a dose of 50-200 mi-crograms SC tid. Administration of octreotide in patients with carcinoid syndrome is necessary at laparotomy and preoperatively to prevent carcinoid crisis including life threatening bronchial obstruction. Side effects of long term somatostatin are rare. The one side effect worth mentioning is the formation of gallstones. Cholecys-tectomy should be performed at laparotomy if a patient will require long term somatostatin analog treatment.

Complications of PN

Hepatobiliary complications, including steatosis and cholestasis, are associated with PN patients due to the lack of enteral stimulation and limited gastrointestinal motility. Cholestasis is universal in patients receiving PN for more than 6 weeks without enteral feedings. Transition to enteral or oral feedings will help prevent the potential development of gallstones associated with cholestasis. In adults, hepatic steatosis, or fatty liver, is generally

Get Rid of Gallstones Naturally

Get Rid of Gallstones Naturally

One of the main home remedies that you need to follow to prevent gallstones is a healthy lifestyle. You need to maintain a healthy body weight to prevent gallstones. The following are the best home remedies that will help you to treat and prevent gallstones.

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