Gallstones
Gallstones
Why They Are
a "Woman's Problem"
The chocolate Chambord birthday cake was a mistake.
Duffy's boss had brought it to the picnic to celebrate her employee's 40th birthday. And everyone loved every bite of the dark, decadent chocolate--including Duffy. But half an hour after her last forkful, a sharp, stabbing pain began between her shoulder blades. Two hours later she could hardly breathe. Three hours later, she was in an emergency room and a surgeon was preparing to operate.
Not every woman reacts to a chocolate birthday cake by getting a gallstone stuck in the duct that leads from the gallbladder--where bile acids used for fat digestion are stored--to the upper intestine. But the fact is that women are more than twice as likely as men to complain of gallstones: Of the 971,000 Americans who report gallstones to the National Center for Health Statistics in Hyattsville, Maryland, every year, 666,000--more than two-thirds--are women.
Women at Risk
Why do women have more than twice the risk? In a word, hormones. Hormones that regulate our cycles and our pregnancies, along with oral or implanted contraceptives and hormone replacement therapy (HRT), put us at increased risk, says Henry Pitt, M.D., director of the Johns Hopkins University Gallstone and Biliary Disease Center in Baltimore.
Two factors affect gallstone formation, he explains. One is the amount of cholesterol that saturates the bile stored in the gallbladder; the other is how quickly the gallbladder fills with bile and how quickly it empties into the intestine. The more cholesterol in the gallbladder and the longer it stays there, the more likely it will thicken into the soft lumps that eventually solidify into gallstones.
The problem for women is that the two sex hormones--estrogen and progesterone--may affect the amount of cholesterol in bile. These hormones may also affect how the gallbladder fills and empties as well as the function of the sphincter between the bile duct and intestine. The result is the perfect incubator for stones.
Obesity, Smoking and Other Risk Factors
But increased hormone levels are not the only reason women form gallstones, says Dr. Pitt. Obesity, rapid-weight-loss dieting, diets high in fat and cholesterol and a family history of gallstones are other factors that put both men and women at risk. Fortunately, gallstones can frequently be prevented. Here's what Dr. Pitt suggests.
Take fish-oil supplements. In several studies at Johns Hopkins, Dr. Pitt and his colleagues have found that the oils found in fish can prevent or at least reduce the formation of gallstones. Their animal studies indicate that fish oil prevents the formation of stones altogether. Their studies in people, which were limited to a two-week period before participants were scheduled to have their gallstones removed, indicated that 960 milligrams of fish oil--the amount found in one soft-gel capsule--taken three times a day alters the tendency to form stones. As a result, Dr. Pitt suspects that including fish oil in your diet will prevent the formation of gallstones.
Keep your diet low in fat and cholesterol. Both fat and cholesterol provide the raw cholesterol from which most stones are made, says Dr. Pitt. Reducing them will also reduce your risk.
Eat at regular intervals. Some studies show that fasting for longer than 14 hours increases your risk of gallstones. The problem is that the gallbladder only empties significantly and squirts bile into the upper intestine when food is consumed. (It also releases bile at other times, but not in large amounts.) So if no food is consumed, the likelihood that cholesterol will have the time to thicken into lumps is increased. That's why skipping meals and fasting are not in your gallbladder's best interests.
New Surgery Eased Recovery Linda Weinberger was a 42-year-old elementary school counselor and mother of two preteens in East Greenville, Pennsylvania, when she was struck with gallstones so severe that surgery to remove her gallbladder was the best option. Fortunately, it was at the same time that laparoscopic surgery, in which a telescopic device and surgical instruments are inserted through the abdomen to remove the gallbladder, was starting to be used. She became one of the first women in the country to have the procedure. This is her story. As I recall, I was having a lot of stomach discomfort. But because it was happening near the end of the school year, I thought it was just the normal end-of-the-year stress kind of symptoms. I didn't even go to our doctor, but I had taken one of the boys to his office for something, and while I was there my stomach really hurt. So I said, "If you have time, could you check me out, too?" So he did, and he said, "I think it's probably gastritis," which I've had before. So he said, "I'm going to prescribe this medication"--some kind of little pills--and he said, "Don't drink with them or you'll get really goofy. If anything gets worse, call me right away, but at any rate call me in about three or four days and let me know how this medication works." We went out for dinner that night with friends and I didn't feel really good, but I didn't feel horrible. Then I had a baked potato with sour cream on it. Well, I was so miserable, I thought, "This is how people die." I remember not being very talkative on the way home. I just wanted to curl up in a fetal position and leave the earth. I was horribly nauseated. We got home and I went to bed, but I couldn't sleep, and I thought, "I probably have cancer or something really dreadful," because I knew this was not gastritis. In the morning I stuck my finger down my throat to force myself to throw up, thinking, "Maybe this will help." It didn't. So that morning I went back to the doctor. By then the pain had localized on my right side, a little bit lower than my ribcage. The doctor's verdict was that I probably had a gallbladder problem. He sent me for a sonogram. As I was lying on the table, the technician told me what she saw on the screen. "There are different sizes of grit that we can see when you have gallstones," she said. "They can be anywhere from the size of sand up to the size of boulders. And you've got rocks. Big rocks." My doctor recommended a surgeon at Bryn Mawr Hospital. So I went to his office and he explained the procedure. My concern was that he couldn't do it until August 1. I had to wait two months--mostly living on this liquid stuff called Citrotein. Eating most foods caused me pain and discomfort. I had the surgery at 5:00 p.m. on August 1. The next morning about 7:30, I jokingly said to the doctor, "Oh well, I'm ready to go home. When can I leave?" And he said, "As soon as you eat some breakfast, you can go." I had been there no more than 18 hours from admission to discharge. I had a wonderful recovery. Within a few days I was back to normal. I remember two days after having surgery, I went to a barbecue at somebody's house. I didn't eat a whole lot, but I ate. The following day I was driving. Within a week I was totally recovered.
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Maintain your weight. Studies indicate that overweight women who are five feet four inches tall and weigh 175 pounds are twice as likely to form gallstones as women of the same height who weigh 145 pounds. That's why maintaining your weight makes it less likely that you'll develop gallstones, says Dr. Pitt.
Reconsider taking calcium supplements. Animal studies at Johns Hopkins indicate that taking extra calcium--as many women do to reduce their chances of osteoporosis--may increase their risk of forming stones. Scientists aren't sure why.
"We're not saying 'Don't take calcium supplements' to everyone," says Dr. Pitt. "What we are saying is that if gallstones run in your family, you should talk to your family physician before you do."
Think twice about taking hormones. Given hormones' involvement in making gallstones, women who know that gallstones run in their family should also be cautious about using oral contraceptives or HRT, says Dr. Pitt.
A study of more than 54,000 postmenopausal women at Harvard Medical School found that those who used HRT doubled their risk of having an operation to remove gallstones.
Ask your doctor to help you weigh the pluses and minuses of HRT and your own particular gallstone risk, says Dr. Pitt.
Avoid Norplant. Studies in prairie dogs--which have gallbladders that act like human gallbladders--indicate that using an implanted progesterone contraceptive like Norplant may increase your risk of gallstones over time, says Dr. Pitt.
Swallow bear bile. Rapid weight loss in obese women is one of the major causes of gallstone formation. A review of studies by the National Institute of Diabetes and Digestive and Kidney Diseases in Bethesda, Maryland, reveals that 12 percent of 390 overweight people who went on 520- to 840-calorie diets for 8 to 16 weeks developed gallstones.
The cause? Their gallbladders didn't get enough food to stimulate the contractions that would allow it to empty. Cholesterol was allowed to build up and thicken, and gallstones were the result.
That's why anyone who's planning on using a super-low-calorie diet to lose some serious weight--say 40 or 50 pounds--should also take ursodeoxycholic acid, says Dr. Pitt. The acid--actually a form of bear bile that's sold by prescription as Actigall--will help prevent stone formation.
Rolling Away the Stones
Fortunately, 60 to 80 percent of those who have gallstones will probably never even know they have them. The stones will either stay in the gallbladder or remain so small that they'll pass through the duct between the gallbladder and intestine without causing a problem. And their owners will never experience the pain--located in the right side of the chest below the breastbone or sometimes between the shoulder blades--that occurs when a stone gets stuck in the duct.
But if a stone does gets stuck, you have only one option, says Dr. Pitt: Gallbladder and stones must go.
"The treatment of choice today is a laparoscopic cholecystectomy," says Dr. Pitt. It's a procedure in which the surgeon makes four tiny punctures in and around the navel. Through one puncture he inserts a thin, telescope-like instrument through which he can see the gallbladder, then he inserts surgical instruments through the others. The gallbladder is cut away from surrounding tissue and removed.
A study of 294 women and 86 men at the University of Kansas School of Medicine in Wichita indicates that the procedure carries little risk. The procedure took approximately two hours to complete, and most patients were sent home the next day--though some needed more hospital time for recovery. Only 3 percent experienced any complications.
Moving from a laparoscopic procedure to open surgery is something for which every woman who undergoes gallstone surgery should be prepared, says Dr. Pitt. If the surgeon peers through the laparoscope and finds that he or she cannot adequately see the gallbladder or duct or finds that there is an inflammation, bleeding or scarring from prior disease or surgery--all of which increase the risk of injury during laparoscopic surgery--the surgeon will simply remove the laparoscope, make a standard surgical incision across the abdomen and remove the gallbladder that way.
Studies indicate that this type of surgery--called an "open" cholecystectomy--usually requires a 5- to 12-day hospital stay and heavy-duty postoperative painkillers. The complication rate is a whopping 35 percent--primarily involving respiratory difficulties and infection.
