Dr Sanil Kumar
Gall stone formation is the most common disorder of the biliary tract and it is unusual for the gall bladder to be diseased in the absence of gall stones.
Pathology: Gall stones are conveniently classified into cholesterol or pigment stones, although the majority are of mixed composition. Cholesterol stones are most common in industrialised countries, whereas pigment stones are more frequent in developing countries. Gallstones contain varying quantities of calcium salts, including calcium bilirubinate, carbonate, phosphate and palmitate, which are radio-opaque.
Epidemiology: In westerners, 7% of males and 15% of females are affected in the age-group 18 – 65 years. In >40 years, age-group, there is a 3:1 female preponderence and in elderly, the ratio is equal.
Gallstones are more common in North America, Europe and Australia, and are less frequent in India, the Far east and Africa. In developed countries, the incidence of symptomatic gallstones apear to be increasing and they occue at an early stage.
There has been much debate over the role of diet in cholesterol gallstone disease; an increase in dietary cholesterol, fat, total calories and refined carbohydrate or lack of dietary fibre have been all implicated. At present, the best data support an association between simple refined sugar in the diet and gall stones.
Aetiology: Gallstone formation is multifactorial, and the factors involved are related to the type of gallstones.
Cholesterol gallstones: Cholesterol is held in solution in bile by its association with bile acids and phospholipids in the form of micelles and vesicles. Biliary lipoproteins may also have a role in solubilising cholesterol. In gallstone disease, the liver produces bile which contains an excess of cholesterol either because there is a relative deficiency of bile salts or a relative excess of cholesterol. Such bile, which is supersaturated with cholesterol, is termed “lithogenic”.
Disorders with the potential to induce the production og lithogenic bile are:
- Defective bile salt synthesis
- Excessive intestinal loss of bile salts
- Over-sensitive bile salt feedback
- Excessive cholesterol secretion
- Abnormal gallbladder function.
Threefactors responsible for gallstone formation:
- Bile must be supersaturated with cholesterol.
- Nucleation must be kinetically favourable, and
- Cholesterol crystals must remain in the gallbladder long enough to aggregate into tissues.
Factors initiating crystallisation of cholesterol in lithogenic bile (nucleation factors) are also important; patient with cholesterol gall stones have gall bladder bile forms cholesterol crystals more rapidly than equally saturated bile from patients who do not form gallstones.
Pigment stones: Brown crumbly pigment stones are almost always the consequence of bacterial or parasitic infection in the biliary tree. They are found commonly in the far east, where infection in the biliary tree allows bacterial beta-glucoronidase to hydrolyse conjugated bilirubin to its free form, which then precipitates as calcium bilirubinate. Hemolysis is important as these stones occur in chronic hemolytic disease.
Biliary sluge: The term ‘biliary sludge’ describes bile which is in a gel form that contains numerous crystals of microspheroliths of calcium bilirubinate granules and cholesterol crystals as well as glyco-proteins. It is an essential precursor to the formation of gallstones in the majority of patients. Biliary sludge is frequently formed under normal conditions, but then either dissolves or is cleared by the gallbladder; only in about 15% of patients does it pesists to form cholesterol stones. Fasting, parenteral nutrition and pregnancy are also associated with sludge formation.
Clinical features: The majority of gallstones are asymptomatic, and remain so, anly about 10% of those with gallstones develop clinical evidence of gallstone disease.
Symptomatic gallstones manifest either as biliary pain [biliary colic] or as a consequence of cholecystitis. If a gallstone becomes acutely impacted in the cystic duct, the patient will experience pain. The term ‘biliary colic’ is a misnomer because the pain does nor rhythmically increase or decrease in intensity as in colic experienced in intestinal and renal disease. Instead the pain is typically of sudden onset and is sustained for about 2 hours. Its continuation for more than 6 hours suggests that a complication such as cholecystitis or pancreatitis has develoed. Pain is felt in the epigastrium (70% of patients) or right upper quadrant (20% of patients) and radiates to the inter-scapular region or to the tip of right scapula, but other sites include the left upper quadrant, the epigastrium and the lower chest; the pain can be confused with intra-thoracic disease, qesophagitis, myocardial infarctionor dissecting aneurysm.
Combinations of fatty food intolerance, dyspepsia and flattulence not attributably to other causes have been referred to as ‘gall stones dyspepsia’. These symptoms are not now recognised as being caused by gall stones and are best regarded as non-ulcer dyspepsia.
Investigations: A plain X-ray radiograph will demonstrate calcified gallstones in less than 20% of patients. USG is the method of choice to diagnose gall stones. But oral cholecystography and CT can also be used.
Oral cholecystography shows whether or not the gall bladder is functioning, and this is useful if oral dissolution therapy is being considered. MRI is becoming increasingly available and may demonstrate gall stones or their complications.
In the gallbladder:
- Silent stones
- Chronic cholecystitis
- Acute cholecystitis
In the bile ducts:
- Obstructive jaundice
- Acute pancreatitis
In the intestine
Acute intestinal obstruction (‘gallstone ileus’)
Occlusions of the cystic duct for any prolonged period of time results in acute cholecystitis. Other complications include chronic cholecystitis, and a mucocele of the gall-bladder, in which there is slow distension of the gall-blagger from continuous secretion of mucus. If this material becomes infected, an empyema develops. Calcium may be secreted into the lumen of the hydropic gallbladder, causing limy bile and if calcium salts are precipitated in the gall bladder wall, the radiological appearance of ‘porcelain’ gallbladder results.
Gall stones in the gallbladder (cholecystolithiasis) migrate to the gallbladder (choledocholithiasis) in approximately 15% of patients and cause biliary colic, but they may be asymptomatic. Rarely, fistulae develop between the gall bladder and duodenum, colon or stomach. Air will be seen in the biliary tree on plain abdominal radiographs. If a stone larger than 2.5 cm in diameter has migrated into the gut it may impact either at the terminal ileum or occasionally in the duodenum or sigmoid colon. The resultant intestinal obstruction may be followed by ‘gallstone ileus’. Rarely, gallstones impacted in the cystic duct cause stricting in the common hepatic duct (Mirizzi’s syndrome), resulting in obstructive jaundice.
Carcinoma of gallbladder is uncommon, although it is recognized more frequently in an ageing population and in a ‘porcelain’ gallbladder. Cancer is usually diagnosed as an incidental histological finding following cholecystectomy for gallstone disease.
Management: Asymptomatic gallstones found incidently are not usually treated because the majority will never give symptoms. Symptomatic gallstones are best treated surgically, and minimal access techniques have largely replaced non-surgical treatment. Gallstones can be dissolved and fragmented in the gallbladder or removed mechanically from the common bile duct.
Medical dissolution of gallstones can be achieved by oral administration of the bile acid, ursodeoxycholic acid. Rodio-lucent gallstones, a gallbladder that opacifies on oral cholecystography. Stones not larger than 15 mm in diameter, moderate obesity and no or atmost mild symptoms are the features which suggest that drug therapy may be feasible. Success can be expexted in approximately 75% of patients who fulfill their criteria. Occasionally, direct contact dissolution therapy is attempted via percutaneous catheters or catheters placed at ERCP. ESWL is expensive and not widely available. Bile salt therapy is necessary following lithotripsy to dissolve the gallstone fragments within te gallbladder. As in the case of oral bile salt therapy, only 30% of all patients with gallbladder disease are suitable for lithotripsy. All the therapeutic regimens which retain the gall bladder have a 5% reccurence of stones after 5 years.
In synthesis, ver 10.2
Abdomen, gallstones: (↗Pain – liver – colic) ARS, aur, bapt, bell, berb, bold, Bry, calc, calc-f, card-m, Cham, chel, chin, chion, chlf, chol, coloc, cupr, dig, dios, eberth, euon, euon-a, euonin, fab, fel, ferr-s, fuma-ac, gels, guat, hed, Hydr, jug-c, lach, Lept, lith-c, lob, lyc, mag-p, mag-s, mand, mang, MERC, merc-d, myric, morg-g, morg-p, nat-s, nat-sal, nit-s-d, nux-v, Phos,podo, ptel, sang,sulph, tarax, thlas, verat, vichy-g.
Abdomen, gallstone colic: (see pain – liver –colic) ars, atro, atro-s, Bapt, BELL, BERB, Bry, cal-bil, Calc, CARD-M, Cham, Chel, CHIN, Chion, Chlf, Chlol, colch, Coloc, cupr, dig, Dios, Fab, gels, hep, hydr,Ip, Iris, kali-ar, Kali-bi, Kali-c, Lach, laur, Lept, Lith-c, LYC, mag-bcit, Mag-m,Mag-s, mand, mang, menth, merc, Merc-d,morph-act, NAT-S, Nux-v, op, podo, puls, rhus-t,ric, Sep, sil, staph, sulph, tab, ter, trios,VERAT.
In Boericke’s repertory
Abdomen, gall-bladder – biliary calculi (cholelithiasis) – Aur.; Bapt.; Berb.v.; Bolod.; Bry.; Cal.c.; Card.m.; Chel.; Chionanth.; Cholest.; Cinch.; Diosc.; Fel tauri; Ferr.s.; Gels.; Hydr.; Jug.c.; Lach.; Lept.; Myr.; Nux-v.; Pichi.; Pod.; Ptel.; Tarax.
Abdomen, gall-bladder, Biliary colic – Ars.; Atrop. sul.; Bell.; Berb.v.; Calc.c.; Card. m.; Chionanth.; Cinch.; Col.; Dig.; Diosc.; Gels.; Hydr.; Ipec.; Lyc.; Morph. acet.; Nux v.; Op.; Tereb.
In complete repertory
Abdomen, pain, general, liver, colic, gall-stones – Aml-n, Arge, Ars, Atro, Aur, Bamb-a, Bapt, BELL, BERB, Bold, Bry, Calc, Calc-f, CARD-M, Cham, Chel, CHIN, Chion, Chlf, Chlol, Chol, Coloc, Cupr, Dig, Dios, Erig, Euon, Fab, Fel, Ferr-s, Gels, Hep, Hydr, Ip, Iris, Jug-c, Kali-ar, Kali-bi, Kali-c, Kreos, Lach, Laur, Lept, Lith-be, Lith-c, Lob, LYC, Mag-c, Mag-m, Mag-p, Mag-s, Mang, Menth, Merc, Merc-d, MORG, Morph, Myric, NAT-S, Nux-v, Op, Ozone, Phos, Podo, Ptel, Puls, Rhus-t, Ric, Sang, Sep, Sil, Sulph, Tab, Tarax, Ter, Trio, VERAT.
In Clarke’s clinical repertory
Clinical, gall-stones: berb, calc, card-b, chel, chlf, chol, euonin, euon-a, fel, lach, lith-c, lob, mang, nit-s-d, nux-v, fab, podo, ptel, tarax, thlaspi, vichy-g.
In Murphy’s repertory
Liver, gallstone, colic pain from – am-m, alum, ars, aur, bapt, BELL, BERB, bry, CALC, CARD-M, cham, chel, CHIN, chion, CHOL, COLOC, cupr, dig, DIOS, euon, fel, ferr-s, gels, hep, hydr, ip, iris, jug-c, kali-ar, kali-bi, kali-c, lach, laur, lept, lith, LYC, mag-p, mang, merc, merc-d, MORG, myric, NAT-S, nux-v, op, osm, phos, podo, puls, rhus-t, sang, sep, sulph, tab, tarax, ter, thuj, VERAT.
In Kent’s repertory: Abdomen, pain , liver, colic, gallstones: Ars, bapt, Bell, Berb, bry, calc, Card-m, cham, chel, Chin, chion, chlf, chlol, cupr, dig, dios, ip, iris, kali-ar, kali-bi, kali-c, lach, laur, lept, lith, Lyc, mang, merc, Nat-s, nux-v, podo, puls, rhus-t, sep, Verat.
In Boger’s repertory: Hypochondria, gallstones and colic: Ars, bell, Calc-c, card-m, chel, Chin, colo, hep, lach, lyco, Mag-m, Merc-d, Nat-s, nux-v, Pod, sil, Sul, terb, ver-a.
Some indication of frequently prescribed medicines for gall-stones:
Belladonna: Extreme sensitiveness: especially to jarring. Face red: hot. Hyperaesthesia: extreme irritability of whole economy or nerve centres. Extreme irritability.
Chelidonium: Pains from region of liver, shooting towards back and shoulder. Pain in region of liver, extending quickly down across navel into intestines. Biliary calculi: chill: intense pain in gall-bladder region; vomiting; clay-coloured stools. Cutting pains and stitches: constriction like a cord. Pain in the inner angle of right shoulder blade, running into chest. Yellow tongue with intended edges. Liver region tense and tender.
China: FARRINGTON says: ‘Bell. Is useful in cholelithiasis, but the remedy to cure the condition permanently is Cinchona. Unless some symptom or symptoms call specifically for another drug, put your patient on a course of Cinchona.
Pain in the hepatic region, worse from touch. Shooting in region of liver, tenderness and pain on touching the part. Liver region sensitive to least pressure. Obstruction in gallbladder with colic; periodic reccurence; yellow skin and conjunctivae; constipation with dark greenish scybala. Biliary calculi. Intensely sensitive to touch, to motin, to cold air. Periodicity: pains come on regularly at a given time each day; or every night at 12 o’ clock. Drenching night sweats.
Nux-vom: Gall-stone colic with sudden severe pains on right side; spasms of abdominal muscles with stitching pains in liver. Jaundice, aversion to food, fainting turns; gall-stones. Constipation nearly always. Liver swollen, indurated, sensitive, with pressure and stinging. Cannot bear tight clothing. Oversensitive, irritable, touchy. Ineffectual urging to stool, irregular peristalsis. Chiily, if he uncovers or moves.
Berberis: “An excellent remedy for renal calculi; also for gall-stones associated with renal disease. Pain shooting. The patient cannot make the slightest motion, sits bent over to painful side with relief. Symptom peculiar to Berberis is a bubbling feeling as if water coming up through the skin. Stitching pains under border of false ribs in right side, shoot from hepatic region down through abdomen.” FARRINGTON.
Radiating pains from a particular point puts Berb almost alone for radiating pains. Has cured renal colic many times, bcoz of its well-known ability to shoot out in every direction. It cures gall-stone colic when little twinges go in every direction from that locality. The liver is full of suffering. Sudden stabbing like a knife pucturing the liver. Dreadful suffering.
Berberis, when indicated, will let the little gall-sone loos, and it will pass through, and the patient will take a long breath…… Anything that is spasmodic can be relieved instantly.” KENT.
Dioscorea: Hard, dull pain, gall-bladder, at 7 p.m. Neuralgia and spasmodic affections of liver and gall-ducts. Cutting, squeezing, twisting pain. Colic begins at umbilicus and radiates to all parts of body, even extremities. A constant pain, aggravated at regular intervals by paroxysms of intense suffering. Unbearably sharp, cutting, twisting, griping or grinding pains; dart about and radiates to distant parts. Worse doubling up. Better stretching out, or bending back. Better hard pressure.
Podophyllum: Pod indicated in biliary colic. Stools constipated and clay-coloured. Tongue yellow or white, takes imprint of teeth. Pain liver, inclined to rub part with hand. Colic at daylight every morning. Better bending forward: external warmth.
Lithium carb: Gall-stones. Violent pain in hepatic region between ilium and ribs. Soreness and pain in bladder: sharp, sticking. Red nose is characteristi
Cardus marianus: Liver engorged. Gall-stones. Tongue, white centre with red intended edges. Crawling sensation , like the passage of a small body like a pea through a narrow canal on posterior side of liver extending to pit of stomach.
Iris: Gall-stone colic. Cutting pain, region of liver: < motion. Tongue dry, coated dry, coated on each side: red streak in centre. Great burning distress in epigastrium.
Leptandra: Burnings, liver: near gall bladder. Dull aching, liver < near gall bladder. Yellow coated tongue. Jaundice. Better lying on stomach or side.
Chionanthes: A great liver and gall-stone-colic medicine. Better lying on abdomen. Heat with aversion to cover. Very bitter eructations. Hot, bitter, sour, sets teeth on edge. Hypertrophy of liver: obstruction: jaundice. Soreness. Nausea and retching with desire for stool. Sensation of double action in stomach, while vomiting, one tying to force something up, the other sucked it back. Colic and cold sweat on forehead.
Lycopodium: Pain in liver; recurrent bilious attacks with vomiting of bile. Subject to gall-stone colic. After Lyc. The attacks come on less frequently, the bilious secretion becomes normal and the gall-stones have a spongy appearance, as though being dissolved. Lyc. patients are always belching: sour erucations like strong acid burning in pharynx. Bloating: obliged to loosen clothes. Worse cold drinks, often > warm drinks.
Worse afternoons: 4-8 p.p. aggravation. Generally, craving for sweets.
Hydrastis: Skin yellow; stools white and frequent: fullness and tenderness over hepatic region. Catarrhal inflammation of mucous lining of gall-bladder and biliary ducts. Cutting from liver to right scapula. < lying on back on right side.
Hepar: LILIENTHAL gives Hepar as one of the remedies of gall-stone colic. It has stitches in region of liver. Hepatitis, stools white or green. Is extremely sensitive mentally and physically. Cannot bear the slightest touch: or pain. Cannot stand draughts: craves vinegar.
Verat. Alb: Is in Kent’s repertory for gall-stone colic. It has, Hyperaemia of liver, gastric catarrh, putrid taste, disgust for warm food, great pressure on hepatic region with vomiting and diarrhea. In verat cases, there will be profuse sweating; cold sweat on forehead; Hippocratic face. Pain maddening, driving patient to delirium. Typically, cold skin, cold face, cold back, cold hands, feet and legs, cold sweat.
Merc.Sol: Pressing pains; stitching in liver. Cannot lie on right side. Jaundice: violent rush of blood to head: bad taste: tongue moist and furred: soreness hepatic region: from gall-stones.
Violent stitches in hepatic region, could not breathe or eructate. Worse night: worse warm in bed: worse for the profuse sweat. Foulness of mouth and sweat. Merc loves bread and butter.
Phosphorus: Probably more important for the treatment of liver, leading to gall-stones, then for the acute attack? Great tenderness liver region. Craving for ice-cold drinks, vomited when warm, vomiting followed by great thirst. Worse lying on left side. Anxious and restless in the dark.
Nitri spiritus dulcis: HERING says: “incarcerated gall-stones (with yolk of egg beaten up and applied inwardly and outwardly)….. Has the same action upon disturbed innervation as the so-called anti-spasmodics.”
HAHNEMANN said it should be given (in certain fevers) a few drops dissolved in an ounce of water, a teaspoonful every three hours. Desire for salt: or ailments from eating too much salt and salt food. < Cheese.
Ether: FARRINGTON: “In the passage of gall-stones, when remedies fail to relieve, I find that ether, externally and internally, is very good. Acting better than chloroform.”
Chloroformum: Cholesteric gall-stones and biliary colic. CLARKE says: “Chloroform will dissolve gall stones, and cases have been treated by injection of chloroform into gall-bladder.”
Hot wet flannels: Squeeze a flannel out in hot water, and apply. Have a hot bottle over this, to keep up the moist relaxing heat.
Carlsbad waters: Almost specific, RUDDOCK says, for gall-stone colic.
Dr Sanil Kumar BHMS,MD(Hom)
Department of Forensic Medicine & Toxicology
Govt. Homeopathic Medical College. Calicut.10. India
Email : [email protected]