April 2004

The gallbladder syndrome

by Dr. Howard Loomis

Gallbladder dysfunction is one of the most common health problems encountered in clinical practice today. Like most digestive problems, it is difficult to diagnose. Right shoulder pain accompanied by flatulent dyspepsia has long been considered to be the best indicator. But, this is far from accurate. Often we hear it referred to as the "5‑F Syndrome" that is fair, fat, female, fertile, and over 40.

Before making such a judgment, however, the following key points should always be stressed when discussing biliary dysfunction and gallstones with patients:

***  Gallstones are extremely common. Their occurrence in women is roughly double their occurrence in men. The occurrence and size of the stones increase with age and, depending on the ethnic group being examined, their incidence can range as high as 44% of the population.

***  Gallstones usually do not cause symptoms. Three major studies involving over 3,000 patients found that 67% of all confirmed cases of gallstones were asymptomatic. Other studies put the figure at above 80%. This is an incredibly important statistic for the chiropractic profession.

***  Patients with gallstones who are asymptomatic are likely to remain so. Studies indicate the chance of asymptomatic gallstones becoming symptomatic in the next five years is less than 10%. Not only that, but the rate decreases as time goes by ‑‑ to less than one percent after 10 years.

***  The majority of gallstones are found by chance ‑‑ even in patients with abdominal pain. Because the use of abdominal ultrasound is increasing, more gallstones are being detected incidentally. Therefore, the opportunity to recommend gallbladder removal is increasing.

***  Once the presence of gallstones is confirmed, the usual procedure is to schedule surgical removal of the gallbladder. More than 600,000 cholecystectomies are performed in this country every year despite overwhelming evidence that most are not necessary. Repeated warnings have been printed in medical journals against this practice but to no avail.

***  Cholecystectomy does not always relieve symptoms traditionally thought to be caused by gallstones. Most studies show complete relief of symptoms in 75‑80% of patients after surgery. However, studies concentrating on the relief of symptoms in those that had symptoms before surgery indicate relief in only about one‑half of the cases! The most persistent symptoms remaining after surgery are flatulent dyspepsia and chronic, dull pain in the upper right quadrant.

***  Biliary colic should be used as the indication for surgery ‑‑ not the accidental finding of gallstones. Biliary colic is understood to mean severe "colicky (spasmodic wave‑like) pain" or constant (cystic duct obstruction) pain lasting up to four hours ‑‑ occasionally accompanied by low‑grade fever (only 13% of the time), and characteristically followed by a "washed‑out" feeling for up to 24 hours. The occurrence of constant pain is much more common (57‑94%) than the colicky wave‑like pain.

***  Oddly enough, upper right quadrant location for biliary colic is not a requisite for diagnosis. The pain may be anywhere in the abdomen, including the periumbilical area (the reported home of colicky pain in infants). For example, 30‑60% of biliary colic cases report pain in the epigastric region. Another 8‑24% report pain in the lower left quadrant.

***  Don't bet on referred pain to the right scapular area. Radiation of pain outside the abdomen occurs only 60% of the time. The pain can radiate anywhere in the torso, including both flanks, both shoulders and scapula, and the mid‑thoracic area (20%).

***  Gallbladder emptying has been shown by ultrasound to be unrelated to the fat content of a meal. In fact, there is no proof that biliary attacks are precipitated by eating. In one study "fatty food" intolerance was more common in the controls than in those patients with confirmed gallstones.

***  Bloating, belching, and flatulence are no more common in patients with gallstones than in the controls without gallstones. Therefore, a cause and effect relationship cannot be established. Since these symptoms often persist after surgery, they cannot be caused by gallstones. Obviously, it is important for your patients to know this.

***  Tenderness in the upper right quadrant is only present during an episode or when the biliary system is stressed. When patients are between meals or between attacks, abdominal examination is normal. This is a very important point for examiners to remember. The body only evidences contraction in muscles that share a common innervation with a viscera while that organ is being stressed or challenged beyond its capabilities.

I learned years ago to refer to the gallbladder and its functions as the "biliary system" because so many patients with "gallbladder symptoms" have had their gallbladder removed. They are convinced that it can no longer be at fault since their surgeon told them that the symptoms would be gone after the gallbladder was removed.

(Dr. Loomis welcomes input on the subjects covered in this column. To make a comment or ask a question, or to receive a free copy of his video titled, "Using Enzymes in Clinical Practice: The Loomis System," call 800/662‑2630 or write to him at 6421 Enterprise Lane, Madison, WI 53719. Visit www.loomisenzymes.com online for information on upcoming Loomis Institute seminars.)