Biliary colic

Related Terms

Biliary colic, cholagogue, cholecystitis, cholelithiasis, choleretic, cholestasis, gallbladder, gallbladder attacks, gallbladder colic, gallbladder disease, gallbladder disorders, gallstones, Gilbert's syndrome, pancreas, pancreatic disease, pancreatic disorders, pancreatic insufficiency, pancreatitis.

Background

The biliary tract is a system of organs and tubes (ducts) that help transport a digestive fluid, called bile, from the liver to the small intestine. Bile, which is produced in the liver and stored in the gallbladder, is needed to breakdown and absorb fats in foods. Gallbladder disorders, also called biliary tract disorders, occur when there is a disruption in this process.
For instance, the most common gallbladder disorder is gallstones. This occurs when the bile becomes too concentrated and tiny particles in the fluid form a stone-like mass in the ducts that blocks proper bile flow.
The pancreas, which is located behind the stomach, is another organ that helps break down foods that are consumed. The pancreas produces enzymes that are released into the small intestine to break down proteins, carbohydrates, and lipids (fats) in food. A section of the pancreas also produces insulin and glucagon; both help regulate the amount of sugar in the blood.
Pancreatitis is a common pancreatic disorder that occurs when the organ becomes inflamed.
Most gallbladder and pancreatic disorders can be successfully treated with medications and/or surgery.

Integrative therapies

Good scientific evidence:
Globe artichoke: Globe artichoke is a perennial, thistle-like plant originating in southern Europe around the Mediterranean Sea. Globe artichoke leaf extract has been found to increase bile secretion in animal, human, and laboratory studies. Additional human study is needed to make a firm recommendation for artichoke as a choleretic for patients who have cholestasis.
Use cautiously if allergic/hypersensitive to members of the Asteraceae or Compositae family (e.g. chrysanthemums, daisies, marigolds, ragweed, and arnica), due to possible cross-reactivity. Use cautiously with cholelithiasis or biliary/bile duct obstruction or kidney disease. Avoid if pregnant or breastfeeding.
Probiotics: Supplementing with Lactobacillus plantarum 299 may help prevent pancreatic infection (sepsis), reduce the number of operations needed, and reduce the length of hospital stay in acute pancreatitis. Additional research is needed to make a conclusion.
Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.
Unclear or conflicting scientific evidence:
Bromelain: Bromelain is a digestive enzyme that is extracted from the stem and the fruit of the pineapple plant (Ananas comosus). There is currently little reliable scientific research on whether bromelain is helpful for pancreatic insufficiency. Better study is needed before a firm conclusion can be made.
Avoid if allergic to bromelain, pineapple, honeybee, venom, latex, birch pollen, carrots, celery, fennel, cypress pollen, grass pollen, papain, rye flour, wheat flour, or members of the Bromeliaceaefamily. Use cautiously with history of a bleeding disorder, stomach ulcers, heart disease, or liver or kidney disease. Use cautiously before dental or surgical procedures with bleeding risks. Use cautiously while driving or operating machinery. Avoid if pregnant or breastfeeding.
Chlorophyll: Chlorophyll is a chemoprotein commonly known for its contribution to the green pigmentation in plants; it is related to protoheme, the red pigment of blood. It can be obtained from green leafy vegetables (broccoli, Brussels sprouts, cabbage, lettuce, and spinach), algae (Chlorella and Spirulina), wheat grass, and numerous herbs (alfalfa, damiana, nettle, and parsley). Based on early study, it has been suggested that chlorophyll-a may reduce the mortality rate in chronic pancreatitis. Additional study is needed in this area.
Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes, or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or antidiabetes agents. Avoid if pregnant or breastfeeding.
Danshen: Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. For many years, danshen has been used as a traditional Chinese medicine (TCM) remedy to treat acute pancreatitis. However, little scientific research is currently available regarding the use of danshen in humans.
Avoid if allergic or hypersensitive to danshen. Use cautiously with altered immune states, arrhythmia, compromised liver function or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin, or hypotensives including ACE inhibitors such as captopril, or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders, low blood pressure, and following cerebal ischemia. Avoid if pregnant or breastfeeding.
Grape seed: Limited available human study suggests that grape seed may reduce abdominal pain in chronic pancreatitis. Further research is needed.
Reports exist of people with allergy to grapes or other grape compounds, including anaphylaxis. Individuals allergic to grapes should not take grape seed and related products. Use cautiously if taking anticoagulants. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Grape seed may interfere with the way the body processes certain drugs that use the liver's cytochrome P450 enzyme system. Avoid if pregnant or breastfeeding.
Greater celandine: Greater celandine(Chelidonium majus)and turmeric (Curcuma longa) have traditionally been used to support the liver and gallbladder. However, clinical study is currently lacking. Early human study provides initial data on the efficacy of a Chelidonium and Curcuma combination for pain relief in biliary colic and dyskinesia. The herbs did not appear to be beneficial in resolving associated symptoms, raising questions about the usefulness of this combination in fully restoring biliary function. Additional research is necessary to clarify the optimal dose, length of treatment, and clinical applications for these two herbs individually and in combination.
Use cautiously in patients taking amphetamines, morphine, hexobarbital, MAOIs, dopaminergic drugs, or serotonergic drugs. Use cautiously in patients undergoing radiation therapy. Avoid in patients with liver disease, or in pregnant and lactating women.
SAMe: SAMe (S-adenosyl-L-methionine) is a natural substance found in every cell of the body. SAMe may be beneficial for pruritus (severe itching) and serum bilirubin levels associated with cholestasis. Additional study is needed. Currently, there is insufficient available evidence to determine if SAMe is an effective treatment for cholestasis during pregnancy. Information on the use of SAMe prior to the third trimester is currently lacking.
Avoid if allergic to SAMe. Use cautiously with diabetes or anxiety disorders. Avoid with bipolar disorder. Avoid in the first and second trimesters of pregnancy or if breastfeeding, due to a lack of safety information.
Selenium: There is currently inconclusive evidence regarding the use of selenium in pancreatitis. Additional study is needed in this area.
Avoid if allergic or sensitive to products containing selenium. Avoid with a history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
Soy: Due to limited human study, there is not enough evidence to determine if soy is an effective treatment for gallstones (cholelithiasis). Further research is needed before a conclusion can be made.
Avoid if allergic to soy. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been one case report of vitamin D deficiency rickets in an infant nursed with soybean milk that was not specifically designed for infants. People who experience intestinal irritation from cow's milk may experience intestinal damage or diarrhea from soy. It is unknown if soy or soy isoflavones share the same side effects as estrogens (e.g. increased risk of blood clots). The use of soy is often discouraged in patients with hormone-sensitive cancers (e.g. breast cancer or prostate cancer). Other hormone-sensitive conditions, such as endometriosis, may also be worsened. Patients taking blood-thinning drugs like warfarin or aspirin should check with their doctors and pharmacists before taking soy supplements. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there are limited scientific data.
Turmeric: Turmeric is a perennial plant native to India and Indonesia that is often used as a spice in cooking. Anecdotally, it has been observed that there is a low incidence of cholelithiasis in Indian populations. Animal research reports that adding the turmeric constituent, curcumin, to the diet reduces the incidence of chemically-induced gallstones in mice, and it has been suggested that turmeric may inhibit the formation of cholesterol gallstones. Preliminary human data suggest that curcumin may function as a cholagogue (gallbladder contracting agent) and may be of benefit for cholelithiasis prevention. However, use of turmeric may be inadvisable in patients with active gallstones.
Avoid if allergic to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma or Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously if taking blood-thinners like warfarin (e.g. Coumadin? or aspirin). Use cautiously if pregnant or breastfeeding.
White horehound: The expert German panel, the Commission E, has approved white horehound as a choleretic for the treatment of dyspepsia (upset stomach) and lack of appetite. The evidence supporting this use is largely anecdotal and based on historical use, and there is currently insufficient scientific research to recommend for or against this use of white horehound.
Avoid if allergic to white horehound or any member of the Lamiaceae (mint) family. White horehound is generally considered safe when used to flavor foods. Use cautiously with diabetes, high/low/unstable blood pressure, high levels of sodium in the blood, irregular heartbeats, or gastrointestinal disease. Use cautiously if taking diuretics. Avoid if pregnant or breastfeeding.
Zinc: In early study, zinc sulfate supplementation was shown to decrease serum unconjugated bilirubin levels in patients with Gilbert's syndrome. Well-designed clinical trials are needed to confirm these results.
Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.
Fair negative scientific evidence:
Iridology: Iridology is the study of the iris for diagnostic purposes. Conventional medicine regards iridology as an unsubstantiated alternative diagnostic technique, although some studies have suggested it may have some potential validity. Preliminary study examined the potential of iridology for gallbladder disease diagnosis using slide photographs of patients with the disease, and found no evidence of agreement or diagnostic accuracy. Therefore, there is currently insufficient evidence supporting the use of iridology as a diagnostic tool in gallbladder disease.
Iridology should not be used alone to diagnose disease. Studies of iridology have reported incorrect diagnoses, and potentially severe medical problems may thus go undiagnosed. In addition, research suggests that iridology may lead to inappropriate treatment.

Prevention

Avoid or minimize alcohol consumption because it may lead to pancreatitis and may also worsen symptoms of bile reflux by relaxing the lower esophageal sphincter and irritating the esophagus.
Patients can reduce their risks of developing gallstones by maintaining a healthy body weight, exercising regularly, and consuming a reduced-fat, high-fiber diet that includes a variety of fresh vegetables, fruits, and whole grains.
Patients are encouraged not to smoke because it increases the risk of developing pancreatitis.
Patients who have a history of gallstones should take bile salt tablets, called ursodiol (Actigall?), daily to prevent gallstones from recurring.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

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Shrestha S, Pradhan G, Bhoomi K, et al. Review of laparoscopic cholecystectomy in Nepal Medical College Teaching Hospital. Nepal Med Coll J. 2007 Mar;9(1):32-5. .

Cholecystitis

Overview: Cholecystitis is the inflammation of the gallbladder wall and nearby abdominal lining.
Causes: Most cases of cholecystitis occur when a gallstone becomes lodged in the cystic duct, which is the tube that connects the gall bladder to the common bile duct. Other less common causes include bacterial infections in the bile duct system, tumors of the liver or pancreas, or decreased blood supply to the gallbladder. Diabetics have an increased risk of developing a decreased blood supply to the gallbladder.
Symptoms: Symptoms may develop suddenly or gradually over the course of several years. Most cholecystitis attacks last one to two days. Common symptoms include severe pain in the upper right part of the abdomen after meals that usually lasts for several hours, nausea, vomiting, mild fever, rigid abdominal muscles, yellowing of the skin and eyes (jaundice), and loose, light-colored bowel movements. In rare cases, cholecystitis may cause itching, especially in the hands and feet.
Diagnosis: There are several tests available to detect abnormalities of the gallbladder. After a detailed medical history and physical examination are performed, the healthcare provider determines the appropriate tests needed to diagnose the underlying cause.
An ultrasound, which involves rubbing a wand-like instrument (called a transducer) over the lower abdomen, may be performed to take pictures of the gallbladder.
Patients may also undergo a computerized tomography (CT) scan that takes pictures of the internal organs. A dye is often injected into the patient before the CT scan is performed to help the healthcare provider view the tubes and organs of the biliary system in more detail.
An endoscopic retrograde cholangiopancreatography (ERCP) may be performed at a hospital to check for problems in the liver, gallbladder, bile ducts, and pancreas. During the procedure, a thin, flexible tube with a camera at the tip (called an endoscope) is inserted through the mouth and into the small intestine until it reaches the biliary ducts and pancreas. A small plastic tube is then inserted through the endoscope and a colored dye is injected. This allows the healthcare provider to see detailed images of the biliary tract.
If the patient has a fever in addition to cholecystitis symptoms, a blood culture may be performed to diagnose an infection. A sample of the patient's blood is analyzed for the presence of disease-causing microorganisms.
Treatment: Treatment depends on the underlying cause. Infections are treated with medications called antibiotics. The specific dose and type of antibiotic used depends on the specific type and severity of the infection.
If a gallstone is causing the condition, the gallbladder is usually surgically removed. If the gallbladder is removed, patients can expect a full recovery. Complications are rare but may include damage to the common bile duct, bleeding, and infection. Non-surgical procedures, such as bile salt tablets and sound wave therapy, are only considered if the patient is unable to undergo surgery or the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.

Cholestasis

Overview: Cholestasis occurs when the flow of digestive fluid produced by the liver (called bile) is either limited or stopped at some point between the liver and the small intestine. As a result, a waste product, called bilirubin, leaks into the bloodstream where it accumulates.
Bilirubin is yellow to green in color. When it leaks into the bloodstream, it may cause the skin and eyes to become yellow in color.
Causes: Cholestasis may be caused by problems in or outside of the liver the liver. For instance, acute liver inflammation (hepatitis), alcoholic liver disease, primary biliary cirrhosis, cirrhosis of the liver, certain medications (e.g. birth control pills or an antipsychotic and antinausea drug called chlorpromazine), hormonal changes during pregnancy, and cancer that has spread to the liver, may cause cholestasis.
Problems outside of the liver, such as gallstones, narrowing of a bile duct, cancer of a bile duct, cancer of the pancreas, and inflammation of the pancreas (pancreatitis), may cause cholestasis.
Symptoms: Many times the only symptom noticed is itchy skin (especially on the hands and feet). This is because waste products from the bile leak into the bloodstream and irritate the skin. Other symptoms may include yellowing of the eyes and skin (jaundice), light-colored stools, oily and foul-smelling stools (steatorrhea), dark urine, abdominal pain, vomiting, loss of appetite, and fever.
Bile is needed to emulsify fats, as well as calcium, vitamin D, and vitamin K from foods. This process allows the intestines to absorb important nutrients. When not enough bile is released into the intestine, these vitamins are unable to be absorbed into the blood. If left untreated, these nutrient deficiencies may lead to the development of weak or brittle bones or increased bleeding.
Diagnosis: Blood tests can confirm a diagnosis of cholestasis. Patients with the disorder typically have high levels of two liver enzymes: alkaline phasphatatase and gamma-glutamyl transpeptidase. Patients with cholestasis generally have three times the normal amount of alkaline phosphatase in their blood. Healthy individuals have 44-147 international units of alkaline phosphatase per liter of blood and 0-51 international units of gamma-glutamyl transpeptidase.
A healthcare provider may be able to tell if the condition is caused by an obstruction inside or outside of the liver after a detailed medical history and physical examination. If the patient has a history of hepatitis or alcoholism or is taking new drugs, an obstruction in the liver is usually suspected. If the physical examination shows that the gallbladder is rigid or painful, an obstruction outside of the liver is suspected.
Additional tests, such as a computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, or ultrasound, may be performed to help determine the underlying cause of the condition. If it is suspected that the ducts in the liver are blocked, a liver biopsy may be performed to confirm a diagnosis. If it is suspected that the bile ducts are blocked, either an endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography (MRCP) is performed. Both of these tests provide detailed images of the gallbladder ducts.
Treatment: Treatment of cholestasis depends on the underlying cause.
If a gallstone is blocking the flow of bile, the gallbladder is usually surgically removed. If the gallbladder is removed, patients can expect a full recovery. Complications are rare but may include damage to the common bile duct, bleeding, and infection. During the procedure, a flexible tube called an endoscope is inserted through the anus. Additional surgical tools are inserted through the tube to remove the gallbladder. Non-surgical procedures, such as bile salt tablets and sound wave therapy, are only considered if the patient is unable to undergo surgery or the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
If a medication (e.g. birth control pills or chlorpromazine) is the suspected cause, a healthcare provider may recommend switching to an alternative drug. Patients should not stop taking their medications or change their doses without first consulting their healthcare providers.
If hepatitis is causing the condition, symptoms will resolve once the swelling and/or infection resolves. In general, there are few treatment options for hepatitis. Patients may receive medications, including antivirals and immunomodulators (e.g. interferons), but they are not always effective.
Calcium, vitamin D, and/or vitamin K supplements may be necessary if the patient has nutritional deficiencies. Patients should only take supplements under the strict supervision of their healthcare providers.
In addition, a medication called cholestyramine (Questran?) may be taken by mouth to reduce itchiness associated with cholestasis. This medication binds with certain substances in the bile, preventing them from being reabsorbed to irritate the skin. It remains unknown if cholestyramine is safe for pregnant or breastfeeding women.
Patients with cholestasis should avoid substances that may be toxic to the liver, including certain medications (e.g. chlorpromazine) and alcohol, because they may worsen symptoms.

Gallbladder attacks

Overview: A gallbladder attack, also called gallbladder colic, is characterized by pain and nausea and may accompany many types of gallbladder disorders.
Causes: A gallbladder attack may occur when a gallstone moves through the biliary tract towards the small intestine or if the gallbladder becomes inflamed (a condition called cholescystitis). An attack may also be the result of cholestasis, which occurs when the flow of bile is blocked or if the gallbladder becomes inflamed (cholecystitis).
Symptoms: Gallbladder attacks generally last one to four hours. Common symptoms include dull, sharp, or excruciating pain on the right side of the abdomen, as well as nausea, vomiting, and bloating. The gallbladder, which is located in the lower right side of the abdomen, is usually tender to the touch. It is common for pain to radiate to the right shoulder blade.
Diagnosis: A healthcare provider will be able to tell if a patient is having gallbladder attacks after a detailed medical history and physical examination are performed. The next step is to determine the underlying cause of the symptoms.
Blood tests are usually performed to determine if the patient has cholestasis. Patients with cholestasis typically have high levels of two liver enzymes: alkaline phosphatase and gamma-glutamyl transpeptidase. Healthy individuals have 44-147 international units of alkaline phosphatase per liter of blood and 0-51 international units of gamma-glutamyl transpeptidase per liter of blood.
A computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, or ultrasound may also be performed. These tests produce images of the internal organs and may help the healthcare provider detect abnormalities, such as gallstones, that may be causing the gallbladder attack.
Endoscopic retrograde cholangiopancreatography (ERCP) may be performed at a hospital to check for problems in the liver, gallbladder, bile ducts, and pancreas. During the procedure, a thin, flexible tube with a camera (called an endoscope) is inserted through the mouth into the small intestine until it reaches the bile ducts and pancreas. A small plastic tube is inserted through the endoscope and a colored dye is injected. This allows the healthcare provider to see detailed images of the biliary tract.
Treatment: Treatment of gallbladder attacks depends on the underlying cause. For instance, if a gallstone is causing a gallbladder attack, the gallbladder is usually surgically removed. Antibiotics may be prescribed if an infection is the cause. The type of antibiotic used depends on the specific type of infection and severity of the condition. If a medication is the suspected cause, a healthcare provider may recommend an alternative dose or different medication.

Gallstones (cholelithiasis)

Overview: Gallstones, also called cholelithiasis, develop when small particles of the bile in the gallbladder solidify into a stone-like mass. Sometimes gallstones are too large to pass through the biliary ducts and the stone becomes stuck inside the tubes in the gallbladder. In such cases, surgery is necessary to remove the gallbladder.
Causes: Bile consists of bile salts and a fatty compound called lecithin. Lecithin is needed to dissolve the cholesterol in the bile excreted by the liver. Individuals may develop gallstones if there is more cholesterol in the bile than can be dissolved. It is important to note that cholesterol in the blood is not related to cholesterol in the liver. If patients have high levels of cholesterol in the liver it does not mean that they have high levels of cholesterol in the blood. In healthy individuals, the liver is able to control the amount of cholesterol produced in order to keep levels constant. Therefore, cholesterol-lowering drugs cannot prevent gallstones from developing.
Gallstones may also develop if the gallbladder does not empty completely or often enough. When this happens, the bile may become too concentrated. This is especially common among pregnant women because high levels of estrogen during pregnancy increases bile cholesterol levels and decreases the number of the times the gallbladder empties. Also, eating too little fat or not eating for extended periods of time may also increase the risk gallstones because it causes the gallbladder to empty less frequently.
Symptoms: If the biliary ducts become blocked with a gallstone, bile flow is disrupted. As a result, the bile duct muscles continually contract to try to force the bile through the tubes. This causes a sudden, steady, moderate, or intense pain in the abdomen (called biliary colic or a gallbladder attack). Most pain is felt in the upper or middle abdomen. In some cases, the pain may radiate to the right shoulder blade. Although pain may develop at any time, it is usually felt a couple hours after eating. Pain may last anywhere from 15 minutes to several hours. Some patients may develop nausea and vomiting during an attack. Once the pain goes away, patients may continue to feel a mild aching or soreness in the abdomen for about one day.
Diagnosis: There are several tests available to diagnose gallstones. An ultrasound is typically performed. During the procedure, a wand-like device, called a transducer, is rubbed over the abdomen. Sound waves produce images of the internal organs, including the gallbladder, and the healthcare provider is able to detect gallstones.
Additional test may also be performed such as a computerized tomography (CT) scan. A CT scan produces detailed images of the internal organs.
A radionuclide scan (also called a cholesintigraphy, hydroxyl iminodiacetic acid scan, or HIDA scan) may be performed. During a radionuclide scan, the patient is injected with a radioactive dye, called HIDA, because it accumulates in the liver and biliary system. Pictures of the abdomen are then taken. This dye is visible in the ducts and organs in the abdomen. If a gallstone is present in the cystic duct, the dye will not make it all the way to the gallbladder. The amount of radiation emitted during the test is less than that of an X-ray. However, most healthcare providers do not perform this test in pregnant or breastfeeding mothers unless it is absolutely necessary.
Treatment: If the gallstone is blocking a biliary duct, the gallbladder is usually surgically removed. A procedure called endoscopic sphincterotomy is most often performed. During the procedure, which is performed at a hospital, the patient receives general anesthesia. Then, a thin, flexible tube called an endoscope is inserted through the patient's anus. Additional surgical tools are inserted through the tube to remove the gallbladder. The gallbladder may also be removed through an incision in the abdomen. However, this type of surgery is performed less often because it is more invasive and requires a longer recovery time than an endoscopic sphincterotomy.
Once the gallbladder is removed, patients can expect a full recovery. Some patients may experience more frequent bowel movements and/or loser-than-normal stools or diarrhea. In some cases, these symptoms may gradually improve over time. Complications are rare but may include damage to the common bile duct, bleeding, and infection.
Non-surgical procedures, such as bile salt tablets or sound wave therapy, are only considered if the patient is unable to undergo surgery or if the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.
Bile salt tablets called ursodiol (Actigall?) may be taken by mouth to dissolves cholesterol gallstones. In order to prevent gallstones from recurring, most patients need to take the medication daily for the rest of their lives.
Patients with cholesterol gallstones may undergo a procedure called extracorporeal shock wave lithotripsy (ESWL). Sound waves (shock waves) are used to break the stone into smaller pieces. Patients receive sedatives and/or anesthesia before the procedure. The patient will either be partially submerged in a tub of water or will lie on a soft cushion. Patients wear headphones because the shock waves are loud. High-energy sound waves then pass through the patient's body and break the stone into smaller pieces. The healthcare provider usually uses X-rays or an ultrasound to ensure that the stone breaks down. Treatment usually lasts for about one hour. Patients then take ursodiol (Actigall?) daily for the rest of their lives to help prevent the gallstones from recurring.
Side effects of shock wave therapy include blood in the urine, bruising on the abdomen or back, bleeding around the kidney or nearby organs, and pain when the stone fragments are passed in the urine. This therapy is not recommended for pregnant women or patients with cholecystitis or cholangitis.

Gilbert's syndrome

Overview: Gilbert's syndrome is a common inherited disorder that occurs when the liver is unable to properly process the yellow-green pigments in bile (called bilirubin). The increased levels of bilirubin in the bloodstream may lead to yellowing of the skin (jaundice), but the liver itself remains normal. In fact, this condition is so mild that is not usually considered a disease.
Causes: Gilbert's syndrome is an inherited disorder, which is why it is more common among men than women. The condition is passed down as an autosomal dominant trait. This means patients only need to inherit one copy of the mutated gene in order to develop Gilbert's syndrome.
Several factors may worsen symptoms of Gilbert's syndrome by slightly increasing the amount of bilirubin in the blood. Examples include illnesses (e.g. the common cold or the flu), fasting or skipping meals, menstruation, dehydration, or overexertion.
Symptoms: Gilbert's syndrome rarely causes any symptoms. Some patients may periodically develop a condition called jaundice, which causes the skin and eyes to appear yellow.
Although some patients experience periods of fatigue and abdominal pain, it is unclear if they are related to Gilbert's syndrome.
Diagnosis: Gilbert's syndrome is diagnosed after a blood test. Patients with the condition will have more than 0.3-1.9 milligrams of total bilirubin per deciliter of blood and more than 0-0.3 milligrams of direct bilirubin per deciliter of blood. However, levels of bilirubin normally fluctuate throughout the day. Therefore, if Gilbert's syndrome is strongly suspected but initial results are normal, repeat testing may be recommended at a different time of day.
Treatment: Gilbert's syndrome generally does not require treatment. Even if a patient experiences periods of jaundice, each symptomatic episode is very mild and will go away in a few days.

Pancreatitis

Overview: Pancreatitis is severe inflammation of the pancreas. When the pancreas becomes inflamed, the digestive enzymes in the organ become active too soon. Instead of becoming active in the intestines, they become active inside the pancreas, where they can cause organ damage.
Once the underlying cause is treated, most patients experience a full recovery. However, if the condition is left untreated, scarring may occur in the pancreas. Once the organ becomes scarred, the condition cannot be reversed and the patient will require long-term treatment to manage the symptoms.
Causes: Alcohol is the leading cause of pancreatitis. Individuals who drink heavily for many years have an increased risk of developing it. It is not clear exactly how alcohol affects the pancreas. However, researchers have found that alcohol causes digestive enzymes to be released sooner than normal. Alcohol also increases the permeability of the small ducts. As a result, the pancreatic digestive enzymes are able to damage healthy tissues inside the pancreas. In addition, alcohol abuse has been shown to cause protein plugs, which may develop into gallstones.
Gallstones are another common cause of pancreatitis. Gallstones develop when small particles of the bile in the gallbladder solidify into a stone-like mass. Sometimes the gallstones move from the gallbladder to a small tube called the common bile duct. This common bile duct connects to another tube called the pancreatic duct. If the stone blocks the pancreatic duct, it causes the pancreas to become inflamed. If left untreated, enzymes may leak from the pancreas and damage healthy tissues.
Some medications, including antibiotics such as pentamidine (Pentam?) and the anti-HIV drug didanosine (Videx?), have been shown to cause pancreatitis. Also, studies have shown that some drugs, including the antiretroviral tenofovir (Viread?) and the anti-cancer drug hydroxyurea (Droxia? or Hydrea?), may increase the amount of didanosine in the blood, which further increases the risk of pancreatitis
Symptoms: Acute symptoms of pancreatitis appear suddenly and may lasts for several hours or even days. Common symptoms include nausea, rapid pulse, fever, vomiting, and severe abdominal pain and swelling. The abdomen may be tender when touched. Drinking alcohol causes the symptoms to worsen.
If the underlying cause of pancreatitis is not treated, the condition may become chronic (long-term). Common symptoms of chronic pancreatitis include nausea, vomiting, fever, and unintentional weight loss. Chronic pancreatitis may lead to temporary diabetes, malnutrition, and severe pain.
Diagnosis: A blood test may be performed to determine if there are elevated levels of the pancreatic enzymes amylase and lipase in the blood. Patients with pancreatitis will test positive for these enzymes.
Imaging studies, such as an abdominal X-ray or computerized tomography (CT) scan, may be performed to determine whether the pancreas is larger than normal. Both of these tests, which are performed at a hospital, produce images of the internal organs. Patients with pancreatitis will have an inflamed pancreas.
An endoscopic retrograde cholangiopancreatography (ERCP) may be performed at a hospital to evaluate the damage of the pancreas. During the procedure, a thin, flexible tube with a camera is inserted through the mouth into the small intestine until it reaches the bile ducts and pancreas. During the test, a small tissue sample may be removed and analyzed in a laboratory for infections or cancer. Because this procedure may damage the pancreas if not performed by a qualified physician, it is only conducted if all other tests are inconclusive. There is also a slight risk of infection.
Treatment: There is no cure for chronic pancreatitis. However, alcohol avoidance and pain medications can effectively relieve symptoms of the condition.
Acute pancreatitis usually improves after about one week of treatment.
If a medication, such as pentamidine (Pentam?) or the anti-HIV drug didanosine (Videx?), is suspected to be causing acute pancreatitis, a healthcare provider may recommend switching to an alternative dose or medication. Patients should not stop taking medications or take different dosages without first consulting their healthcare providers.
Antimicrobials are used to treat infections that cause pancreatitis. Antibiotics are used to treat bacterial infections, antifungals are used to treat fungal infections, and antivirals are used to treat viral infections. The exact type of medication and length of treatment depends on the type and severity of the infection, as well as the patient's overall health.
If a gallstone is causing acute pancreatitis, the gallbladder is usually surgically removed. A surgical procedure, called endoscopic sphincterotomy, is most often performed. During the procedure, which is performed at a hospital, the patient receives general anesthesia and is asleep during the surgery. Then, a thin flexible tube, called an endoscope, is inserted through the patient's anus. Additional surgical tools are inserted through the tube to remove the gallbladder. Non-surgical procedures are only considered if the patient is unable to undergo surgery or if the stone is primarily made up of cholesterol. This is because gallstones usually recur when non-surgical procedures are used.

Bile reflux

Overview: Bile reflux is a condition in which bile, a fluid that helps digest fats, flows upward from the small intestine into the stomach and esophagus. Bile reflux disease may cause or occur simultaneously with gastritis, causing further irritation and inflammation. Because bile reflux and acid reflux may occur together, the patient is at a higher risk for developing esophageal complications.
Causes: Bile reflux most often occurs when the pyloric valve (a ring of muscle that separates the stomach from the duodenum) or the lower esophageal sphincter (an opening which separates the esophagus and stomach) do not function properly, which causes backflow of bile into the stomach and esophagus. Bile reflux has also been found to be common after gallbladder removal, or as a result of complications from gastric surgery which may damage the pyloric valve such as gastrectomy, or gastric bypass. Further inflammation and damage to the lining of the stomach and esophagus may occur as a result.
Symptoms: Symptoms of bile reflux may include a burning, biting, or gnawing pain in the upper abdomen, nausea, frequent heartburn, vomiting of bile, and a dry hacking cough. Symptoms may be very similar to acid reflux, making it difficult to distinguish one condition from the other, especially because both frequently occur together.
Diagnosis: Diagnosis of bile reflux is often difficult to distinguish from gastritis or acid reflux, because they may both occur simultaneously. Common tests assess damage to the esophagus and stomach and may include endoscopy, ambulatory acid tests, and esophageal impedance tests.
Treatment: Bile reflux is generally not known to be completely treated solely by dietary or lifestyle changes such as smoking cessation, alcohol avoidance, eating smaller, healthier (lower fat) meals, weight reduction and relaxation, although these methods may provide relief of symptoms. Rather, bile reflux is often managed with medications or surgery in cases where other treatments have failed. Because bile reflux and gastritis often occur together, there may be some overlap in treatment approaches.
Prescription medications include ursodeoxycholic acid to promote bile flow, and proton pump inhibitors to prevent gastric acid production. Surgical interventions may include bile diversion surgery, in which a connection for bile drainage is made further down in the intestine, and anti-reflux surgery, in which the part of the stomach closest to the esophagus is gathered, wrapped, and then attached around the lower esophageal sphincter.