Submitted by David Overton, Natural Medicines & Family Practice
90% of gallbladder attacks are due to stones, but there are three possibilities:
- acute calculous (gallstone) cholecystitis (inflammation of the gallbladder).
- acute acalculous (without gallstones) cholecystitis is fairly common
- chronic cholecystitis (with or without stones)
Acute calculous (with gallstones) cholecystitis symptoms are due to severe irritation and inflammation of the gallbladder because bile is an acid (which is very caustic when not neutralized by normal digestive functions) that irritates the gallbladder when stones block bile flow. There are two types of stones and they must have sufficient calcium inside the stones to be seen on scans. Cholesterol stones only show on scans in 10-20% of cases. Pigmented stones only show in 50-70% of cases. Pigmented stones are associated with mucus production (potentially a biofilm – see my article on biofilms) and infections. Cholesterol stones form in the absence of infections. Both types of stones are very common in patients with insulin resistance (schedule your glucose tolerance test with us to diagnosis and manage insulin resistance). Treatable factors that lead to gallstone formation include:
- Poor diet and excess calories
- Excess weight
- Insulin resistance (abnormal glucose/insulin)
- Metabolic syndrome (a combination of the above three issues plus high CRP, high blood pressure, high cholesterols and other factors)
- Female
- Advancing age
- Estrogen drugs
- Pregnancy
- Rapid weight loss
- Genetic bile acid problems
- Genetics: northern European, North and South American, Native American & Mexican American family background.
Acalculous (without gallstones stones) cholecystitis is thought to be caused by ischemia (impaired blood supply) and is potentially much more serious. Causes include:
- Poor circulation to the gallbladder
- Immune system problems. Infections are commonly a cause.
- Cardiovascular disease and/or general circulation problems
- Gallbladder stasis (impaired activity, also known as dyskinesis)
- Accumulation of micro-crystals (sludge), thick bile and gallbladder mucus which transiently plug up the gallbladder duct. These may not be clearly seen on scans and could be mistaken as “polyps”. The symptoms tend to go away then come back without proper treatments.
- Cholangitis means infection or obstruction (plugged up) bile system. Most clinicians think about bacterial infections when viruses, fungi and parasites can also cause infections. Pancreatitis, auto immune disease or tumors can also cause cholangitis.
- Bacterial infections more commonly cause fevers and jaundice. Viral, fungal and parasitic infections often do not cause fevers or jaundice. Many infections are not seen with standard tests but are detectable or treatable with specialized tests:
- Viral infections include herpes viruses (1, 2, 6, cytomegalovirus or Ebstein Barr), HIV, hepatitis C, D, E or G and other possible viruses
- Fungal infections can include candida, mucormycosis or aspergillus
- Parasites include malaria, schistomosomiasis, strongyloidoasis, crytosporidiosis, leichmaniasis, echinocococosis and the liver flukes (fasciola hepatic and clonorchis sinensis). These infections more commonly cause liver cysts (seen with scans)
- Bacterial infections can include syphilis, mycoplasma, Chlamydia pneumonia, e. coli, Klebsiella, enterococcus, enterobacter, bacteroides and others
This form of gallbladder problems is potentially more serious. Complications seen with acute acalulous cholecystitis include:
- Progressive infections and multiple organ problems (heart, kidneys, pancreas, liver, etc.)
- Infections commonly lead to low or high blood pressure, which compromises circulation more, leading to multiple organ problems
- Immune system becoming progressively suppressed or depleted
- Insulin resistance progressively impairs immune and circulation functions
- Infections are common and should be considered in this order: viral, bacterial, fungal then parasitic. These often do not show on standard tests.
Patients with gallstones tend to have progressive right upper or upper abdominal pain, frequently with mild fever, poor appetite, sweating, nausea and vomiting. The pain may be in the mid back or left shoulder. Mild elevations in white cell counts or alkaline phosphatase are common.
Patients with acalculous cholecystitis tend to have confusing symptoms because the symptoms are obscured by the contributing factors (immune, circulation or other problems). White blood cell counts tend to be low normal or low initially, then become more abnormal over time. Enzyme tests such as alkaline phosphatase or “liver” enzymes (i.e. ALT, AST) tend to be normal initially, then become low or high, with low being indicative of more serious problems. Symptoms may occur suddenly and subside within 7-10 days and frequently within 24 hours without treatment. However, symptoms tend to relapse because the causes were not treated and complications may set in slowly or quickly. A high percentage of these patients do not have the classic gallbladder symptoms. Because the diagnosis is delayed, progressive problems are common, especially progressive infectious problems. An indolent form (with symptoms that come and go) is common in patients with vasculitis (immune problems and inflammation of the blood vessels), atherosclerosis (ischemia) of the heart blood vessels, patients with viral infections and patients with liver and gallbladder infections.
Chronic cholecystitis is caused by obscure problems. It is not clear that gallstones play a role in chronic cholecystitis and the indolent acalculous form should be suspected. Bacteria such as e.coli or enterococci can be cultured from the bile in one third of cases. One should be aware they can also have chronic viral, other bacterial or parasitic infections that do not culture well or show on standard lab tests.
Proper diagnosis and management of any form of cholecystitis is important to prevent complications:
- Progressive infection
- Gallbladder perforation or abscess formation
- Gallbladder rupture
- Aggravation of pre-existing medical problems, especially immune, cardiac, kidney, liver, pancreas or lung problems.
If you have gallbladder problems without gallstones or classic symptoms or if you have persistent problems after gallbladder surgery (because underlying immune and circulation problems were not addressed), work with a clinical experienced with the underlying causes and factors. Remember, just surgically removing the gallbladder may not eliminate underlying immune, circulation and other treatable problems.
Reference: Pathological Basis of Disease, 2010, Kumar et. al.
