Gallstone disease primary prevention: Difference between revisions
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==Overview== | ==Overview== | ||
Effective measures for the primary prevention of gallstone disease include diet with sufficient fat and protein, maintaining a low body weight, and avoiding prolonged fasting. | |||
==Primary Prevention== | |||
Patients at highest risk for developing gallstones are: | |||
*Pregnant women | |||
*Patients who rapidly lose weight | |||
*Patients on long-term octreotide | |||
*Patients on long-term total parenteral nutrition (TPN) | |||
*Patients treated with Ceftriaxone | |||
Biliary sludge, which is often detected incidentally during imaging testing performed for other reasons, frequently occurs during pregnancy, following prolonged fasting (eg, after total parenteral nutrition), and in patients treated with ceftriaxone. Pregnancy is associated with both a qualitative change in bile and delayed gallbladder emptying, both of which promote stone formation [8]. Ceftriaxone, which is excreted in bile, can bind calcium and precipitate in bile [9]. (See "Epidemiology of and risk factors for gallstones".) | |||
Patients with biliary sludge who are consuming an oral diet should be encouraged to eat three meals daily, with each meal containing sufficient fat or protein to ensure good gallbladder contraction. In addition, their diet should be high in fiber and calcium, and low in saturated fats. They should also be encouraged to maintain a low body weight through regular exercise (which may itself prevent gallstone formation) [10] and calorie restriction. However, care should be taken to maintain nutritional requirements, especially in pregnancy. | |||
Biliary sludge and gallstones may resolve following pregnancy or when a normal diet is reinstituted in patients treated with TPN [11-13]. Prophylaxis in such cases is usually not necessary. However, in addition to dietary recommendations, we have used bile acid therapy in patients who develop pain and/or cholestasis that was thought to be secondary to biliary sludge, and who had no evidence of acalculous cholecystitis or serious complications. These patients have been followed with serial ultrasonography to confirm clearance of the sludge. | |||
Patients receiving total parenteral nutrition (TPN) should be periodically assessed for possible enteral feeding. A number of modalities have been used in an attempt to minimize the risk of gallstone disease in these patients: | |||
One study suggested that, in patients who require prolonged TPN, daily injections of cholecystokinin may promote gallbladder emptying and clearance of sludge [14]. However, subsequent data did not support this initial observation [15]. | |||
High doses of crystalline amino acids may produce the same effect by inducing secretion of endogenous cholecystokinin [16]. | |||
Screening of patients on long-term TPN for the development of biliary sludge has not been established to be beneficial. However, some patients in whom sludge is documented (either because of clinical symptoms or when found incidentally) may benefit from prophylactic bile acid therapy. Such patients have a significant rate of subsequent gallstone formation, although most remain asymptomatic. We consider using prophylactic treatment in patients who would tolerate symptomatic gallstone disease or complications related to gallstones poorly. | |||
The use of prophylactic bile acid therapy in individuals following surgery for weight reduction has received increased interest in recent years. The risk of developing gallstones is greatest during the period of rapid weight reduction and falls once the patient's weight has stabilized [17]. Several studies have suggested that the risk of gallstone formation is as high as 35 to 70 percent [17-19]. As a result, cholecystectomy is now performed in many patients undergoing bariatric surgery. | |||
Some studies have shown a striking benefit from ursodeoxycholic acid in patients undergoing rapid weight reduction without a prophylactic cholecystectomy [17]. On the other hand, treatment with ursodeoxycholic acid is not always successful, possibly because of poor compliance [19]. | |||
Secondary prevention — Secondary prevention refers to the prevention of symptoms in patients who have gallstones but are asymptomatic. These patients are usually identified by ultrasonography performed for some other reason. While dietary maneuvers and bile acid therapy may result in gallstone dissolution and prevent further progression of gallstone disease, there are few data suggesting that drug therapy is cost-effective or should be used in this setting. At the present time, medical therapy of asymptomatic stones is not indicated. (See "Approach to the patient with incidental gallstones".) | |||
Tertiary prevention — Symptomatic gallstone recurrence following successful medical therapy remains a major concern because the gallbladder is left in place and patients currently selected for medical management are frequently poor surgical candidates. Without treatment, approximately 60 percent of patients who have undergone extracorporeal shockwave lithotripsy (ESWL) or medical dissolution have recurrent gallstone disease. In such cases, retreatment may be effective. Recurrent gallstones are often not "true to type." Even in the case of previous calcified gallstones, recurrent gallstones are usually lucent on CT, rich in cholesterol, and likely to be suitable for bile acid therapy [20]. | |||
Prevention of recurrence may be a more effective strategy than retreatment. Methods for the prevention of gallstone recurrence include dietary and other lifestyle modifications (see 'Primary prevention' above) and continued bile acid therapy. Long-term bile acid therapy is likely to prevent further gallstone recurrence and the development of symptoms, but is expensive [21-23]. Aspirin and other nonsteroidal antiinflammatory drugs have also been assessed [24]. These agents are thought to work through the inhibition of mucin secretion and the alteration in gallbladder mucosal function. Their efficacy is not well established in humans and therefore cannot be recommended at the present time. | |||
We use long-term bile salt therapy in patients whose medical condition precludes cholecystectomy, or in whom the risk of gallstone recurrence remains high because of lack of reversible predisposing features. (See "Nonsurgical treatment of gallstones".) | |||
==References== | ==References== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Overview
Effective measures for the primary prevention of gallstone disease include diet with sufficient fat and protein, maintaining a low body weight, and avoiding prolonged fasting.
Primary Prevention
Patients at highest risk for developing gallstones are:
- Pregnant women
- Patients who rapidly lose weight
- Patients on long-term octreotide
- Patients on long-term total parenteral nutrition (TPN)
- Patients treated with Ceftriaxone
Biliary sludge, which is often detected incidentally during imaging testing performed for other reasons, frequently occurs during pregnancy, following prolonged fasting (eg, after total parenteral nutrition), and in patients treated with ceftriaxone. Pregnancy is associated with both a qualitative change in bile and delayed gallbladder emptying, both of which promote stone formation [8]. Ceftriaxone, which is excreted in bile, can bind calcium and precipitate in bile [9]. (See "Epidemiology of and risk factors for gallstones".)
Patients with biliary sludge who are consuming an oral diet should be encouraged to eat three meals daily, with each meal containing sufficient fat or protein to ensure good gallbladder contraction. In addition, their diet should be high in fiber and calcium, and low in saturated fats. They should also be encouraged to maintain a low body weight through regular exercise (which may itself prevent gallstone formation) [10] and calorie restriction. However, care should be taken to maintain nutritional requirements, especially in pregnancy.
Biliary sludge and gallstones may resolve following pregnancy or when a normal diet is reinstituted in patients treated with TPN [11-13]. Prophylaxis in such cases is usually not necessary. However, in addition to dietary recommendations, we have used bile acid therapy in patients who develop pain and/or cholestasis that was thought to be secondary to biliary sludge, and who had no evidence of acalculous cholecystitis or serious complications. These patients have been followed with serial ultrasonography to confirm clearance of the sludge.
Patients receiving total parenteral nutrition (TPN) should be periodically assessed for possible enteral feeding. A number of modalities have been used in an attempt to minimize the risk of gallstone disease in these patients:
One study suggested that, in patients who require prolonged TPN, daily injections of cholecystokinin may promote gallbladder emptying and clearance of sludge [14]. However, subsequent data did not support this initial observation [15]. High doses of crystalline amino acids may produce the same effect by inducing secretion of endogenous cholecystokinin [16]. Screening of patients on long-term TPN for the development of biliary sludge has not been established to be beneficial. However, some patients in whom sludge is documented (either because of clinical symptoms or when found incidentally) may benefit from prophylactic bile acid therapy. Such patients have a significant rate of subsequent gallstone formation, although most remain asymptomatic. We consider using prophylactic treatment in patients who would tolerate symptomatic gallstone disease or complications related to gallstones poorly.
The use of prophylactic bile acid therapy in individuals following surgery for weight reduction has received increased interest in recent years. The risk of developing gallstones is greatest during the period of rapid weight reduction and falls once the patient's weight has stabilized [17]. Several studies have suggested that the risk of gallstone formation is as high as 35 to 70 percent [17-19]. As a result, cholecystectomy is now performed in many patients undergoing bariatric surgery.
Some studies have shown a striking benefit from ursodeoxycholic acid in patients undergoing rapid weight reduction without a prophylactic cholecystectomy [17]. On the other hand, treatment with ursodeoxycholic acid is not always successful, possibly because of poor compliance [19].
Secondary prevention — Secondary prevention refers to the prevention of symptoms in patients who have gallstones but are asymptomatic. These patients are usually identified by ultrasonography performed for some other reason. While dietary maneuvers and bile acid therapy may result in gallstone dissolution and prevent further progression of gallstone disease, there are few data suggesting that drug therapy is cost-effective or should be used in this setting. At the present time, medical therapy of asymptomatic stones is not indicated. (See "Approach to the patient with incidental gallstones".)
Tertiary prevention — Symptomatic gallstone recurrence following successful medical therapy remains a major concern because the gallbladder is left in place and patients currently selected for medical management are frequently poor surgical candidates. Without treatment, approximately 60 percent of patients who have undergone extracorporeal shockwave lithotripsy (ESWL) or medical dissolution have recurrent gallstone disease. In such cases, retreatment may be effective. Recurrent gallstones are often not "true to type." Even in the case of previous calcified gallstones, recurrent gallstones are usually lucent on CT, rich in cholesterol, and likely to be suitable for bile acid therapy [20].
Prevention of recurrence may be a more effective strategy than retreatment. Methods for the prevention of gallstone recurrence include dietary and other lifestyle modifications (see 'Primary prevention' above) and continued bile acid therapy. Long-term bile acid therapy is likely to prevent further gallstone recurrence and the development of symptoms, but is expensive [21-23]. Aspirin and other nonsteroidal antiinflammatory drugs have also been assessed [24]. These agents are thought to work through the inhibition of mucin secretion and the alteration in gallbladder mucosal function. Their efficacy is not well established in humans and therefore cannot be recommended at the present time.
We use long-term bile salt therapy in patients whose medical condition precludes cholecystectomy, or in whom the risk of gallstone recurrence remains high because of lack of reversible predisposing features. (See "Nonsurgical treatment of gallstones".)