Thursday, January 17, 2008
It's gratifying that despite my absent posting for many weeks, this blog still gets over five hundred visits and more than a thousand page views daily. This I attribute to the fact that some of my stuff comes up on searches for medical information, which makes me feel as if, whether or not I regain my enthusiasm for bloggery, my work will have been of use. (Or maybe it's just that people like coming by when I'm not around so they don't have to worry about running into me.) Anyhow, I still get comments and questions; quite frequently on the subject of gallstones, about which I wrote a series (one, two, three, four) of posts many months ago. A recent visitor asked some good questions about non-operative management of gallstones, and I was surprised and disappointed to discover that I hadn't really covered it in my prior series. So this is an attempt to rectify (a term which I used in a punny context -- and one which gets hits now and again, from the perverted and/or the easily amused, ever since -- here, and here.)
Let's start with a gentle statement of fact: OF ALL THE BOGUS, DISHONEST, DISINGENUOUS AND STUPID BULLSHIT THAT MASQUERADES AS ALTERNATIVE MEDICAL METHODOLOGY, "GALLBLADDER FLUSH" IS AT THE TOP OF THE LIST. THE PURVEYORS OF IT ARE, AT BEST, CREDULOUS; AT WORST, THEY ARE CHARLATANS AND (LITERAL) SNAKE-OIL SALESMEN WHO WILLFULLY DECEIVE AND STEAL FROM THE SICK AND THE VULNERABLE, AND ARE TO BE COUNTED AMONG THE SCUM OF THE EARTH.
OK, let me tell you what I really feel.
Over the years, particularly after the dawn of that series of tubes called the internet, patients have asked me about "gallbladder flush" as a method of eliminating gallstones. They've handed me recipes (which commonly include some sort of oil and something acidic like lemon-juice, with a few plants thrown in), and, in some cases, have proudly presented me with little cartons of their stool, containing what they are certain are stones they have pooped out as a result of drinking their herbalicious and natural remedies. Fortunately, as a surgeon, I'm well-used to staring at excrement in its many forms, both within and without the confines of the viscera generally expected to contain it. What I saw was curds. I know stones, and I know curds. These was curds, is what they was. Evidently, if you drink some kinds of oils and chase it with certain acidic substances, what you get is curds in your turds. What you don't get -- and trust me, I've seen the proof in pre- and post-glugging ultrasounds -- is change one in the number and nature of stones in your gallbladder.
As with most other forms of medical woo, the pharaohs of phlushes toss around terms like "toxins", and "weak liver," and "detoxify." They make extravagant claims with no proof. Potions of prevention, like methods to keep the elephants away, are hard to disprove. If my writings over the past couple of years confer me with any credibility at all, please trust me: it simply doesn't work, and the proof -- when there actually are stones -- is easy to obtain. If you really believe it, do it. And then get another ultrasound.
There are, of course, those who push these flushes onto the healthy, onto those with no gallbladder problems at all. Generally those are the ones who have something to sell, and, sad to say, they easily manage to separate the credulous from their cash. Like chiropractic on healthy kids and homeopathy on anyone, it most often does no harm, other than to one's economic well-being, and in the situations wherein it delays needed and actual treatment.
A truism: people who produce the kind of bile that can precipitate crystals will, as long as they have a gallbladder (which is where the crystalization occurs), form gallstones. A corollary: treatments that eliminate stones but retain the gallbladder are generally followed by the return of the stones.
Indeed there are pills that can dissolve gallstones. I've prescribed them, for people who really, really want to try everything to avoid surgery, or for people in whom I've thought the surgery would not be tolerated. The main problems are with side-effects (nausea, cramps, diarrhea typically), and the fact that success depends on the nature of the stones (big ones are unlikely to dissolve, as are ones that contain calcium), as well as the tendency for stones to come back again, eventually. Also, it takes months for the stones to dissolve. But since -- as opposed to flushes -- they may work, such pills are an option, and should be part of the discussion for people facing surgery.
You can also smash gallstones. Twenty years ago, extra-corporeal shockwave lithotripsy (ESWL) got a fair hearing, if for no other reason than it was cool to say the phrase. Results have been predictably disappointing. (My hospital contracted a privately owned, trailer-borne machine to occupy the physicians' parking lot once or twice a month, into which the gallstone-bearing were rolled and pounded. I was told -- by the owners, not the hospital -- I could accompany my patients into the unit and sit there while the technicians did all the aiming and calibrating, and then I could push a button and charge a grand or so. I demurred.) Similarly, you can guide a catheter directly into a gallbladder and irrigate with a form of ether which, in addition to giving you weird breath for a while, has a chance of dissolving stones comparatively instantly. Long-term, the results are as expected. Short-term, there may be the really rare situation in which it could make sense.
Of all the things a person can do to live non-operatively with gallstones, dietary changes make the most sense. Typically, gallbladder attacks happen after eating a fatty meal, so, theoretically, modifying one's diet to avoid fat and any other personal triggers makes sense. Theoretically. In some people it's a very linear relationship: eat fat, have attack. Don't eat fat, don't have attack. But for many, the attacks come in no relation to eating. On the other hand, by far the majority of people with gallstones who have symptoms (NB: not everyone with stones has problems from them. I was among those surgeons who leaned away from operating in the absence of symptoms) don't go on to have the really serious complications that can occur with gallstones. So for the average person, absent risk factors that could make complications more serious were they to occur (diabetes being high on the list), and absent a crystal ball, trying to live without surgery by judicious dietary behavior -- and, for some, trying pills -- is not entirely unsensible. Just, in the name of all that's holy -- or unholy, if you prefer -- don't waste your time, or your money, or your self-respect, on flushes. Really. It's the poster-child, the sine qua non, the Platonic ideal, the Mona Lisa of quack.