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Gallstones are NOT a cholesterol problem

Most gallstones are made of cholesterol….

So, putting two and two together, if you want to “make” a gallstone, you need “lots of cholesterol”.

And this is precisely what happens….

Bile supersaturated with cholesterol

When bile is collected and analysed, someone with gallstone disease, will have bile that is supersaturated with cholesterol.   Doctors quantify this, using the cholesterol saturation index or CSI for short.

So if your CSI is high………..

BE WARNED, you ARE at risk of a gallstone.

Stop that “high” cholesterol

Since you MUST BE secreting, TOO MUCH cholesterol, into the bile, to mitigate your risk, you must do what you can to lower cholesterol levels.

Don’t eat it.  Don’t make it. Excrete it.

Well that is the current thinking……but it’s “wrong” !

This is what a team of researchers from the Karolinska Institute discovered, when they changed the way, the cholesterol levels, in the bile, were reported.

Bile is a mixture

The three big ingredients are

• Cholesterol
• Bile acids
• Phospholipids

When the CSI is calculated, the three ingredients are expressed as a percentage (mol % value) of each other.

The cholesterol percentage

So  “normal” bile, would typically have….

Cholesterol levels around 5 %.

And when someone has lithogenic bile i.e. bile that favors gallstone formation, the amount of cholesterol is definitely up, typically……….

The cholesterol levels  DOUBLE, to around 10 %.

Of course, since the calculation is based on total number of molecules,  if there are more cholesterol molecules,  there must be less bile acid and/or phospholipid molecules, present.

But that does not mean there is actually more cholesterol………

The concentration of cholesterol

To get the full picture, we need to know exactly how much cholesterol  there is.

So this is what our team did.

Using historical data, from 232 gall bladder removal surgeries, which took place between 1981 and 1998, the team, calculated the actual amount of cholesterol, in the bile samples.

NOTE :  There were 145 patients with cholesterol gallstones (111 women, 34 men) and 87 without gallstones (73 women, 14 males).

 Cholesterol levels unchanged

When they did this calculation, they found, the cholesterol levels in the bile of  people with gallstones, was not higher.

In fact,cholesterol levels, were exactly the same.

Accordingly, the idea, that their liver was pumping excess cholesterol into their gallbladder, causing the problem, was not correct.

So what was the problem ?

Bile acids were missing

When they measured the absolute levels, the thing that stood out, was the bile acids were “missing”, i.e.

People with gallstones had a bile acid deficiency

NOT a cholesterol excess.

Really ?  The team decided to probe other sets of published data, to see if the pattern persisted.

It did……

Here is a table, summarizing their findings.  When there is a red box, the value is increased, when there is a blue box, the value is decreased.  All but one of the 13 studies analysed, showed bile acids were  significantly lower.

Too much cholesterol is a red herring

The real problem, in gallstone disease, is a bile acid deficiency  !

So the plan of attack,  if you want to mitigate the risk of  a gallstone,  needs to shift from cholesterol lowering, to correcting the bile acid deficiency.

Where have the bile acids gone ?

There are two possibilities………

• The production of bile acids, by the liver, is compromised.

 

• The bile acids that are being produced, are not being recycled adequately.

The Karolinska researchers, think option two, is the problem, for most people.   Future studies will shed more light on the issue.

But the take home message from this study……………

Obsessing about your cholesterol levels, is unlikely to  make much difference to your risk of gallbladder disease.

Further reading

 

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