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CCM Student Research

Laurence Bridgeland


Cholelithiasis (Gallstones) and Biliary Cholic
Treatment with TCM.



Cholelithiais (chole = gall; lith = stone), commonly called gallstones, is a frequent health problem and one of the major reasons for abdominal surgery, responsible for over half a million cholecystectomies (gallbladder removals) in the U.S. each year. Surgery is performed to prevent several potential problems: severe abdominal pain due to movement of a stone into the bile duct; potential blockage of bile flow causing liver and pancreatic damage; and inflammation of the gallbladder (cholecystitis), causing fever, pain, and digestive disturbance. There is plentiful evidence to show that treatment of Cholelithiais by the methods of Traditional (and modern) Chinese Medicine can be very effective in removing the causes and symptoms of this complaint. I will look at research into three different approaches used for this problem in Chinese medicine, Traditional Acupuncture, Chinese Herbal Medicine and Auricular Acupuncture, all of which have been proved effective.

DESCRIPTION
Cholesterol or pigmented stones formed and contained in the gallbladder. Cholelithiasis is usually incidentally discovered by routine x-ray study, surgery, or autopsy. Virtually all gallstones are formed within the gallbladder, an organ that normally functions to store bile excreted from the liver.
Bile is a solution composed of water, bile salts, lecithin, cholesterol and some other small solutes. Changes in the relative concentration of these components may cause precipitation from solution and formation of a nidus, or nest, around which gallstones are formed.

These stones may be as small as a grain of sand, or they may become as large as an inch in diameter, depending on how much time has elapsed from their initial formation. Depending on the main substance that initiated their formation (for instance, cholesterol), they may be yellow or otherwise pigmented in color.

Three types of gallstones exist. They are (1) cholesterol (most common), (2) pigment, and (3) mixed stones. The formation of each type is caused by the crystallization of bile into stones. The physiology that determines the substrate of the stone, however, is different. 

Cholesterol stones are the most common type of stone. Normally, bile acids, lecithin, and phospholipids help to maintain cholesterol as a solute. When bile is supersaturated with cholesterol, it crystallizes and forms a nidus for stone formation. Calcium and pigment also may be incorporated in the stone. Impaired gallbladder motility, bile stasis, and bile content predispose people to the formation of gallstones. 

Gallbladder sludge is crystallization within bile without stone formation. Sludge may be a step in the formation of stones or it may occur independently. In one study, sludge resolved in 71% of cases, became stones in 9%, and developed acalculous cholecystitis in 7%. 

Pigment stones, which comprise 15% of gallstones, are formed by the crystallization of calcium bilirubinate. Diseases that lead to increased destruction of red blood cells (hemolysis), abnormal metabolism of hemoglobin (cirrhosis), or infections (including parasitic) predispose people to pigment stones. Black stones and brown stones exist. Black stones are found in people with hemolytic disorders. Brown stones are found in the intrahepatic or extrahepatic duct. They are associated with infection in the gallbladder and commonly are found in people of Asian descent.

Cholelithiasis is a common health problem worldwide, affecting approximately 1 out of 1,000 people. The prevalence is greater in women, Native Americans, and people over the age of 40. In general, risk factors include increasing age, ethnic and hereditary factors, female gender, obesity, diabetes, liver cirrhosis, long-term intravenous nutrition (total parenteral nutrition) and certain operations for peptic ulcers.

Causes and Symptoms

SYMPTOMS Symptoms usually manifest after a stone of sufficient size (usually > 8mm) blocks the cystic duct, which drains the gallbladder, or the common bile duct, which is the main duct draining into the duodenum. 

Collectively, these ducts form part of the biliary system. A stone blocking the opening from the gallbladder or cystic duct usually produces symptoms of biliary colic, which is right upper quadrant abdominal pain that feels like cramping. If the stone does not pass into the duodenum, but continues to block the cystic duct, acute cholecystitis results.

If the common bile duct is blocked for a substantial period of time, certain bacteria may find their way up behind the stone and grow in the stagnant bile producing symptoms of cholangitis. Cholangitis is a serious condition and usually requires hospitalization for treatment. Furthermore, the continued blockage of normal bile flow may produce jaundice.

In addition, stones blocking the lower end of the common bile duct where it enters the duodenum may obstruct secretion from the pancreas producing pancreatitis. This condition can also be serious and may require hospitalization. In general, pay attention to the following symptoms:

o Abdominal pain 
    ¤ in the right upper quadrant or in the middle of the upper abdomen
    ¤ may be recurrent
    ¤ sharp or cramping or dull
    ¤ may radiate to the back or below the right shoulder blade
    ¤ made worse by fatty or greasy foods
    ¤ occurs within minutes following meals
o Jaundice 
o Fever 

1*

Pregnancy or the use of birth control pills slow down gallbladder activity and increase the risk of gallstones, as do diabetes, pancreatitis, and celiac disease. This is due to an individual's higher levels of cholesterol, insulin, or estrogen from oral contraceptives. Other factors that may encourage gallstone formation are:

o infection
o anemia
o obesity
o intestinal disorders
o coronary artery disease
o multiple pregnancies
o a high-fat, low-fiber diet
o smoking
o heavy drinking
o rapid weight loss

Diagnosis:

When gallstones are suspected, blood tests for liver enzyme levels are often given. The levels are usually elevated when the stone cannot pass through the cystic duct or bile duct. Test results, taken together with symptom history (see above) and a physical exam, are simple and relatively inexpensive for diagnosing the presence of gallstones. However, ultrasound is the method of choice for a definite diagnosis. It has a high degree of accuracy, except in diagnosing cholecystitis (a stone in the cystic duct). Cholescintigraphy is an alternative method of diagnosis, in which radioactive dye is injected and photographed as it passes through the biliary system.

Treatment.
Allopathic Treatment

Watchful Waiting

One-third of all patients with gallstones never experience a second attack. For this reason, many doctors advise an attitude of "wait and see" after the first episode. Changing the diet or following a sensible weight loss plan may be the only treatments required. A person having only occasional mild gallstone attacks may be able to manage them by using non-prescription forms of acetaminophen, such as Tylenol or Anacin. A doctor should be notified if pain intensifies or lasts for more than three hours; if the fever rises above 101ºF (38.3ºC); or if the skin or whites of the eyes have a yellowish cast.

Surgery

Surgical removal of the gallbladder, called cholecystectomy, is the most common conventional treatment for recurrent or worsening gallstone attacks. However, surgery is unecessary in most cases where the gallstones remain without symptoms. Laparoscopic cholecystectomy is the technique most widely used. It has mostly replaced traditional open surgery because of a shorter recovery time, decreased pain, and reduced scarring. However, the open surgery procedure is still used in about 5% of cases because of various complications.

Nonsurgical Therapy

If surgery is considered inappropriate, gallstones can be dissolved in 30-40% of patients by taking bile acids in tablet form. Dissolution of gallstones by this method may take many months or years depending on the size. Unfortunately, though, recurrence of stones is common after cessation of the medication.

Lithotripsy uses high-frequency sound waves directed through the skin to break up the stones. The process can be combined with the use of bile acid tablets. However, lithotripsy requires special equipment and is not always readily available.

Direct cholangiography can be used to remove gallstones by contact dissolution. The procedure is used to insert a catheter to inject medication into the gallbladder. Stones are often dissolved within a few hours by this method.

Expected Results

Forty percent of all patients with gallstones have "silent gallstones" that do not require treatment. If symptoms develop, however, medical intervention may become necessary. Gallstone problems requiring treatment may also develop infections that require antibiotics. In rare instances, severe inflammation can cause the gall-bladder to burst, causing a potentially fatal situation. The gallbladder is not an organ that is required to retain health. It can be successfully removed, with no recurrence of stones. Fat digestion, however, becomes more difficult after surgery, since the gallbladder is no longer there to store and release bile as needed.

Prevention

It is easier, in general, to prevent gallstones than to reverse the process. The best way to prevent gallstones is to minimize risk factors. Since gallstones seem to develop more often in people who are obese, eating a balanced diet, exercising, and losing weight may help keep gallstones from forming. In addition, a diet high in dietary fiber and low in fats, especially saturated fats, is recommended. Processed foods should be replaced by complex carbohydrates, such as whole grains.

Increased intake of fluids will dilute the bile and inhibit gallstone formation. Six to eight glasses of water should be consumed daily, along with plenty of herbal teas and diluted juices.

Recent studies indicate that consumption of about two tablespoons of olive oil per day, which can be mixed with food, helps reduce cholesterol levels in the bloodstream and the gallbladder. However, large amounts of olive oil, taken as a so-called liver flush, should be avoided. This method can stress the gallbladder and lead to an emergency situation

2*
TCM Perspective

Associated Chinese Syndromes:

Stagnation in the Gallbladder with Phlegm Heat (yellow slimy tongue coating)

Damp Heat in Liver and Gallbladder (Yellow Slimy Tongue Coating)

Liver Blood and Qi Stagnation (purplish with purple spots)

Possible Symptoms:

Pulse may be Rapid, Tense, Taught or Slippery (particularly Liver)

Bitter Taste in Mouth, 
Hypochondriac Pain
Sharp Stabbing Pain (right side under ribs often radiating to the back of the left shoulder)
Nausea
Headaches (migrane)
Blurred Vision
Red Swollen Eyes
Yellowing of Sclera
Exhaustion
Bloating/Distension
Jaundice
Fever and Chills
Wind
Itchy Skin (Head and Face)
Irritability
Depression
Clay Coloured Stools
Heart Burn

3*


TCM Treatment:

Treatments aimed specifically at the removal of Gallbladder Stones using herbs were first described in the post war period. The decoctions mainly consisted of herbs from three categories;

o regulating qi to improve the flow of bile and vitalizing blood to alleviate abdominal aching; 
o dispelling heat and dampness that are the main physiological causes of the qi stagnation; and 
o removing stagnation by purgation.

Herbs

Most commonly used herbs for this condition;

Classical Formula (4)

Jin Qian Cao/lysimachia (100 grams), Mu Xiang/saussurea (25 grams), Chi-Shi/Red Halloysite (25 grams), hu-chang (100 grams), Da Huang/rhubarb (25 grams), Zhi Zi/gardenia/ (20 grams),Yan Hu Suo/ corydalis (25 grams).

According to laboratory animal studies, these decoctions relaxed Oddi's sphincter (this is mainly attributed to the action of rhubarb) and promoted duodenal peristalsis (most strongly affected by mirabilitum). It is believed that the expulsion of stones came about primarily from increasing the flow of bile (herbs with this property are called cholegogues and this action is accomplished mainly by the herbs that clear damp-heat) while relaxing the sphincter that controls the output of bile, thus allowing stones to exist. This method of therapy relies on heavy dosage decoctions with quick action, usually taken over a period of just one week.

Although most patients so treated would excrete some stones, the effectiveness of this method was somewhat limited in terms of the proportion of patients who could become either free of stones or have very few residual stones, so new methods were developed, mainly during the 1970's. The new methods involved a "general attack therapy" aimed at an even stronger and more rapid stone expulsion. 
The method had three steps:

1. Herbs were used to stimulate the liver's production and excretion of bile to the gallbladder; 
2. Herbs and drugs were then given to contract Oddi's sphincter in order to get a temporary retention of bile; 
3. Herbs and acupuncture were administered to relax the sphincter and drain the bile.

According to the information from a review of the medical literature through 1985, the largest stones that appear capable of being passed are on the order of one centimeter in diameter. This size is probably a reasonable upper limit for anyone considering a non-surgical procedure and may represent the maximum dilation of the duct. The gentler stone-expelling methods to be used by Western practitioners who are not working in a hospital setting may not be able to expel stones of quite this size, since the strong build up of bile pressure and the sudden relaxation of the sphincter are unlikely to be accomplished. Therefore, somewhat smaller than 1 cm stones may be the largest one can expel and patients seeking to expel larger stones should be cautioned about the lower chance of success.
It is therefore beneficial to try and shrink the stones as much as possible before attempting to expel them.


Stone Shrinking Herbs
The ability to reduce the size of stones using herbs or other methods is not an established fact. However, certain Chinese herbs have been selected as stone-dissolving herbs. There is one traditional-style formula that is reputed to dissolve stones, called San Jin Tang, or the Decoction of Three Golds. The three golds (jin = gold) are jin qian cao, hai jin sha, and ji nei jin. The formula was devised at the Shuguang Hospital of the Shanghai College of Traditional Chinese Medicine.

In general, these herbs are said to be sweet, cooling, and able to promote urination. They are mainly used to treat damp-heat syndromes that involve urinary retention, and they are reputed to dispel urinary stones. The herbs are mild in nature and often used in high dosage (e.g., 15-60 grams of the dried herb per day in decoction, and double that dose for the fresh herb, with some recommendations of up to 250 grams fresh herb per day). San Jin Tang was originally made with Guang Jinqiancao (Desmodium). The species of jinqiancao obtained in the West will depend on the market source relied on by the herb supplier. Among the most commonly supplied items in the West are Desmodium and Glechoma; However, the widely-used common name for the herb is lysimachia and the most frequently referenced material in Chinese texts, as well as the species listed in the Pharmacopoeia of the PRC, is Lysimachia christinae. 

Jinqiancao, one of the three golds, has been incorporated into numerous modern Chinese therapies for both liver and gallbladder diseases, including most formulas for treating gallstones and cholecystitis. In the Advanced Textbook of Traditional Chinese Medicine and Pharmacology (6), lysimachia is said to be useful for stone expulsion, including gallstones: "For its effects in expelling stones, this drug is frequently used to treat hepatic, cholecystic, and urinary stones. To achieve the desired results, it is usually used in large dosage and administered for a long time." The same text mentions that jineijin "removes stones and is indicated for urinary calculus and biliary calculus." On the other hand, haijinsha is only mentioned in that text as a treatment for urinary stones. Whether or not jinqiancao actually dissolves stones, it is known to stimulate bile secretion; further, haijinsha has been used clinically in some formulas for treating gallstones (7) and was mentioned as one of the more commonly used herbs for that purpose in a recent review article examining 40 different gallstone formulas (8)



Haijinsha is a very slippery material, that looks like yellowish sea sand (hai = sea, jin = gold, sha = sand); it is the spores of a fern, Lygodium japonicum, commonly called lygodium (see Figure 9). The slippery quality is associated with the ability to dissolve stones. The material is described as sweet and cold in nature, and it is diuretic. Like jinqiancao, this herb is mainly used for damp-heat syndromes with urinary retention and it is said to help remove urinary stones. The usual daily dosage is 6-12 grams in decoction, or 2-3 grams in powder form.

Jineijin is the inner lining of the gizzard of the chicken (ji = chicken; nei = inside), commonly called gallus (the genus name of the chicken). The chicken gizzard is capable of reducing hard food masses to small pieces; it is included in some herb formulas because it is thought to resolve masses. The material has a sweet taste, a neutral property, and is used mainly to eliminate food stagnation. The usual dosage is 6-12 grams and it may be used in decoction or a smaller amount, 1.5 to 3 grams, taken as a powder

Herbs for damp-heat of the liver/gallbladder can be added to this basic formula. The herbs suitable for this purpose generally have a bitter taste, a cold property, and a dispersing or purging action; for example, one can administer Chai Hu/bupleurum, Huang Qin/scute, Yin Chen Hao/capillaris, and Da Huang/rhubarb. One can also add to the therapy herbs to disperse liver-qi stagnation and accumulation, such as Mu Xiang/saussurea, Hou Po/magnolia bark, Chi-shi, and Da Fu Pi/areca peel.
There are two main uses for a stone-dissolving formula: one is to attempt to shrink stones prior to expelling them, by reducing the outer layer that has recently been deposited and is most susceptible to re-suspension into the bile fluid, and the other is to prevent stones from forming or enlarging in persons who have a history of developing stones. The stone dissolving therapies are given for at least 2-3 months.


STONE EXPULSION WITH CHINESE HERBS

The herbs used in the strong stone expelling decoctions, as described earlier, have been formulated into easy to use tableted patent formulas that are given at much lower dosage. For example, Lidan Pian (Gallbladder Normalizing Tablets) and Lidan Paishi Pian (pai = expel; shi = stones) are readily available patent remedies recommended for cholecystitis and cholelithiasis. These tablets have a milder action than the corresponding decoctions and may be used in a complete program of gallstone therapy for treating smaller sized stones or mild gallbladder inflammation.
Lidan Pian contains lysimachia, scute, saussurea, capillaris, bupleurum, isatis leaf, lonicera, and rhubarb. Isatis leaf and lonicera are included as anti-infection herbs for cholecystitis.

Lidan Paishi Pian contains lysimachia, saussurea, capillaris, rhubarb, areca peel, magnolia bark, chih-shih, curcuma, and mirabilitum. The amount of mirabilitum present is relatively small and does not cause a strong purgative effect.

The latter formula is based on the traditional Da Chengqi Tang (Major Rhubarb Combination) of the Shanghan Lun, comprised of rhubarb, mirabilitum, magnolia bark, and chih-shih, which had been formulated as a purgative therapy for severe abdominal stagnation. This formula's action has been extensively investigated (see Appendix 1). The modification to make Lidan Paishi addresses stagnation of qi and blood in the abdomen. A decoction of the Lidan Paishi formula was tested in patients who were monitored for gallbladder function (9). The treatment, using 10 grams of each ingredient, increased the frequency of bile excretion and did so to an extent greater than that accomplished by Da Chengqi Tang, indicating a valuable contribution for the added herbs. Lidan Paishi Tablets are produced by several Chinese companies. One company lists the following ingredients, with proportions used in manufacturing: lysimachia (250 grams), capillaris (250 grams), scute (75 grams), saussurea (75 grams), curcuma (75 grams), and rhubarb (125 grams); this formula listing leaves out areca peel, magnolia bark, chih-shih, and mirabilitum.

Treatment time with stone expelling formulas is usually several months, though excretion of gallstones may begin to occur within days. In one clinical report (10), a formula called Dandao Paishi Tang (dan = bile or gallbladder; dao = movement) was administered twice daily. The formula included lysimachia, chih-ko, saussurea, scute, lonicera, gardenia, peony, red peony, atractylodes, gallus, rhubarb, and glauber's salt (xuangmingfen; sodium sulfate); in addition, mirabilitum was given separately, 40 ml each time, twice daily, at 33% solution. Treatment time ranged from one month to 10 months (a few cases continued for longer). 

A formula called Paishi Tang (Stone Expulsion Decoction) was reported to be moderately effective for treating residual stones in the biliary tract after gallbladder surgery (11). The decoction contains lysimachia, capillaris, bupleurum, cyperus, melia, chih-ko, saussurea, citrus, and rhubarb (mirabilitum was given separately, 30-40 ml of 50% solution, once or twice daily). Complete removal of stones was claimed for just over half of the patients treated (12)

Various Clinical Studies have been carried out in China to research the use of Chinese Herbs for this condition with very positive results. The following extracts are a few examples.


Wei DQ.
Dept. of Surgery, Affiliated Hospital of Hubei College of TCM, Wuhan.
There were 41 postoperative patients of cholelithiasis with manifestation of Qi-Yin deficiency, had treated with Yiqi Yangyin Prescription. The regimens was 2 weeks as a course, thereafter bile specimens were taken through T tube drainage, and biochemical analysis were performed in order to determine the composition in consequence of the comparison of the treated patients with the control groups. There were 19 patients of bile pigment stone in whom 10 treated with the prescription and 9 were served as control. The results showed that the total bilirubin, unconjugated bilirubin, the concentration of calcium ion and the activity of beta-glucuronidase were markedly decreased as compared to those in the control group (P less than 0.05), the concentration of bile acid markedly increased than that in the control group (P less than 0.05). There were 22 patients of cholesterol stone, 11 treated with the prescription and 11 were served as control group. The results were the same as in bile pigment stone group except decreased in conjugated bilirubin (P less than 0.05), and the unconjugated bilirubin were remained unchanged (P greater than 0.05) as compared to the control group. The ratio of unconjugated bilirubin to total bilirubin and the ratio of bile acid to bilirubin were markedly decreased as compared to those in the control group. The above observation showed promptly that Yiqi-Yangyin Prescription gave a promise influence on lithogenic bile of cholelithiasitic patients, and also investigated the mechanism of the prescription used for deficiency patients with biliary troubles.

13* Zhang GS, Li SZ.
This paper reports the clinical treatment of 120 patients with cholelithiasis for 2 months with Jinquiancao Gao. The Results showed that the clinical effective rate was 92.5%, among which 29 cases were cured, 42 cases markedly improved and 40 cases ineffective. Animal experiments showed that this medicine can prevent gallstone growth. The gallstone growth rate was 78.5% in the control group and 42.8% in the experimental group (P less than 0.05). The mechanism of the decrease of gallstone growth rate suggests that the said medicine could inhibit the activity of beta-Glucuronidase in the bile, diminish the non-combined bilirubin and prevent the bile from forming bilirubin stones. The result of cultured liver cells in vitro showed that the cholesterol synthesis was markedly inhibited by Jinqiancao Gao. Thus the cholesterol concentration of bile was decreased. These effects in turn prevented the bile from forming cholesterol stones.

14* Vanherb September 28, 02 With Removing Stone Capsule Dr. Tang Qiani, Dr. Liu Zujun and Dr. Wu Songhe, et al. ( The First Affiliated Hospital of Guangxi College of Traditional Chinese Medicine, Nanning, China. ) treated 68 cases of cholelithiasis after operation as treatment group which was given orally during and 3 months after operation ( 4 ~ 6 capsules each time, thrice daily ), and control group ( 68 cases ) was treated by routine treatment.

Results: in treatment group, 48 cases were cured, 12 cases effective, 7 cases improved and 1 case ineffective, the tatol effective rate being 98.5%; in control group, 36 cases were cured, 20 cases effective, 5 cases improved and 7 cases ineffective, the total effective rate being 89.7%. The difference between two groups showed markedly significant ( P < 0.05 ). The residual stone rate and recurrence rate within one year was 29.4% ( 20 / 68 ) in treatment group and 47.1% ( 32 / 68 ) in control group ( P< 0.05 ).

Ingredients of Removing Stone Capsule: Radix Rhizoma Rhei ( Da Huang ), Radix Glycyrrhizae ( Gan Cao ), Radix Astragali ( Huang Qi ), Endothelium Corneum Gigeriae Galli ( Ji Nei Jin ), Natrii Sulfas ( Mang Xiao ), Fructus Aurantii ( Zhi Qiao ), Herba Lycopi ( Ze Lan ), etc. (incomplete)

Dr. Tang et al suggest Removing Stone Capsule can decrease residual stone rate and recurrence rate of cholelitiasis after operation. 

15*

CCM Formula (Clear Heat and Damp from Liver and Gallbladder + Dissolve Stones) 

Jin Qian Cao (Dissolves Stones)
Che Qian Zi (Damp/Heat)
Yu Jin (Contracts Gall Bladder and Expels Stones)
Ji Nei Jin/Jing Jin (Dissolves Stones and Cholesterol in GB)
Zhi Zi (Inflammation and Dissolves Cholesterol in GB)
Yan Hu Suo (Pain Killer)
Chuan Lian Zi (Pain Killer)
Xiang Fu (Regulates Hormones + Hypo Pain)
Chuan Mu Tong (Regulates Hormones Clear Damp/Heat)
Chai Hu (Conduct to Liver)
Yin Chen Hao (Liver Damp/Heat, Jaundice)
Nn Ling Gee (cant) (Pain)
Long Dan Cao (Liver/Gb Damp/Heat, Jaundice)
Huang Qin (Damp/Heat)
Ze Xie (Damp/Heat)
Sheng Di Huang (Clear Blood Heat, Improve Bile)
Dang Gui (Regulate Blood, Improve Bile)
Gan Cao (Balance and Detoxify)

Acupuncture:
Much research has been carried out on the use of Acupuncture to help in the treatment of Cholelithiasis with very positive results;

The most commonly used points for the treatment of this condition are:
qimen (LV-14) and riyue (GB-24), juque (CV-14).(local points to relieve pain and stagnation) yanglingquan (GB-34), qiuxu (GB-40), and zusanli (ST-36) neiguan (PC-6) and zhigou (TB-6), (dannangxue), just below GB-34 (about 1-2 cun lower). Qimen and riyue are the front mu points of the liver and gallbladder meridians respectively; zhigou and yanglingquan can relieve hypochondriac pain, while zusanli helps strengthen the spleen and disperse dampness-heat. Dannangxue is feature point for Gallbladder disharmony

The following are examples of extracts of research into this subject using Traditional, Electro and Auricular Acupuncture with impressive results.
Zhang Y, Zhang L, Yang H, Zhang H, Zhu Y.

Da Tong Railway Hospital.
Since 1985, the authors began to use electric shock on otoacupoints of varying electric resistance for the treatment of cholelithiasis. The instrument used was the Channel Therapeutic Instrument made in China, and the otoacupoints of varying electric resistance were Sympathetic, Pancreas--Gall Bladder, Stomach, Liver, Sanjiao, Endocrine, and Ermigen. In the 1291 cases treated, the total effective rate was 99.69%, the rate of calculus excretion was 91.32%, and the rate of total excretion was 19.51%. The composition of the calculi was cholesterol crystals (31.25%), bilirubin crystals (28.17%), and mixed crystals (40.58%). The largest calculus excreted was an extrahepatic biliary duct calculus of 1.75 cm X 1.5 cm; the largest number of calculi excreted was 152 cholecystic stones 0.3 cm X 0.5 cm in size. In 100 random cases, the biliary system was shown to manifest vigorous dilations and constrictions under Ultrasonic B-scan when the relevant otoacupoints were stimulated with electric shock. Among the 78 control cases, no cholecystic stones were excreted, inspite of the Magnesium Sulfate, Folium Cassiae and fatty meals administered to many cases with constipation.

16*

Ma C, Yang W.
Nanjing University of TCM, Institute of Acupuncture.
In this study, the 38 golden hamsters, male and female each half, were divided into four groups: the control and control treating groups to feed normal foods; cholelithiasis model and model treating groups to feed special diet, which made high fat, high cholesterol and high carbohydrates to cause the cholelithiasis model of hamsters. After 30 day, the natural formation rate of gallstone rose to 50% (contral group), while model group, the formation rate was 100%. On the 30th day, the treatment was carried out. The control treating group and model treating group were acupunctured at Yanglingquan(G 34) and Qimen(Liv 14) through Riyue(G 24) on the right side of body respectively by electrotherapy. The period of treatment was total 7 days, once everyday and 10 min every once. The results showed: (1) In control treating group, the natural formation rate of gallstone of normal hamsters was dropped from 50% to 10%, the number of gall-tones was reduced markedly(P < 0.05) and number of huge gallstones was dropped to zero(P < 0.01). (2) In the cholelithiasis model treating group, the treatment of electrotherapy could significantly reduced the formation rate of cholelithiasis, the number of gallstones and the huge gall-stones(P < 0.05 or P < 0.01). Also, content of the cholesterol in plasma and bile were reduced, but the contents of the cholic acid secreted from the liver were obviously increased in the model hamsters. It was significant difference to compared with model group(P all < 0.05). (3) The electrotherapy increased the rhythmic actions and frequency of Oddi's sphincter electromyogram markedly(P < 0.05, P < 0.01) as well as secretion of hepatic bile(P < 0.05, P < 0.01). The effects of electrotherapy could continued 30 to 40 minutes. The results suggest that some points to acupuncture with electrotherapy can reduce the contents of cholesterol in plasma and bile, and increase the volumes of secretion of cholic acid, thus inhibit the crystallization of cholesterol from bile. At the sometime, the electrotherapy causes the rhythmic contractions of Oddi's sphincter and increase the secretion of bile, so the gallstones are discharged on its own initiative. Therefore the cholelithiasis is cured by acupuncture.

Xuemei C, Jiaping T, Ling W.

Acupuncture Department of Shenzhen Municipal TCM Hospital, Guangdong 518033, China.
Thirty-six cases of cholelithiasis were treated by acupuncture at the Back-Shu and Front-Mu points plus oral decoction. The total effective rate was 97.2%, and the cured plus markedly effective rate was 83.3%, which were much better than those of 83.3% and 52.8% in the control group of 36 cases treated with oral decoction alone. The statistical differences between the two groups were respectively P < 0.05 and P < 0.

[The preventing and treating effects of electro-acupuncture on cholelithiasis in golden hamster]

[Article in Chinese] 

Ma C, Yang W.

Nanjing University of TCM, Institute of Acupuncture.
In this study, the 38 golden hamsters, male and female each half, were divided into four groups: the control and control treating groups to feed normal foods; cholelithiasis model and model treating groups to feed special diet, which made high fat, high cholesterol and high carbohydrates to cause the cholelithiasis model of hamsters. After 30 day, the natural formation rate of gallstone rose to 50% (contral group), while model group, the formation rate was 100%. On the 30th day, the treatment was carried out. The control treating group and model treating group were acupunctured at Yanglingquan(G 34) and Qimen(Liv 14) through Riyue(G 24) on the right side of body respectively by electrotherapy. The period of treatment was total 7 days, once everyday and 10 min every once. The results showed: (1) In control treating group, the natural formation rate of gallstone of normal hamsters was dropped from 50% to 10%, the number of gall-tones was reduced markedly(P < 0.05) and number of huge gallstones was dropped to zero(P < 0.01). (2) In the cholelithiasis model treating group, the treatment of electrotherapy could significantly reduced the formation rate of cholelithiasis, the number of gallstones and the huge gall-stones(P < 0.05 or P < 0.01). Also, content of the cholesterol in plasma and bile were reduced, but the contents of the cholic acid secreted from the liver were obviously increased in the model hamsters. It was significant difference to compared with model group(P all < 0.05). (3) The electrotherapy increased the rhythmic actions and frequency of Oddi's sphincter electromyogram markedly(P < 0.05, P < 0.01) as well as secretion of hepatic bile(P < 0.05, P < 0.01). The effects of electrotherapy could continued 30 to 40 minutes. The results suggest that some points to acupuncture with electrotherapy can reduce the contents of cholesterol in plasma and bile, and increase the volumes of secretion of cholic acid, thus inhibit the crystallization of cholesterol from bile. At the sometime, the electrotherapy causes the rhythmic contractions of Oddi's sphincter and increase the secretion of bile, so the gallstones are discharged on its own initiative. Therefore the cholelithiasis is cured by acupuncture.


17* 

CCM Formula
Yin System- K3, Sp 6, 9(Reduce) Clear Digestive Heat and Damp. Ease Abdominal Pain and Distension
Yang System -St 36, Liv 3, Gb 41,40, 34, Bl 60(Reduce) Clear Heat and Stagnation from Gall Bladder and Liver
Extra pt ½" Below Gb 34 Gall Bladder Pain
CV 12, 17 (reduce + moxa) Relieve abdominal Food Stagnation and Pain
Hua To Points (1/2 " beside midline) T5, 6, 9, 10, L2 (Reduce + Moxa all except T 9, 10)
Regulate Heart, Liver, Gall bladder, Intestines and Kidneys.
Governing Vessel - T 5, 6, 9, 10, L2 (Reduce + Moxa except T9,10)
Clear Liver and Gall Bladder Heat and Damp
Lr 14- Ease Stagnant Liver Qi and Intercostal Pain
Gb 24- Promote Gall bladder, Ease Intercostal Pain
Cv 16- Unbind Chest and Costal Region, Contract Gall Bladder

Traditional Technique:
L1, T12, 10, 9, 7 (1 ½ "Beside Midline) (Reduce) Clear Digestive Heat and Damp Stagnation

Bl 15 Heart Shu- (Reinforce + moxa) Strengthen Heart and Blood
Bl 16 Governing Shu- (Reinforce +moxa) Strengthen Circulation
Bl 20 Spleen Shu- (Reinforce + moxa) 
Extra Spleen pt 1 ½ " Beside Bl 20 Strengthen Spleen, Blood Production
Bl 23 Kidney Shu + 1 ½ " Beside - (Reinforce + moxa) Open and Regulate Water Passages
Bl 25- Large Intestine Shu- Strengthen LI
Bl 27- Small Intestine Shu- Strengthen SI

Tw 5, H 7, Li 4 (Reduce) Clear Digestive Heat
LI 11- (Reduce) Clear Digestive Heat 
St 25- Relieve Mid Abdominal Pain, Ease Food Stagnation
St 28- Relieve Mid Abdominal Pain, Ease Food Stagnation
St 29- Relieve Mid Abdominal Pain, Ease Food Stagnation
St 37- Regulate Intestines Ease Food Stagnation
St 44- Ease Abdomen, Reduce Food Stagnation
Sp 15- Relieve Mid Abdominal Pain, Ease Food Qi Stagnation

PROPOSAL FOR COMPREHENSIVE GALLSTONE THERAPY
A patient presenting with gallstone reduction or elimination as the objective of treatment should be provided with a substantial number of therapeutic approaches to be used in combination. 

These include:

1. A diet and exercise program that emphasizes a low fat, high fiber diet and regular daily exercise. For obese patients, a carefully monitored diet with appropriate caloric controls should have a goal of gradual weight loss of not more than 2 pounds per week on average. A digestive enzyme preparation that includes ox bile and lipase may be used to help treat symptoms of poor fat digestion. 

2. A regular meal schedule that encourages the gallbladder to fill completely between meals. This means minimizing snacking (which is an approach contrary to some dietary recommendations for managing eating disorders and some other health problems). 

3. Daily consumption of stone dissolving substances, including the "three golds" and, if possible, bile salts. 

4. Consumption of moderate amounts of coffee (with or without caffeine) and/or other herbs that promote bile flow (mainly herbs that treat qi stagnation and damp-heat). 

5. Acupuncture therapy to regulate circulation of qi, purge the gallbladder, and alleviate pain in the gallbladder region (see Appendix 2). 

6. A gallstone purging therapy to eliminate stones that have a diameter of less than 1 cm, to be taken over a period of several days. This therapy would include rhubarb and mirabilitum.


The dietary program is no different than that widely recommended for maintaining health and normal body weight, such as following the U.S.D.A. food pyramid recommendations or the modified food pyramid for a high flavonoid diet (see: The role of dietary and herbal flavonoids in gastro-intestinal health). The exercise program is also no different than that generally recommended, which involves a daily minimum of 20-30 minutes of moderate exercise (e.g., fast walking), with more vigorous exercise for those who are physically capable. The dosage of stone-dissolving substances should be relatively high, corresponding to about 50-60 grams per day in decoction, or about 10-12 grams per day in dried extract form. As with the treatment using bile salts, stone-dissolving therapies may require as much as six months continual treatment. The gallstone flushing therapy, relying on purgative herbs, may be accompanied by a high fat meal to stimulate gallbladder emptying (some Western practitioners use the so-called "liver flush" which is actually a gallbladder purge, comprised of a large dose of olive oil moderated by lemon juice).

4*


Conclusion:
In conclusion it can be seen from the research evidence that Chinese Medicine treatments can be very effective in the treatment of Cholelithiasis and its related symptoms. Both Herbal Medicine and Acupuncture have showed good results but the combination of both is most effective. There is no one formula in either Herbs or Acupuncture that is most effective but there is a consensus on the causes and approaches needed to affect a positive recovery. As with all treatments in TCM the formula must be specific to the individual and it is therefore very difficult to provide repeated clinical "proof" of one particular formula or approach.

Nutritional Support:
Nutritional
Acidophilus; Soothe digestion
Taurine, Strengthen Gb
Methionine, Strengthen Gb,
Lecithin, Emulsify Cholesterol
Vitamin C & E, Fight Inflammation
Magnesium

Herbal Homoeopathic
Milk Thistle
Golden Seal
Dandelion
Artichoke
Quebra Pedra, Break Stones
Cleavers, Break Stones
Chelidonium,
Toxicity and Inflammation
Calc Flor and Silica,
Symptomatic relief


RESOURCES & REFERENCES:

1* Herbchina2000.com

2* Books

The Editors of Time-Life Books. The Medical Advisor: The Complete Guide to Alternative and Conventional Treatments. Alexandria, VA: Time-Life, Inc., 1996.

Gottlieb, Bill, ed. New Choices in Natural Healing. Emmaus, PA: Rodale Press, Inc., 1995.

Murray, Michael, N.D., and Joseph Pizzorno. Encyclopedia of Natural Medicine. Rocklin, CA: Prima Publishing, 1991.

Shaw, Michael, ed. Everything You Need to Know About Diseases. Springhouse, PA: Springhouse Corporation, 1995.

Periodicals
"Exercise Prevents Gallstone Disease." Journal Watch

Organizations
National Digestive Diseases Clearinghouse (NDDIC). 2 Information Way, Bethesda, MD 20892-3570.http://www.niddk.nih.gov/health/digest/nddic.htm.

National Institute of Diabetes and Digestive and Kidney Disorders of the National Institutes of Health. Bethesda, MD 20892. http://www.niddk.nih/gov/.

Other Gallbladder Problems. http://www.sleh.com/fact-d04-gall.php.
http://www.thriveonline.com/health/Library/illsymp/illness229.php.

WebMD/Lycos. "How Are Gallstones and Gallbladder Disease Diagnosed?" 
http://webmd.lycos.com/content/dmk/dmk_article_3961803.

3* A C E Acupuncture Expert

4* Journal of Traditional Chinese Medicine, in a 1986 article: Advances in the treatment of cholelithiasis by expulsion of the gallstones 

5* Diagnosis in Chinese Medicine. Giovanni Maciocia. Isbn 0-4430-6448-2 Chinese Acupuncture and Moxibustion. ISBN. 7-119-01758-6

6*State Administration of Traditional Chinese Medicine, Advanced Textbook on Traditional Chinese Medicine and Pharmacology, 1995-6 New World Press, Beijing.

7*Hson-Mou Chang and Paul Pui-Hay But (eds.), Pharmacology and Applications of Chinese Materia Medica, 1986 World Scientific, Singapore.

8*Pan Tianfu, A review of treatment of cholelithiasis, Journal of the Shandong College of Traditional Chinese Medicine 1994; 198(3): 203-208.

9*Deng Xuejia, et al., Video-choangiographic study of the effect of Li Dan Pai Shi Tang on biliary dynamics in 130 cases, Chinese Journal of Integrated Traditional and Western Medicine

10*Chen Ying, Treatment of 67 cases of choelithiasis by integrated Chinese and Western medicine, Chinese Traditional Patent Medicine 1989; 11(10): 24-25.

11*Zhang Shiguo, Treatment of post-operational biliary tract residual cholelithiasis by integrated Chinese and Western medicine, Sichuan Journal of Traditional Chinese Medicine 1986; 4(1): 32-33.

12*Deng Xuejia, et al., Video-choangiographic study of the effect of Li Dan Pai Shi Tang on biliary dynamics in 130 cases, Chinese Journal of Integrated Traditional and Western Medicine 1985; 6(5): 338-339.

13*Wei DQ.Dept. of Surgery, Affiliated Hospital of Hubei College of TCM, Wuhan.
PMID: 2208433 [PubMed - indexed for MEDLINE

14*Zhang GS, Li SZ. PMID: 2791156 [PubMed - indexed for MEDLINE

15* New journal of traditional chinese medicine vol.34 no.6, June, 2002 )

16* PMID: 1861515 [PubMed - indexed for MEDLINE

17*Ma C, Yang W. Nanjing University of TCM, Institute of Acupuncture
PMID: 9388323 [PubMed - indexed for MEDLINE

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