Table 2: Current status on preventive approaches to cholesterol GSD.

 

Condition

Approach

Expected outcome (s)

Notes

PRIMARY PREVENTION

 

 

 

General population

Healthy lifestyles

Maintainance of ideal body weight

Weight decrease and maintainance

Regular physical activity

Healthy diet

Vitamin C consumption

Prevention, cure of concomitant metabolic disturbances

 

e.g. dyslipidemia, overweight, obesity, insulin resistance, diabetes, etc.

Obese patients on rapid weight loss

- very low calorie diets

- bariatric surgery

Weight loss of less than 1.5 Kg/week

Decreased biliary saturation with cholesterol

Decreased propensity to cholesterol crystallization

Consider close clinical follow-up

 

Increased amount of dietary fat (at least 7g/day)

Improved gallbladder motility

Controversial effect

 

Oral UDCA (300-1, 200 mg/day)

Decreased biliary saturation with cholesterol

Decreased propensity to cholesterol crystallization

Limited period (decreased risk after body weight stabilization)

 

Fish oil supplementation

Experimental and preliminary data

Increased biliary phospholipids (?)

Effect on intrahepatic cholesterol transport (?)

In particular during very low calorie diets. No effect on cholesterol saturation index [48].

 

Aspirin

Anti inflammatory effect

No indication

 

Prophylactic cholecystectomy (during Roux-en-Y gastric bypass)

 

Not routinely indicated

Patients on long-term therapy with somatostatin or analogues

Oral UDCA (300-1, 200 mg/day)

Decreased biliary saturation with cholesterol

Decreased propensity to cholesterol crystallization

Few prospective studies

Patients with marked transient gallbladder stasis

No indication for medical therapy

Spontaneous disappearance of sludge/small gallstones after restoration of physiological condition

Consider clinical follow-up

- Total parenteral nutrition

Oral UDCA (300-1, 200 mg/day)

Decreased biliary saturation with cholesterol

Decreased propensity to cholesterol crystallization

Controversial indication (spontaneous disappearance of gallstone/sludge after restoration of oral diet).

Consider clinical follow up

- Pregnancy

Healthy lifestyles

Maintainance of nutritional requirement

Sludge, microstones can be transient

Spontaneous disappearance of gallstone/sludge in the postpartum period.

Consider clinical follow up

Patients on hormone therapy

No indication

Lack of controlled trials

Physicians who prescribe hormone replacement therapy should be aware of the increased risk for gallstones. Currently there is no indication for pharmacological or surgical stone prevention during hormone replacement therapy

SECONDARY PREVENTION

 

 

 

- Risk of recurrent gallstones

Oral UDCA (300-1, 200 mg/day)

Limitations: overall costs of chronic treatment and poor compliance. Advisable only in high risk subgroups (not fitting the criteria for subsequent cholecystectomy)

No specific recommendation can be given for the pharmacological prevention of recurrent gallstones

- Risk of recurrent bile duct stones

No indication

 

No specific recommendation can be given for the pharmacological prevention of recurrent gallstones

- Risk of recurrent gallstones, intrahepatic sludge and microlithiasis (low phospholipid-associated cholelithiasis)

Oral UDCA (300-1, 200 mg/day)

 

Prophylactic long term therapy with UDCA to be initiated as early as possible.

 

 

Abbreviations: GSD: gallstone disease, UDCA: ursodeoxycholic acid