Biliary Dyskinesia: definition

What Are Kidney Stones?

[dropcap]K idney stones, also called renal calculi, are abnormal hard formations in the kidneys that are composed mainly of calcium oxalate, also uric acid, and cystine.

Q: How big are kidney stones?

A: Stones can vary in size from microscopic crystals to several centimeters in diameter.

Some stones that are able to enter a ureter can cause excruciating pain while small stones can pass out with urine unnoticeed. A ureter is a tube that connects a kidney to the bladder for the purpose of removing urine. There are two ureters, one for each kidney.

What Are Kidney Stones In Celiac Disease and/or Gluten Sensitivity?

• Relationship between kidney stones and celiac disease. Renal calculi are an associated disorder in celiac disease and an atypical presenting feature of celiac disease.
• Relationship between kidney stones and malabsorption of fat. Urinary calculus formation is a result of the abnormal increased absorption of oxalate from food caused by malabsorption of fat (steatorrhea).¹
• Relationship between kidney stones and children with celiac disease. A study investigating the risk of kidney stone formation (nephrolithiasis) in children demonstrated that, in contrast to adults, increased urinary excretion of oxalate was not detectable in children presenting with celiac disease. Therefore, the risk of nephrolithiasis appears not to be increased compared to healthy children. The observed hypocalciuria (low calcium in urine)  probably further decreases the tendency to form kidney stones.²

How Prevalent Are Kidney Stones In Celiac Disease and/or Gluten Sensitivity?

Prevalence  of kidney stones in celiac disease is not established, but the association is shown by case reports.³

What Are The Symptoms Of Kidney Stones?

Renal calculi are marked by various pains that can be excruciating when passing stones, although many calculi are asymptomatic, or with any of these symptoms:

• Obstruction.
• Bleeding.
• Chills.
• Fever.
• Genital pain.
• Nausea.
• Vomiting.
• Abdominal distention.

How Do Kidney Stones Develop In Celiac Disease and/or Gluten Sensitivity?

Renal calculi that are composed of calcium and oxalate develop from malabsorption of fats in the small intestine in celiac disease. The mechanism, called enteric hyperoxaluria (EHO), is a common cause of hyperoxaluria (abnormally high level of oxalate present in urine) by which oxalate combines with calcium to form calcium oxalate kidney stones.⁴

The fact to remember is that calcium wants to bind oxalate.  The problem is that binding is supposed to happen in the bowel (enteric), whereas in celiac disease it happens in the kidney, forming stones. Here are the steps:

• In health, following digestion of a meal, dietary calcium combines with oxalate that is present in the bowel and thereafter travels out of the body with the next movement. This chemical reaction normally limits unwanted oxalate absorption into the bloodstream.
• However, in EHO excess free fatty acids in the colon that result from fat malabsorption in the small intestine, actively compete with oxalate for calcium binding, so that fat binds calcium (fat+calcium) instead of calcium binding oxalate (calcium+oxalate). This leads to an increased availability of oxalate for absorption (solubility theory).  Unbound oxalate is left free to be absorbed in the colon, which is made more permeable to unabsorbed bile salt and fatty acids (permeability theory).
• In other words, the fat bound calcium gets excreted in feces while the oxalates are left unbound, and hence free, to be absorbed into the body where they are not wanted.
• Oxalates in the body are excreted by the kidneys in the making of urine as the only way left to get rid of it. This situation results in high oxalate concentration in urine produced, called hyperoxaluria. Concentrated oxalate freely combines with calcium in urine to form stones.
• The identification and correction of hyperoxaluria is important to prevent recurrent calculi and oxalate nephrosis, especially because patients with urolithiasis (stone forming condition) are often advised to eat a low-calcium diet. Paradoxically, this promotes oxaluria, increasing the risk of further kidney stones in hyperoxaluric patients.⁵

Do Kidney Stones Respond To Gluten-Free Diet?

Yes. Celiac disease-related calculi formation improves gradually on a gluten free diet.⁶

6 Steps To Improve Kidney Stones In Celiac Disease and/or Gluten Sensitivity:

• [dropcap]1 Remove the Trigger. Maintain a Strict, Nutritious Gluten Free Diet:

[box type=”shadow” ]Treatment. This condition responds to the complete elimination of gluten, which is the required treatment that improves both kidney stones and gut health.

• Gut health is the foundation to restore ALL health. Restored health will enable you to maintain a strict gluten free diet, just as other life tasks will be easier.
• A strict gluten free diet means removing 100% of wheat, barley, rye and oats from the diet.
• Cutting out bread and other obvious sources of gluten is not good enough for recovery. Even 1/8th teaspoon of flour or bread crumb is enough to sustain the inflammation that is damaging your small intestine, causing increased permeability (leaky gut) and allowing undigested gluten to enter your body where it can damage structures and function, and instigate immune inflammatory responses.

Correct Your Individual Nutritional Needs.

• Eat foods that can replenish missing nutrients. Find them under NUTRIENT DEFICIENCIES.
• Take nutritional supplements as needed. Find them under NUTRIENT DEFICIENCIES.

Recovery. You should begin to feel better within a week and notice more energy as inflammation subsides and the  absorbing cells that make up the surface lining of your small intestine are better able to function.

• Intestinal lining cells are replaced every 5 days. The healing process is like sunburn where the damaged surface layer of skin sloughs off and is replaced with new normal cells.
• Leaky gut normally resolves in two month after starting a gluten free diet and brings about a big improvement in health. Improvement in intestinal permeability precedes morphometric recovery (cell appearance and structure) of the small intestine in celiac disease.⁷
• The intestinal lining may take up to a year to heal.[/box]

• [dropcap]2  Reduce Inflammation. Foods to Eat and Foods Not to Eat:

Because gluten is inflammatory, eliminate OTHER inflammatory foods from your diet to reduce an additive effect to gluten. At the same time, try to eat foods that reduce inflammation (anti-inflammatory).

Important: To reduce oxalic acid in the diet as a promoter of kidney stones, decrease the amount of plant sources that are high in oxalate such as soy, peanuts, nuts (almond, cashews), beets, leafy vegetables (spinach, red beet greens, and Swiss chard), berries (strawberries, blackberrries, raspberries, blueberries) figs, plums and chocolate.

Lesser amounts are in grapes, parsley. collard greens and leeks.

[box type=”shadow” ]Here Are Major Inflammatory Food Types That Reduce Healing:

• Damaging Foods. In susceptible persons, includes corn, dairy (cow), and soy. Lactose, the sugar in any animal milk disrupts intestinal permeability causing leaky gut.⁸
• Allergenic Foods. Includes foods that trigger the immune sytem to produce IgE antibodies. Allergy testing is the usual way to discover these offending foods.
• Shelf Stable Processed Foods. Includes any that contain additives and preservatives. Look for them on the nutrition label of the box or package. Additives and preservatives also disrupt intestinal permeability causing leaky gut.⁸
• Fats. Limit deep fried foods, trans-fats, saturated fats (animal fat/butter), and EXCESSIVE omega-6 fatty acid oils like corn oil. Rancid fats, sodium caprate (a medium chain fat), and sucrose monester fatty acid (a food grade surfactant) induce significant disruption of the intestinal barrier that causes leaky gut.⁸.
• Excessive Refined White Flours (bran layer removed). Includes products made from them such as cookies, bread, cakes, pies. Bran contains the vitamins and minerals that metabolize grains and slows the otherwise rapid entry of sugar from their digestion into the bloodstream. Also disrupt intestinal permeability causing leaky gut.⁸
• Refined Sugars.  Includes white sugar, corn fructose and high fructose corn syrup.
• Certain Spices. Includes paprika and cayenne pepper which disrupt intestinal permeability causing leaky gut.⁸
• Alcohol and Caffeine. Disrupt intestinal permeability causing leaky gut.⁸[/box]

[box type=”shadow” ]Here Are Important Anti-Inflammatory Food Types to Promote Health:

• Fruits. Contain ample amounts of vitamins, minerals and phytochemicals which are naturally occuring components in plants that detoxify toxins, carcinogens (reducing the risk by 50%) and mutagens.
• Non-Starchy Vegetables. Support intestinal integrity and provide ample amounts of vitamins, minerals and phytochemicals. Includes green leafy vegetables such as lettuce and kale, also onion, broccoli, garlic, and others.
• High Quality Complex Carbohydrates. Provide vitamins, minerals, and fiber while boosting serotonin levels to help you relax and feel calm. Includes whole grains, legumes, and root vegetables such as carrots, parsnips, sweet potatoes, turnips, red beets, and others.
• Antioxidants. Protect the body from inflammatory oxidant molecules that continually occur and help us handle stress and reduce irritability. Includes vitamin C-containing foods such as lemon, grapefruit, apricot, Brussels sprouts and strawberries, and others. Also, includes vitamin E-containing foods such as nuts, seeds, avocado, olive oil, and others. Cocoa is good, too.
• Omega-3 Fatty Acids. Balance opposing omega-6 fatty acids and bad fats. Fish sources includes tuna, salmon, cod, and others. Plants sources include flax, chia seeds, canola oil, and others.
• Probiotics. Supply normal microbes needed for colon health and health of the body such as these fermented foods: yogurt, kefir, and unpasteurized apple cider vinegar.
• Prebiotics/ High Fiber Foods.  Food with fiber keeps our population of colonic microbes healthy.
• Protective Herbs and Spices.  See below #6 below for examples.[/box]

• [dropcap]3  Information Sheet You Can Take to Your Doctor or Other Health Professional:

Click here.

• [dropcap]4  Manage Your Medications Safely:

[box type=”shadow” ]

Certain medications that bind fat in the small  intestine in order to prevent absorption into the body unintentionally allow increased absorption of oxalates that in turn promote formation of calcium oxalate kidney stones.  Ask your doctor or pharmacist about this possible adverse effect if you are taking any of the drugs listed below. Do not stop prescribed medications without supervision.

 This is not a complete listing.

CHOLESTEROL DRUGS that bind fat.

• Colestid® and Questran® also deplete Vitamin A, Vitamin B12, Vitamin D, Vitamin E, Vitamin K, Beta-carotene, Folic Acid, Iron.

WEIGHT LOSS DRUGS THAT BIND FAT also interfere with absorption of some nutrients.

• Zenicol (Orlistat®) depletes Vitamin A, Vitamin D, Vitamin E, Vitamin K, Beta-carotene.

[/box]

• [dropcap]5 Nutritional Supplements To Help Correct Deficiencies:

[box type=”shadow” ]

The type and quantity of nutritional supplements that may be needed depend on which nutrients are deficient.

• Multivitamin/mineral combination once a day is useful to improve overall nutrient levels. This is a safe dose, but always check with your doctor to avoid interactions with medications.which limits their absorption
• Calcium is recommended to bind oxalates in the gut.

Storage Note: Store container tightly sealed, away from heat, moisture and direct light to avoid loss of potency. That is, in a safe kitchen cabinet – not in the bathroom or on the kitchen table.[/box]

• [dropcap]6 Manage Natural Remedies: 

[box type=”shadow” ]Hydration:

• Eight glasses of water are recommended per day unless there is a contraindication such as kidney or heart disease. The Institute of Medicine recommends approximately 2.7 liters (91 ounces) of total water, from all beverages and foods, each day for women and 3.7 liters (125 ounces) daily of total water for men.
• If you are thirsty, drink water. Add fresh, squeezed lemon to water. Lemon is anti-inflammatory, alkalizing and provides vitamin C.
• Hydration Test: Urine should be pale yellow. Fingertips should be plump, without pruning but this may not be reliable when fingers are swollen with edema. Lips should be plump, without puckering. The feeling of thirst can be unreliable.
• What is wrong with soda, coffee, tea, and alcohol? These drinks are dehydrating, increase acid, and deplete nutrients.[/box]

[box type=”shadow” ]Carminatives. The following  anti-inflammatory plant sources called carminitives help heal the digestive tract. They also tone the digestive muscles which improves peristalsis, thus aiding in the expulsion of gas from the stomach and intestine to relieve digestive colic and gastric discomfort.

Carminative Food Remedies:

• Carrot is also a cleansing digestive tonic.
• Cabbage also stimulates and improves digestion and is also a liver decongestant.
• Lettuce also stimulates and improves digestion and is also an alterative, meaning it improves the function of organs involved with the digestion and excretion of waste products to bring about a gradual change.
• Potatoes are antispasmodic (due to atropine like properties) and a liver remedy.

Carminative Herb Remedies:

• Sage is also a digestive, astringent, bile stimulant and energy tonic that heals the mucosa.  Drink as tea or use in cooking.
• Chamomile, lemon balm, and fennel, (as a tea) also help relieve nervous tension.
• Rosemary as a tea and in cooking also is a nervous system tonic for stress and fatigue, bile stimulant, and can relieve headaches and indigestion.
• Thyme is also soothing remedy useful for stimulating digestion of rich, fatty foods.

Carminative Spice Remedies:

• Cloves are also antispasmodic.
• Nutmeg is also useful for indigestion.
• Ginger.[/box]

[box type=”shadow” ]Exercise Helps:

Exercise improves circulation and rids the body of toxins.

• Walking is aerobic exercise that reconditions the whole body to improve stamina. Read more about Exercise and Fitness.
• Weight training builds muscle. Read more about Exercise and Fitness.
• Stretching improves flexibilty. Read more about Exercise and Fitness.

Note: Exercise is important, but the amount and type of exercise undertaken depends on your health. Your first priority is to heal. [/box]

What Do Medical Research Studies Tell About Renal Calculi In Celiac Disease and/or Gluten Sensitivity?

RESEARCH STUDY SUMMARIES

“Analysis of urinary parameters as risk factors for nephrolithiasis in children with celiac disease.” This study investigating urinary excretion of electrolytes in children with celiac disease to assess the risk of nephrolithiasis (kidney stone formation) demonstrated that in contrast to adults, increased urinary excretion of oxalate was not detectable in children presenting with celiac disease. Therefore, the risk of nephrolithiasis appears not to be increased compared to healthy children. The observed hypocalciuria probably further decreases the tendency to form kidney stones.

The study population consisted of 115 children 1 to 16 years old (mean 5 years) with positive serological tests for celiac disease (anti-endomysium and anti-tissue transglutaminase antibodies) referred to us for jejunal biopsy to confirm the diagnosis. Assessment was requested because patients presented with poor growth, anemia, gastrointestinal disorders or a family history of celiac disease. After obtaining informed consent we performed urine tests to measure urinary variables and blood tests to exclude metabolic disorders and evaluate renal function.

All patients had a biopsy confirmed diagnosis of celiac disease. Oxaluria was normal in all children studied. However, levels of urinary calcium were decreased in patients with celiac disease and were inversely associated with disease severity.²

CASE REPORT SUMMARIES

“Renal calculus: a unique presentation of coeliac disease.” This case report of a 49 year old man with renal colic and left renal calculus describes celiac disease presenting with a urinary calculus in the absence of GI symptoms. Investigations showed hyperoxaluria for which there was no dietary or drug cause. The presence of hyperoxaluria with hypercalciuria prompted malabsorption studies. Celiac disease was diagnosed, and 3 months on a gluten free diet led to normalization of urinary oxalate excretion, resolution of small bowel pathology and disappearance of endomyseal antibodies.

Enteric hyperoxaluria (EHO) is a common cause of hyperoxaluria and calcium urolithiasis. In health, dietary calcium is complexed with luminal oxalate, limiting its absorption. In EHO, the excess free fatty acids, from fat malabsorption, compete with oxalate for calcium binding, leading to an increased availability of oxalate for absorption (solubility theory). This oxalate is absorbed in the colon, which is made more permeable to unabsorbed bile salt and fatty acids (permeability theory). The identification and correction of hyperoxaluria is important to prevent recurrent calculi and oxalate nephrosis, especially as patients with urolithiasis are often empirically advised to eat a low-calcium diet. Paradoxically, this promotes oxaluria, increasing the risk of further kidney stones in hyperoxaluric patients.⁹

“Urolithiasis and enteric hyperoxaluria in a child with steatorrhea.” This case report describes a 10 year old girl with steatorrhea, hyperoxaluria, and a renal calculus in a single functioning kidney presenting with celiac disease. Successful management of the steatorrhea corrected both the chronic diarrhea and hyperoxaluria. Pediatricians caring for children with malabsorptive conditions should be aware of the risk of urinary calculus formation as a result of increased dietary oxalate absorption.¹⁰

Sources:

1. Jones DP, Stapleton FB, Whitington G, Noe HN. Urolithiasis and enteric hyperoxaluria in a child with steatorrhea. Clinical Pediatrics. Jun 1987;26(6):304-6. [↩]
2. Saccomani MD, Pizzini C, Piacentini GL, Boner AL, Peroni DG. Analysis of urinary parameters as risk factors for nephrolithiasis in children with celiac disease. J Urol. 2012 Aug;188(2):566-70. doi: 10.1016/j.juro.2012.04.019 [↩] [↩]
3. Gama R, Schweitzer FAW. Renal calculus: a unique presentation of coeliac disease. BJU International. 1999;84:528-9. [↩]
4. Gama R, Schweitzer FAW. Renal calculus: a unique presentation of coeliac disease. BJU International. 1999;84:528-9. [↩]
5. Gama R, Schweitzer FAW. Renal calculus: a unique presentation of coeliac disease. BJU International. 1999;84:528-9. [↩]
6. Gama R, Schweitzer FAW. Renal calculus: a unique presentation of coeliac disease. BJU International. 1999;84:528-9. [↩]
7. Cummins AG, Thompson FM, Butler RN, et al. Improvement in intestinal permeability precedes morphometric recovery of the small intestine in coeliac disease. Clinical Science. Apr 2001;100(4):379-86. [↩]
8. Farhadi A, Banan A, Fields J, Keshavarzian A. Intestinal barrier: an interface between health and disease. Journal of Gastroenterology and Hepatology. 2003;18:479-91. [↩] [↩] [↩] [↩] [↩] [↩]
9. Gama R, Schweitzer FAW. Renal calculus: a unique presentation of coeliac disease. BJU International. 1999;84:528-9. [↩]
10. Jones DP, Stapleton FB, Whitington G, Noe HN. Urolithiasis and enteric hyperoxaluria in a child with steatorrhea. Clinical Pediatrics. Jun 1987;26(6):304-6. [↩]