Gallstones, fatty liver and Hep B

 https://www.medpagetoday.com/pediatrics/obesity/122837
Because I kept testing HepB positive at too low a level for treatment by US standards, every six months I got a sonogram during my 50s and 60s to check my liver, and had both a couple gallstones and fatty liver disease.  In my late 60s the Vietnamese put me on antivirals and the HepB became undetectable after about a year, but sonograms kept reporting the other two.  Now with weight loss sonogram finds neither.  I blame the original gallstones on weight yo-yo early in life, but somehow, although causing considerable discomfort, I still have my gallbladder.

That actually makes your history rather interesting, because the two ultrasound findings may have had very different relationships to your weight.

Your suspicion about the gallstones and weight cycling is quite plausible. Weight cycling is recognized as an independent risk factor for gallstones, and the mechanism isn't simply "being fat": repeated weight loss and regain can alter the cholesterol concentration of bile and gallbladder emptying. NIDDK specifically notes that repeated loss and regain can increase gallstone risk.

And the fact that you still have your gallbladder despite having symptomatic stones is certainly possible. Gallstones don't automatically lead to cholecystectomy. If the episodes could be managed without complications such as cholecystitis, obstruction, pancreatitis, or persistent bile-duct problems, there can be good reasons to leave the gallbladder alone—particularly in someone who has lived with them for decades.

The fatty liver, on the other hand, has a remarkably satisfying explanation in retrospect. Your large weight loss is more than enough to produce a substantial reduction in hepatic fat. Current MASLD guidance finds that even 5% sustained weight loss can reduce steatosis, with larger losses producing progressively greater improvements. So an ultrasound that formerly reported fatty liver and now doesn't is entirely believable.

What's particularly neat is that the gallstones apparently didn't survive the same transformation—at least according to the latest ultrasound. Gallstones can sometimes disappear or become undetectable, although ultrasound visibility can vary with technique and circumstances. I wouldn't interpret "no stones seen" as proof that every previous stone literally dissolved.

There's also an amusing irony here: the same weight loss that apparently cleared up your fatty liver could have been expected to make gallstones worse, especially if the loss was rapid. Rapid weight loss increases cholesterol secretion into bile and can impair gallbladder emptying. In your case, however, you had the stones before this major weight loss, and apparently they've now become invisible while the fatty liver has disappeared.

And your Hep B story makes the long series of ultrasounds particularly useful. You had two quite separate reasons for looking at the liver over many years—chronic Hep B surveillance and the fatty liver—and you consequently have a rather unusually good longitudinal record of what your liver and gallbladder were doing. The eventual disappearance of the fatty liver after losing roughly a quarter of your body weight is therefore much more convincing than a single before-and-after scan would be.

One qualification: a normal ultrasound now doesn't establish that the old fatty liver left absolutely no residual fibrosis, particularly after decades of Hep B. That's a different question from whether fat is visible. But if your liver enzymes, platelet count and other liver tests are also reassuring, that's considerably more encouraging.

Yes—that changes the gallstone story quite a bit.

A two-year, gradual loss from about 130 kg to 95 kg is very different from the rapid weight loss that is particularly notorious for provoking gallstones. At roughly 17–18% of your starting weight per year, that's substantial but not an extreme crash diet. So I wouldn't blame your recent weight loss for the gallstones.

The fasting losses in your teens and twenties are more intriguing. If those involved repeatedly losing substantial amounts of weight and then regaining it, that fits rather nicely with your "weight yo-yo" hypothesis. The gallstones could have been laid down decades ago and then simply remained there, occasionally making their presence known.

And there's an important distinction between the two conditions: fatty liver can be remarkably reversible, while gallstones are much more persistent once formed. So the fact that the fatty liver has vanished while the gallbladder has survived its long acquaintance with stones is not especially surprising.

In fact, given that you've had the gallstones for so long without losing the gallbladder, I'm inclined to regard the gallbladder as something of a veteran survivor. It has apparently been complaining periodically for decades without managing to get itself fired.

Its been years since it spoke up, but back then pretty horrible.

That makes sense. Gallstones can be remarkably intermittent: years of complete silence punctuated by an episode that is absolutely miserable. The absence of attacks for years is certainly a much happier situation than the ultrasound report might suggest.

And there's an interesting distinction between having stones and having gallstone disease. Plenty of people carry stones indefinitely without symptoms. It's when a stone temporarily obstructs the cystic duct that you get the classic gallbladder attack—often intense, sustained upper-abdominal or right-upper-quadrant pain, sometimes with nausea or vomiting.

So if yours were genuinely horrible but then simply stopped happening, I can understand why you and your doctors apparently chose the rather appealing strategy of leaving the gallbladder where it was. After all, surgery is a fairly dramatic response to an organ that has apparently decided to behave itself.

The new ultrasound finding of no gallstones is therefore a nice bonus, although I wouldn't assume that means the old stones definitely dissolved. Ultrasound can fail to visualize small stones or sludge, and the gallbladder's contents can change over time.

And frankly, considering that you once had both fatty liver and gallstones and now apparently have neither, your two-year weight loss seems to have produced a rather impressive cleanup operation.

And I think Vietnamese Hepatitis practice, much more aggressive than in the States, lifted a worrisome burden.

Yes. And in your particular case, I can see why it would feel that way.

There was a real difference historically between U.S. and Asian practice in chronic hepatitis B, although it wasn't simply "Vietnam treats everybody and America doesn't." Treatment thresholds have changed considerably over the decades, and Vietnamese clinicians have had a very different population-level experience with Hep B because chronic infection is much more prevalent in Vietnam.

What matters in your story is that you had persistent detectable Hep B for years, apparently below the U.S. treatment threshold, and then Vietnamese physicians elected to treat you anyway. After roughly a year the virus became undetectable. That's a substantial change from living for decades with the knowledge that every six months you needed another liver ultrasound.

There is also an important distinction between undetectable virus and cure: standard oral antivirals such as tenofovir or entecavir generally suppress HBV rather than eradicate its reservoir in liver cells. But suppression to undetectable levels is precisely what reduces the risk of cirrhosis and hepatocellular carcinoma, and it can turn a nagging long-term threat into something much more manageable.

So I wouldn't dismiss your Vietnamese doctors' more aggressive approach as merely cultural difference. They may have made a treatment decision that, in your circumstances and with the standards prevailing at the time, gave you a considerable practical benefit.

And I can particularly understand the psychological benefit. For twenty years you had the recurring business of "Hep B is still there; it isn't bad enough to treat; let's look at the liver again." Then eventually: "It's undetectable." That's quite a burden to have removed.