Gallbladder Syndrome
Dr Howard Loomis, DC
Gallbladder dysfunction is one of the most common health problems encountered in chiropractic, osteopathic, and medical offices today. Unfortunately, it is also one of the most misunderstood. Right shoulder pain accompanied by flatulent dyspepsia is considered to be the best indicator. Once the presence of gallstones is confirmed the usual medical procedure is to schedule surgical removal of the gallbladder.
More than 600,000 cholecystectomies (removal of the gall bladder) are performed in this country every year despite overwhelming evidence that most are not necessary. Repeated warnings have been printed in medical journals against this practice, but to no avail. Let me share some pertinent information based on clinical studies.
1. Gallstones are extremely common. Their occurrence in women is roughly double their occurrence in men. The occurrence and size of the stones increases with age and depending on the ethnic group being examined, their incidence can range as high as 25% to 44% of the population.
2. Gallstones usually do not cause symptoms. Three major studies involving more than 3,000 patients found that 67% of all confirmed cases of gallstones were asymptomatic (no problems noticed by patient). Other studies put the figure at above 80%.
3. Patients with gallstones who are asymptomatic are likely to remain so. Studies indicate the chance of asymptomatic gallstones becoming symptomatic in the following five years is less than 10%. Not only that, but the rate decreases as time goes by -- to less than one percent after 10 years.
4. The majority of gallstones are found by chance -- even in patients with abdominal pain. Because the use of abdominal ultrasound is increasing, more gallstones are being detected incidentally. Therefore, the opportunity to recommend gallbladder removal is increasing.
5. Cholecystectomy (gall bladder removal) does not always relieve symptoms traditionally thought to be caused by gallstones. Most studies show complete relief of symptoms in 75% to 80% of patients after surgery. However, studies concentrating on the relief of symptoms in those that had symptoms before surgery indicate relief in only about one-half of the cases! The most persistent symptoms remaining after surgery are flatulent dyspepsia and chronic, dull pain in the upper right quadrant.
6. Symptoms should be used as the indication for surgery -- not the accidental finding of gallstones. By symptoms I mean biliary colic which is understood to mean severe "colicky (spasmodic wave-like) pain." Or, constant (cystic duct obstruction) pain lasting up to four hours -- occasionally accompanied by low-grade fever (only 13% of the time), and characteristically followed by a "washed-out" feeling for up to 24 hours. The occurrence of constant pain is much more common (57% to 94%) than the colicky wave-like pain. Oddly enough the pain may be anywhere in the abdomen, including the periumbilical area (the reported home of colicky pain in infants). For example, 30% to 60% of biliary colic cases report pain in the epigastric region (right below the tip of the breast bone). Another 8% to 24% report pain in the lower left quadrant.
7. Don't bet on referred pain to the right scapular area. Radiation of pain outside the abdomen occurs only 60% of the time. The pain can radiate anywhere in the torso, including both flanks, both shoulders and scapula, and the mid-thoracic area (20%).
8. Gallbladder emptying has been shown by ultrasound to be unrelated to the fat content of a meal. In fact, there is no solid proof that biliary attacks are precipitated by eating. In one study, "fatty food" intolerance was more common in the controls than in those patients with confirmed gallstones!
9. Bloating, belching, and flatulence are no more common in patients with gallstones than in the controls without gallstones. Since these symptoms often persist after surgery they cannot be caused by gallstones. Obviously, it is important for your patients to know this.
10. Tenderness in the upper right quadrant is only present during an episode, or when the biliary system is stressed. When patients are between meals or between attacks, abdominal examination is normal. The body only evidences contraction in muscles that share a common innervation with a viscera while that organ is being stressed or challenged beyond its capabilities.
Let me close by saying that I learned years ago to refer to the gallbladder and its functions as the "Biliary System" because so many patients with "gallbladder symptoms" have had their gallbladder removed. They are convinced that it can no longer be at fault since their surgeon told them that the symptoms would be gone after the gallbladder was removed.
(Dr. Loomis welcomes input on the subjects covered in this column. To ask a question, or make a comment, call him at 800-662-2630. Or write: 6421 Enterprise Lane, Madison, WI 53709.)
The gall bladder is a hollow organ that lies directly under and beside the liver. It is connected to the liver and upper portion of the small intestine via a duct system. The gall bladder's purpose is to collect and store bile from the liver then release it at the appropriate time into the small intestine for digestion of a meal. It is a muscular organ, contracting when needed during the first part of digestion. Ingesting especially fatty meals can increase the intensity of the contraction.
Bile, also called gall, is a greenish yellow secretion that is produced in the liver and passed to the gallbladder for concentration, storage, or transport into the first few inches of the small intestine, the duodenum. Its function is to aid in the digestion of fats in the duodenum. Bile is composed of bile acids and salts, cholesterol, pigments, water, and electrolyte chemicals that keep the total solution slightly acidic (with a pH of about 5 to 6). Bile is continually secreted from the cells of the liver into the common bile duct and gallbladder. Once in the gallbladder it is usually concentrated to about 5 times the strength of the original secretion. The amount of bile secreted into the duodenum is controlled by the hormones secretin, gastrin, and cholecystokinin and also by the vagus nerve. About 1,400 millilitres (about 3 pints) of bile (before concentration) are normally produced daily by the liver.
Bile salts and acids can be synthesized from cholesterol or extracted from the bloodstream by the liver. They pass from the liver into the intestine, where they act like detergents to break up fats and reduce the surface area on fat droplets to prepare them for the action of pancreatic and intestinal fat-splitting enzymes. The salts are large, negatively charged ions that are not readily absorbed by the upper region of the small intestine; consequently, they remain in the intestine until most of the fat is digested. In the lower intestine, the salts and acids are absorbed and passed back into the bloodstream until they are once again extracted by the liver; this cycle, from the liver to the intestine and blood and then back to the liver, is called enterohepatic circulation. Some salts and acids are lost during this process; these are replaced in the liver by continual synthesis from cholesterol. The rate of synthesis is directly related to the amount of acids and salts lost. Bile salts do not normally reach the colon; when they do, however, they inhibit the absorption of water and sodium, causing a watery diarrhea. (Bile is more likely to reach the colon if you have no gall bladder).
Bile salts and acids are transported in a fluid that contains water, sodium, chloride, and bicarbonates. This fluid is produced in the liver, and it serves (along with the pancreatic enzymes) to neutralize hydrochloric acid passed from the stomach into the small intestine. Water-insoluble wastes that the liver removes from blood, such as cholesterol, steroids, drugs, and hemoglobin pigments, are carried in the fluid to the colon to be dumped. Hemoglobin pigments are broken down, producing several bile fluid compounds, including bilirubin which is what turns the stools a brown color.
The bile that is stored in the gall bladder contains various products and byproducts of the liver's metabolism. In addition to the enzymes that will help to breakdown fat, there are chemicals, hormones, cholesterol, and heavy metals. These products and byproducts are usually co-joined with various amino acids, minerals and vitamins. This makes the products and byproducts easier to eliminate into the intestines and out of the body.
The gall bladder can sometimes form gall stones from the constituent parts of bile. These stones can range from pea size to golf ball size or larger. In addition to stones reducing size and scope of the gall bladder's function the bile itself can become thickened. This in turn may cause a sludge buildup on the stones themselves. Both of these problems will restrict the storage and flow of bile and reduce the body's ability to digest foods.
There are a number of nutrients that can be utilized to improve gall bladder function. Diets high in fruits, vegetables, and fiber will help by binding bile, bacteria, molds and yeast and increase their elimination. These foods will reduce the amount of bile that is re-sorbed into the blood stream that feeds directly back to the liver. This prevents the liver from becoming toxic. The elimination of trans-fats from the diet and the inclusion of good oils will help the liver handle fat more efficiently.
The vitamins A, B1, B2, B3, B6 and F and iodine will help the bile become less thick. An herbal combination of Collinsonia Root, Spanish Black Radish, red beet root, and Cholacol ® (from Standard Process) will also help to water down the bile.
People suffering from gall bladder disease should follow a temporary low fat-diet to give your gall bladder a rest. The bile from the gall bladder is necessary for proper digestion of fats. When there is no bile or not enough bile is produced by the gall bladder, fat from food cannot be properly digested and makes one feel ill, or bloated, and/or causes diarrhea. If your gall bladder is diseased, a low fat diet reduces stimulation of the organ and allows your gall bladder adequate rest. Though diet cannot shrink existing stones, it can help small ones be excreted into the gut. Eat more starchy foods like bread, cereals and rice if you have gallstone problems. Also add more vegetables and fruits to your diet for fiber. Cut down on refined foods and red meat as this may lead to further complications. If your gall bladder has been removed you are more prone to get colon cancer if you don’t get plenty of fiber in your diet for the rest of your life. When there is no reservoir for the bile that your liver produces constantly, there is a steady drip of bile through your intestines between meals. Without the acidic stomach contents to neutralize the bile it acts as an irritant on your intestines and, over time, greatly increases your chances of colon cancer. But by increasing your dietary fiber this risk is greatly reduced. So, if your gall bladder was removed, eat PLENTY of vegetables, fruits, nuts and beans. A glass of Metamucil every day wouldn’t hurt either. You cannot get too much fiber, but you can get too little.
The bile salts have two main functions: (1) They have a detergent action on the fat particles in your food which breaks them up into smaller, easier to digest, particles. (2) More importantly, bile salts help in the absorption of fatty acids (which make up fats). Without the presence of adequate bile salts in your intestinal tract, up to 40% of the fats in your food are lost in your stools, resulting in fatty acid deficits which, for example, causes hormone imbalances. The extra fats in your stools also increases your chances of diarrhea. Also, when fats are not absorbed, your fat-soluble vitamins are not absorbed which are Vitamins A, D, E and K.
So what does all of this information mean? Number one: hang onto your gall bladder as long as you possibly can. There are ways to eliminate the pain and problems of a problem gall bladder without cutting it out. Number two: if you really have to have your gall bladder removed, get plenty of fiber in your diet (the rest of your life) and supplement your meals with bile salts (the rest of your life) because fats are just as important to your health as proteins and carbohydrates.