For the Love of all things Natural

Tuesday, February 17, 2015

Gallbladder Health

What is the gallbladder?
The gallbladder is a small sac that sits just below your liver on the right side of your upper abdomen.
What does it do?
The main function of the gallbladder is to store bile made by the liver and to eject that bile when fat is detected in the small intestine. Bile is key to breaking down and absorbing fat in the diet. Essentially, without this storage sac you don't eject the full amount of bile ejected with a meal, meaning that the fat cannot be broken down and absorbed as well.

What causes it to have problems?
There are many reasons and forms of gallbladder issues. The biggest concern is usually in regards to forming gallstones, which are balls of components of bile (most often cholesterol) that can irritate and inflame the gallbladder. The bigger concern is when they move out of the gallbladder and into the bile duct where they can completely plug the pipes causing severe backup of bile, which can lead to life-threatening conditions. Some people have gallstones that cause no problems and aren't identified until something causes them to move, which is one of the most common reasons for having a gallbladder removal surgery.

Genes: There is a strong hereditary factor, so if your mom or grandmother had gallbladder issues, you have a higher likelihood of developing gallbladder dis-ease. Many genes have been identified that are associated with gallstone formation and some ethnic groups, such as Native Americans and some Pacific Islanders, have higher rates of gallstones.

The four F's: Female, Fertile, Fat- especially if actively trying to lose weight, and Forty (as in age). This is the classic description of the type of person more prone to gallbladder issues. This is what we learn in the textbook. However, my personal experience has been that the female part is mostly true and more common during fertile years, but the fat and forty is up for debate as I have seen several thin younger women who have had their gallbladders surgically removed. The reason fertility plays into it is due to estrogen/progesterone balance. Many women are what we call estrogen dominant (due to a variety of causes that would be a whole 'nother discussion). Progesterone is the counter balance hormone of estrogen and in women who are estrogen dominant; there is often a relative deficiency in progesterone. Progesterone works on the gallbladder by allowing the sphincter to relax and the bile to be flushed cleanly when it contracts. Without this relaxation there is a perfect stagnation storm brewing.

Diet: There is also a strong dietary component. The standard American diet is often the culprit. As fat is what stimulates the gallbladder to contract in the first place, a lifetime of low fat food can by itself lead to stagnation. Anything that causes stagnation leaves room for sludge to form, and sludge, over time, can turn into stones. Bile contains a large amount of cholesterol and when stagnation leads to stones, cholesterol stones are the most common kind. Conversely, a lifetime diet of eating healthy amounts of fat continually stimulates the gallbladder to contract and keeps the bile from lying stagnant so long as to precipitate stones.

There are also certain foods that have been studied and found to be associated with gallbladder irritation, which in time can cause the walls to swell and the pump to fail. Far and away the most commonly seen food trigger is eggs (up to 95% of patients experience symptoms with eggs). Other common culprits include pork, onions, poultry, dairy, corn, gluten, coffee**, oranges, beans, and nuts.  Eliminating these foods followed by a careful and monitored reintroduction of one at a time can be very helpful in some cases.

**Coffee can trigger gallbladder inflammation in some, but has also been shown to reduce the chances of forming gallstones

Inflammation:  Sugar, always the culprit right? Sugar is a huge player in inflammation in the body and has been implicated in gallbladder dysfunction. The average American eats 130 lbs of refined sugar yearly, is it any wonder that inflammatory based diseases are skyrocketing? Over half a million Americans have their gallbladder removed every year and it is becoming increasingly frequent in young adults and teenagers. Additionally, in the last 50 "fat-phobic" years, healthy fats have often been replaced by starch and sugar in many products. This is an obvious double whammy for gallbladder health.

Additionally, eliminating oils that are high in Omega-6, which is a pro-inflammatory fat, can be very helpful. This includes fats such as canola, peanut, soybean, and all hydrogenated or trans-fats.

So what can I do to avoid gallbladder problems?

Ask your family, particularly female family members, if there is a family history so you can be on your toes. Alternatively, if family history is unavailable a genetic test may show genes associated with gallbladder disease.

Good diet: Eat a whole foods, plant based diet, low in processed foods and high in nutrient dense foods with a good amount of healthy fats (olive oil, coconut oil, avocado, ghee, flax, pasture butter (if dairy isn't one of your triggers), and pasture raised fat in meat). Essentially lowering your inflammatory load can do wonders. However, if your diet is radically different than the one I just described then making the switch gradually can be the best way. I have personally seen several cases where a radical diet change was enough to bring on a gallbladder attack when it is not used to having to contract regularly. Ensuring adequate fiber in the diet is also essential as fiber binds to bile salts lower down in the gut and prevents them from being reabsorbed, forcing your body to make new bile and again lowering the stagnation factor. Good sources of fiber include whole fruits and vegetables along with flax and other seeds.

Love your liver. In many cases of "gallbladder dysfunction", the root of the dysfunction is actually in the composition of the bile produced by the liver, so good liver function can help immensely. Some patients note that even after their gallbladder has been removed, they still feel pain in the same region that follows the same pattern as their gallbladder pain did.  Even with the gallbladder gone, there can still be stagnant bile causing pain in the bile duct coming from the liver.  Eating foods that love the liver such as artichokes, beets, radishes, ginger, turmeric, and milk thistle seeds (delicious roasted!) can be very helpful. Many of these foods are anti-inflammatory, bitter, and full of nutrients and fiber. Also, being mindful of toxins such as alcohol, Tylenol, and many other drugs as these can all have profound effects on the liver and as the liver is the ultimate source of bile, the happier your liver is, the happier your gallbladder will be.

**Beware "liver flushes" that include large amounts of fats as they can trigger acute crisis by causing a stone to move down the duct, causing complete stagnation of the bile which can be life threatening

Identify triggers. As discussed above, many foods are known for the gallbladder irritating properties. My personal culprit was corn. The first time I tried to go gluten free I substituted heavily with corn. Almost immediately I began to get sick with nausea, horrible pain, and elevated bilirubin in my blood. When I cut out corn all of my symptoms vanished! This completely explained a lifetime of stomach aches after movie dates! I realized in hind sight that corn had not agreed with my gut for many years and avoiding it for me has been the key to continued gallbladder wellness.

Bitters. If you come from Swedish ancestry you may have heard of "Swedish bitters." Many cultures have historically taken bitters before or after large, rich meals. Bitters include things like gentian root, wild anise seed, rhubarb, manna, and many others. Often these bitters were infused into alcohol, and many traditional post dinner drinks are bitter based. Bitters are used to stimulate bile flow and contraction of the gallbladder, so adding them in with meals can help the meal digest better and also reduce chances of bile stagnation. Classic food pairings also follow the idea of bitter with fat such as dipping artichoke leaves in butter and pairing cream with coffee. Black coffee is another strong bitter, but don't think that Starbucks Latte counts as a gallbladder friendly food. I'm talking about strong unsweetened coffee.  Sour foods such as vinegar (paired with good fat olive oil?) can also help stimuate healthy digestion. Weren't our ancestors brilliant?

Castor oil packs. This is an old naturopathic home therapy to reduce inflammation in the gut. Essentially you put a dollop of castor oil either onto a flannel cloth or on your upper right abdomen and rub it in (it's about the same viscosity as motor oil), cover it with either plastic or fabric that you don't mind staining, and put a heat pack on it for 20 minutes. Personally, during one gallbladder flare which had lasted several days following some accidental corn contact I did castor oil packs every night for 3 nights. On the third night I felt a strong quiver in my gallbladder region followed by a "plop" sensation. I had complete resolution following.

Mindful eating. This is one of my biggest challenges. As a busy med-school mama I often am eating on the run, standing up, or without much thought of what I'm shoveling in my mouth. This is not good. In order for proper digestion to take place we have to switch our nervous systems away from the sympathetic (think fight and flight) to the parasympathetic (rest and digest). Having a calming food routine such as taking deep breaths or saying grace before meals can help to initiate healthy digestion. Complete chewing of food allows our digestion to work from the top down and also stimulates the gastric juices to do a better job when the food gets down lower. Sometimes simple mindfulness can be enough to break the cycle of chronic indigestion in patients with a lifetime of gut woes.

Smoking.  I know we've all heard a million reasons why smoking is bad for us, but especially if you're prone to gallbladder issues smoking should be a no no.  While studies have been mixed on the effects of smoking before meals, there is good evidence that smoking after meals (which every smoker I've ever known was apt to do) slows refilling of the gallbladder…. Again… stagnation.  Cigarettes also stimulate the sympathetic nervous system, so the ability of the parasympathetic nervous system to  "rest and digest" is subsequently lowered.

Exercise. For all the good that exercise can do you, it can also help the gallbladder! One study found that regular exercise eliminated symptomatic  gallstones in over a third of patients. Like anything else, start slow and work up as extremely rapid weight loss can dump extra cholesterol into the bile and raise the risk of forming stones.

Supplements. There are many supplements which have proven helpful in gallbladder dysfunction. Phosphatidylcholine can help to emulsify bile and lower risk of stones, lecithin can potentially help decrease stone size, Vitamin C which is a cofactor in cholesterol metabolism, fish oil which helps reduce inflammation, and anti-spasmodic herbs such as dioscorea and peppermint for painful spasms. Talk with your local naturopathic doctor to come up with a plan custom tailored to your needs.

What if I've already had my gallbladder removed (a cholecystectomy)?

Most of the above recommendations still apply even after removal of the gallbladder. Immediately after removal fats may cause extreme digestive distress, so adding them back in gradually can be key. Over time your body will adapt and more fats can be incorporated along with the suggestions below.  Eating smaller, more frequent meals can help to maximize the amount of bile that you can still squeeze out and gradually increasing fiber as discussed above can help to promote healthy bowel movements and reduce diarrhea.

The biggest concern long term with removal of the gallbladder is developing fat soluble vitamin deficiencies (such as Vitamin A, E, D, and K). These vitamins have multiple functions in the body and are key in many processes including bone health, immune system, and many other things. There are receptors for vitamin D on virtually every cell in the body, pointing strongly to it's importance. Without a gallbladder, it can be very easy to become too low on these vitamins, but there are things to help!

Bile salts: Many NDs recommend taking supplemental bile salts during a time of gallbladder flare and most importantly in cases where the gallbladder has been removed. Essentially, you are using bile salts from other animals to make up for what your body cannot squeeze out in response to meals. Most commonly used are ox bile salts which can be found in a variety of products with doses ranging from 100-500 mg per capsule. This is something that there is no formula for so experimenting with different doses is key to finding out your range and it will always vary with the fat content of the meal. A good guide is to look at the stool as poor fat absorption and lack of bile will lead to greasy, floating, grey stools (as opposed to healthy solid, formed, brown stool). Bile salts are also often sold in combination with other digestive enzymes such as lipase and amylase which come from the pancreas which also shares the common bile duct. There is some suggestion that long term enzyme supplementation may decrease your natural production of these, however short term they can be very helpful for avoiding malabsorption. A good naturopathic physician can help to guide you in this area.

Vitamins: Due to the concern about developing fat soluble vitamin deficiencies, taking supplemental forms of these vitamins is often advised. Vitamins A, E, D, and K can all be found over the counter, but do your research as there are a lot of shady supplement companies out there. Taking these with meals (with supplemental bile) can help ensure they are absorbed as much as possible. Talk with your ND about recommended doses and forms as this will be an individualized treatment strategy.

Love your liver. The same suggestions given above still apply, but are especially important in cases of gallbladder removal as stones can still form in the bile duct if the underlying dysfunction has not been addressed. People without a gallbladder also have a higher risk of developing fatty liver so being mindful of your liver is crucial to maintain liver function.

If all of this seems overwhelming (it's a lot) I highly encourage you to find a qualified naturopathic doctor near you to help you in your forward gallbladder journey. NDs are licensed in 18 states currently, with more in legislation, but if you don't live in a state that licenses them there are long distance options such as travelling and doing the first visit in office, followed by the rest via telephone. Beware those who claim to be a "naturopath" but don't have an ND behind their name as this indicates that they did not graduate from an accredited naturopathic medical school and for all you know they could have done a 6 month online course and called it good. Seek out the real deal for the best and most evidence based (i.e. there's research to back it up and it's not just wacky quackery) treatment possible. Good luck!

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