Archive for month: March, 2016

This is the outline of the summary of gallbladder disease that I prepared for our Functional Medicine Discussion Group meeting on 3/24/2016. It is intended primarily for Functional Medicine doctors and practitioners.

GALLBLADDER DISEASE

What is Gallbladder Disease?  Essentially we are talking about gallstones and the inflammation of the gallbladder and the symptoms that result from this.  For our (Functional Medicine) purposes, we need to know what causes gallstones and what can be done to prevent them or to remove them or break them up, if possible.

Gallstones affect 10-15% of the adult US population and ~20-25 million Americans have or will have gallstones. There has been a 20% increase in the last 30 years.

Only 20% of those with gallstones develop significant symptoms and the main medical treatment is gall bladder removal—cholecystectomy—and more than 1,000,000 surgeries are performed per year in the US.

Risk Factors for Gallstones

1. Female
2. Ethnicity
3. North American Indians—women 64%/ men 30% (Pima Indian women 100%)
4. Mexican Americans have increased risk
5. Pregnancy
6. Female hormones (HRT, oral contraceptives)
7. Obesity
8. Rapid Weight loss
9. IBD
10. IBS
11. Sickle cell
12. Liver Disease
13. Metabolic Syndrome/Dyslipidemia
    1. High Triglycerides/Low HDL increased risk
    2. High Homocysteine increased risk
    3. Fibrates increase risk since they inhibit cholesterol 7 alpha hydroxylase, which leads to increased cholesterol excretion into the bile

Drugs That Increase Risk

1. HRT, birth control
2. Fibrates
3. Thiazide diuretics ?
4. Ceftriaxone
5. Octreotide (for carcinoid cancer)
6. Hepatic artery infusion chemo
7. Erythromcyin and ampicillin
8. Cyclosporin
9. Dapsone (leprosy)
10. Narcotics
11. Anticholinergics
12. Proton pump inhibitors (reduce gallbladder motility)

Lifestyle Factors that Increase Risk

1. Saturate fats
2. Trans fats
3. Refined sugar
4. Legumes ?  unlikely
5. Niacin ?  unlikely

Lifestyle Factors That Reduce Risk

1. Omega 3 fats
2. Omega 6 fats
3. Vegetarian
4. Increased Fiber
5. Coffee (could promote gallbladder contractions)
6. Alcohol
7. Nuts
8. Vitamin C
9. Calcium
10. Lecithin
11. Statins reduce liver production of cholesterol (as does red yeast rice)
12. Plant sterols

Gallstone Development

When patients present in the ER, like my wife a few weeks ago with acute pancreatitis because a stone has blocked her common bile duct and a gallbladder filled with large stones, there is not much that functional medicine can do.  The key for us is how we can intervene before patients get to this point either before stones form or perhaps when the stones are small and few.  Gallstones develop slowly over time and the formation is preceded by biliary sludge, which consists of calcium bilirubinate and cholesterol microcrystals. This more likely happens if:

1. There is supersaturation of cholesterol in the bile
2. There is increased bilirubin in the bile
3. Increased nucleation of the cholesterol crystals
4. Impaired gall bladder emptying or impaired motility
5. Impaired intestinal motility

These are the stages of stone formation and understanding these stages can help you to determine what will promote stones. Any factors that result in increased saturation of cholesterol in the bile, decreased gallbladder emptying or motility or decreased intestinal motility, could all increase the risk of gallstones forming. As usual, having a healthy gut is a crucial factor in yet another health condition.

This biliary sludge may be marked by an increase in liver enzymes (SGOT and SGPT). Early signs of gallbladder disease could be the inability to break down fat (floating stools) or constipation or diarrhea (may be misdiagnosed as IBS). We need to try to find patients in early stages of sludge or stone formation to intervene with lifestyle changes.

1. Supersaturation of cholesterol in bile. Dietary factors that reduce cholesterol and triglycerides may be helpful such as those already mentioned, as well as soluble fiber and lecithin. It should be noted that the incidence of gallstones in Japan has doubled since WWII with the westernization of their diet.
2. Increased nucleation of cholesterol crystals. Not fully understood, but one factor is:
   1. Increase in mucins. These are glycosylated proteins and this results from excess glucose reacting with proteins, so eating a low glycemic program should be beneficial
   2. Increased immunoglobulins (antibodies) are seen in celiac disease and food allergies, so avoiding gluten and food allergies may be helpful.

The following foods and supplements may increase bile flow or thin the bile:

1. Lecithin
2. Choline
3. Taurine
4. Turmeric
5. Milk Thistle
6. Fenugreek
7. Artichoke leaf
8. Dandelion root
9. Chinese herbs Mu Xiang and Bing Lang
10. Coffee enemas
11. Beets
12. Peppermint

Treatments For Problematic Gallstones

1. The most common treatment is cholecystectomy (gallbladder removal).
2. If a stone is blocking the common bile duct, it can be surgically removed via endoscopic retrograde cholangiopacreatogram(ERCP) .
3. Lithotripsy to break up stones—not used commonly
4. Oral bile salts like ursodeoxycholic acid help to dissolve stones. Can be used in conjunction with lithotripsy. Essentially the same substance found in a Chinese herb Nia Huang.
5. At least one study used a nutritional supplement, Rowachol, in combination with bile salts. Rowachol contains a combination of terpenes like menthol.  It is available by prescription in England and other European countries and also over the internet. (Gut 1979).  http://www.rowa.ie/product_rowachol.html   Dr. Murray recommends using peppermint oil, which is similar to Rowachol.
6. Lecithin?
7. What about the olive oil and lemon juice gallbladder flush? Could increase gallbladder emptying or motility, but probably not effective in eliminating stones and risk a stone being expelled which could lead to a blockage in the common bile duct and possible pancreatitis, which is a medical emergency and could be fatal.

Nutritional Advice after gall bladder surgery

1. Reduce fat intake since liver can only produce a limited amount of bile per day and it is not being properly regulated with timing of meals.
2. Eat smaller meals.
3. Supplement with fat soluble vitamins A, D, E and K.
4. Consider digestive enzymes and/or ox bile prior to or with meals.