Gallbladder Disease

Liver disease is serious and requires treatment and regular monitoring by a liver specialist. A liver specialist is known as a hepatologist and you need to be referred by your family doctor or general practitioner. Over nearly 40 years of practicing medicine I have seen many patients develop severe liver disease, which sadly could have been prevented by early detection and early referral to a hepatologist. There needs to be more awareness of liver disease so that patients can be treated early so that we can prevent cirrhosis, liver failure and liver cancer. Make sure you have your liver function checked annually with a blood test. I have presented my ideas on how to help those with liver diseases using nutritional medicine, which I have been using for many years with good success rates. However my recommendations do not replace the care of your own doctor and you should remain under the care of your own doctor whilst using nutritional therapies. If you have any questions you may contact my naturopath, Christine, on 623 334 3232 or email us at [email protected]

What is the gallbladder and why do we need one?

The gallbladder is a small pear-shaped organ situated directly under the liver in the right upper quadrant of the abdomen. It's main function is to collect and concentrate the bile that the body uses to digest fats. Problems with the gallbladder and biliary system are very common and consist of -

• Inflammation of the gallbladder and bile ducts
• Muscular spasms and/or poor contraction of the gallbladder wall
• Stones forming in the gallbladder and/or bile ducts
• Obstruction to the free flow of bile

Gallbladder problems

The condition of fatty liver is often associated with gallbladder disease such as gallbladder inflammation or gallstones. Gallbladder problems can be helped and often completely resolved. There is no need to panic and rush into surgery for gallbladder disease, unless you are in severe acute pain or your doctor suspects that you have gallbladder cancer. Indeed having your gallbladder surgically removed may not relieve your abdominal pain. According to a study published in The British Journal of General Practice 2004;54:574-79, it was found that having the gallbladder surgically removed (cholecystectomy) does not always relieve upper abdominal pain even in those with proven gall stones. After cholecystectomy, one third of the patients saw their doctor again with the same pain they had suffered prior to the surgery. What a disappointing result for these patients. After 12 months most of the patients who had a cholecystectomy were pain free, but so were 63% of the patients who had kept their gallstones. In this study 45% of the patients with “biliary pain” did not have gallstones. Gallstones are very common but they are not always the cause of the patient’s pain. So if you have upper abdominal pain and proven gallstones, do not assume the pain is caused by the gallstones. It is important to get your doctor to exclude other causes of upper abdominal pain such as stomach ulcers, acid reflux, spasm and pancreatic disorders etc. These can be treated effectively so that it is often possible to avoid gallbladder surgery. Gallbladder problems can cause symptoms that include:

• Nausea and vomiting
• Indigestion
• Intolerance to fatty foods
• Abdominal bloating
• Pain in the right upper and central upper abdomen
• Referred pain may radiate to the back and the right shoulder

Acute Gallbladder Emergencies If the gallbladder or large bile ducts become infected or obstructed with sludge or gallstones, very severe acute symptoms may supervene and these include –

• Severe abdominal pains which may radiate into the back and the right shoulder
• Vomiting
• Fever
• Septicaemia (the infection extends beyond the gallbladder into the blood stream)
• Inflammation of the pancreas (pancreatitis)

This is an acute emergency and requires intravenous antibiotics and removal of the gallbladder to prevent a fatal outcome. Chronic or grumbling gallbladder problems This condition is far more common than acute gallbladder emergencies. What is a grumbling gallbladder? It is a gallbladder that is inflamed and/or sluggish and the causes of this include –

• Weak or uncoordinated contractions of the gallbladder
• Toxic sludge in the gallbladder and/or bile ducts
• Bile that sits in the gallbladder and contains excess toxins
• Gallstones
• Overworked gallbladder, which cannot cope with a normal Western diet

What is meant by grumbling is that the symptoms come and go, especially recurring after indulgence in fatty foods or too much alcohol.

Interpreting your symptoms

Sometimes symptoms of a sluggish liver and/or sluggish bile flow can be interpreted incorrectly as gallbladder disease and the solution is to improve liver function. There may be excessive pressure inside the bile ducts within the liver and this occurs before the bile ducts get to the gallbladder. This increased pressure inside the bile ducts can be caused by thick toxic bile or an inflamed liver. A fatty liver is swollen and congested with fat; this can cause bile flow to be sluggish, resulting in increased pressure and discomfort over the liver. If the increased pressure remains in the bile ducts this can result in back pressure in the bile ducts; this can cause liver cysts. These cysts are small to begin with, but if nothing is done, these cysts can grow in size and become painful. Other problems can masquerade as gallbladder problems and the diagnosis may not be made correctly. Problems that can masquerade as gallbladder problems include:

• Stomach inflammation known as gastritis – this may be caused by infection with bacteria known as helicobacter pylori; these bacteria live in the stomach lining and flare up if you eat excess sugar or excess carbohydrates
• Reflux of acid from the stomach back into the oesophagus
• Ulcers in the stomach or duodenum
• Food allergies
• Gluten intolerance
• Liver cysts caused by sluggish bile flow (these are often small)
• Fatty liver with liver congestion
• Severe emotional stress causing spasm in the smooth muscle in the gut
• Adverse drug reactions from anti-inflammatory drugs which can upset the liver and stomach

If a patient presents with symptoms that could be due to gallbladder disease, the doctor will order various tests such as:

• Blood tests for liver function
• Imaging tests of the upper abdomen to visualise the liver, gallbladder, bile ducts and pancreas such as an ultrasound scan, CT scan, MRI scan or a HIDA scan.
• A HIDA scan (Hepatobiliary Imino-Diacetic Acid scan),) or cholescintigraphy is a nuclear imaging procedure to evaluate the health and function of the gallbladder. A radioactive tracer, usually technetium-99m, is injected through a vein, then allowed to circulate to the liver, where it is excreted into the biliary system and stored by the gallbladder.
• Normally the gallbladder is visualized clearly within 1 hour of the injection. If the gallbladder is not visualized within 4 hours after the injection, this indicates either gallbladder inflammation or cystic duct obstruction.
• An MRI scan of the liver and gallbladder is very accurate but can be expensive - still its worth it, if it can help you avoid uneccessary surgery.

It is not uncommon to find gallstones using these various imaging techniques, even in people with no symptoms, and these gallstones may or may not be the cause of the symptoms. However once the gallstones are detected, they are usually blamed for the patient’s symptoms. Beware – your gallbladder is precious! You may be talked into having your gallbladder out at the earliest convenience. The surgeon may tell you, “Why not get it removed; it’s not important and it’s making you sick?” Another common thing that doctors will say is “After your gallbladder is removed, you can eat whatever you like without any more pain” Dr Cabot disagrees with both of these concepts for several reasons –

• The gallbladder concentrates the bile and supplies a quick shot of bile into the small intestine during a meal – this facilitates the digestion and absorption of fats.
• The gallbladder may not be the cause of any of your symptoms and may not be making you sick.
• The gallbladder may be the cause of only a few of your symptoms and having it out may not relieve all your symptoms
• After your surgery, if you eat whatever you like, you will probably get a fatty liver and gain a lot of weight
• Any operation carries significant risks and if you get complications, you may end up worse off
• You do not need to panic if you have a grumbling gallbladder – why not try to treat the cause first – namely improve your liver function so your liver can make healthy bile allowing your gallbladder to heal

What to do after your gallbladder is removed

Your liver cells are continually making bile, whether you have a gallbladder or not. Once the gallbladder is removed you lose the ability to store and concentrate bile in the gallbladder and bile continually flows through the bile ducts into the small intestine. When you eat a meal you don’t get the extra squirt of bile from the gallbladder into the small intestine and thus your ability to dissolve, digest and absorb dietary fat may be reduced. Some people have problems after losing their gallbladder and this can be helped by various medical treatments. The most common problems after the gallbladder is removed are-

• Indigestion and/or reflux
• Bloating after meals
• Diarrhoea from unabsorbed fats remaining in the gut
• Itching skin and a sallow complexion

These problems can be helped by the following drugs:

• Cholestyramine

Cholestyramine is a medication most often used to lower cholesterol levels and works by binding bile salts in the bowel and taking them out of the body. It is a safe, effective and well tolerated medication that I think is underutilized. Cholestyramine can relieve the awful itching associated with some types of liver disease and jaundice. It is very effective in controlling chronic diarrhea that can be a side effect of gallbladder removal. It is taken in sachets as it is a powder and must be prescribed by a doctor.

• Ursodiol

Ursodiol is a bile acid, found normally in human bile. Ursodiol is also used as a medication (tablets or capsules) and brand names include Actigall, Urso, Urso 250 and Urso Forte. Some people find that Ursodiol helps to reduce indigestion and bloating as well as itching skin. Ursodiol is often prescribed for the treatment of gallstones, as it has been found effective (although very slow), in dissolving them. Gallstones are formed from cholesterol stored in the gallbladder. Ursodiol dissolves the cholesterol from the stones and also reduces cholesterol production by the liver. It works better for smaller gallstones, including tiny stones stuck in bile ducts and those that are loose. The success rate for dissolving gallstones up to 20 mm in size is around 40 percent. Ursodiol can be used as part of a holistic program to prevent gallstones in those who keep forming more stones, even after the gallbladder has been removed. Ursodiol can also be used to prevent the formation of gallstones, especially in patients who are undergoing rapid weight loss. Normally in the gallbladder, there is a balance between bile salts and cholesterol and fast weight loss can cause this balance to be disturbed. During fast weight loss (more than 1.4 kilograms or 3 pounds per week), bile salts tend to decrease and cholesterol increases. A 2008 issue of the medical journal "Obesity Surgery" states that ursodiol medication has been found to be effective and very safe for the prevention of gallstones in patients who have undergone bariatric (weight loss) surgery. Ursodiol is also used as a treatment for primary biliary cirrhosis (PBC), which is a liver disease that destroys the liver's bile ducts. When this happens, bile cannot flow to the small intestine to help with the digestion of fats. The bile remains trapped in the liver and causes damage to the liver's cells which can lead to cirrhosis. Since ursodiol is a bile acid, it improves liver function in those with PBC. It can increase life expectancy and buy time for the patient who is waiting for a liver transplant. Ursodiol must be taken daily for life or until the transplant occurs.

• Digestive Enzymes

These come in the form of capsules and are often used to improve indigestion and bloating associated with loss of the gallbladder. Stronger doses and types of enzymes are best prescribed by a doctor. For vegans it is possible to buy vegetarian enzyme capsules over the counter and these are not as strong but are still helpful.

Continuing Problems

Some people continue to have problems in their tiny or large bile ducts after the gallbladder is removed such as –

• Toxic unhealthy bile inflames the bile ducts

Sluggish thick bile increases back pressure in the bile ducts leading to liver cysts which can be painful. Large to medium cysts can be seen on an ultrasound scan of the liver whereas tiny cysts in the bile ducts may only be seen on an MRI scan of the liver. If the underlying problem of thick, sluggish or toxic bile is not improved the liver cysts may grow much larger causing chronic pain in the area of the liver.

• Auto-immune diseases of the bile tract

There is a liver disease called Primary Biliary Cirrhosis (PBC) and it is caused by inflammation in the bile ducts within the liver; this inflammation extends beyond the bile ducts into the liver tissue surrounding the bile ducts. The cause of this disease is the patients own immune system, which attacks the bile ducts and the surrounding liver tissue; this causes inflammation which damages these tissues. What are the causes of this inflammation?

• Genetic factors – you may have autoimmune disease in your family
• Food allergies
• Gluten intolerance – to determine if this applies to you, have a blood test to see if you have the genes which predispose you for gluten intolerance. This is a genotype test and checks your HLA DQ and HLA DR patterns.
• Adverse reactions of your liver to certain prescribed drugs/medications
• Build up of toxins and bacteria in the bile ducts

Natural Treatments

How to treat gallbladder and biliary problems and cysts in the bile ducts naturally Important things to do

• Do raw juicing using cabbage, carrot, ginger root, mint and apple etc. (see juice techniques and recipes in [products]1012-Raw Juice Can Save Your Life[/products] book by Dr Cabot)
• Include fresh green leafy herbs in your salads and raw juices – the best liver cleansing herbs are mint, parsley, garlic, chives, shallots, basil, coriander and small amounts of thyme and oregano
• Increase the amount of raw vegetables in your diet
• Taking digestive enzymes at the beginning of your meals may reduce symptoms
• Take a good liver tonic twice daily; ensure it contains Saint Mary’s Thistle, B group vitamins, vitamin C, and sulphur bearing amino acids such as glycine and taurine
• Supplement with the amino acids taurine and glutamine and the mineral selenium to support good bile quality and healthy bile ducts in the liver.
• Increase intake of Omega 3 fatty acids - Suitable sources are oily fish, good quality fish oil, walnuts, flaxseed, chia seeds and hemp seeds. Keep oils in the fridge.
• Sip one tablespoon of organic apple cider vinegar mixed in a small glass of water during your meals
• Drink plenty of pure water
• Drink dandelion tea and coffee
• Be careful not to overindulge on dairy products – the best ones are natural cheeses and plain yogurt
• Hot spices are good for the liver and bile ducts and good choices are wasabi, horseradish sauce, mustard, garlic, curry, turmeric and chilli. If you have a sensitive stomach or gastritis only use small amounts of these spices or avoid them.

Things to avoid

• Deep fried foods, margarine, cream and icecream
• Packaged snack foods and take away foods – such as chips, pretzels, cookies, donuts, hot dogs and pizza etc
• Excess sugar – use natural alternatives to sugar such as xylitol or stevia rather than aspartame based products
• Excess alcohol
• Cheap processed vegetable oil
• Sugary soft drinks and diet sodas
• Dehydration

The Liver and Gallbladder Flush

The liver/gallbladder flush is a quick way of flushing toxins, fatty sludge and small gallstones out of the liver and gallbladder. It is becoming quite popular in Russia and the U.S.A. Dr Cabot warns you that it is not for the faint hearted, and can cause some unpleasant reactions including abdominal pain and diarrhea. Quite a few patients of her patients have told her of excellent results from this procedure, so you may find it of interest and also of help. This is particularly so if you have gallstones or sludge in the gallbladder, which may or may not be causing intermittent discomfort. Before attempting a gallbladder flush check with your own doctor that it is suitable for your case. Many people have “silent gallstones” that do not trouble them and these are often discovered accidentally when they are being investigated for some other problem. The natural history of these stones is that they will remain silent and cause no problems, and only around 18% of such stones will cause problems over a 15-year period. If you have stones that are not troubling you, it is suggested that you follow the dietary recommendations either of Dr Cabot's books Heal Your Gut - An A to Z Guide or The Liver Cleansing Diet book and take a good liver tonic – chances are you can watch the stones slowly dissolve and shrink away. Ursodiol is also another way to dissolve gallstones. If, however, the gallstones or sludge are causing upper abdominal pain, nausea, bouts of vomiting, pain in the right shoulder, or if there is a chance of infection or cancer in the gallbladder, then you must be guided by your own surgeon. Laparoscopic surgery (keyhole surgery) has made the recovery time after surgery much shorter. In some very acute gallbladder attacks, surgery can be life saving. However, remember this type of surgery can have complications and although these are not common, Dr Cabot has seen patients who have had more problems after cholecystectomy than they had before. These problems included leaking bile, permanently damaged bile ducts, liver haemorrhage and infection. These are the reasons why some people opt to use the liver/gallbladder flush to try and avoid surgery. Once again if you decide to do this, please talk to your doctor first. One evening Dr Cabot was giving a seminar in Florida, when a middle-aged gentleman stood up in front of several hundred people and proudly told his account of how he had flushed out his liver and gallbladder with olive oil and lemon juice. This had resulted in him passing 1425 smallgallstones in his bowel actions over several hours, which he had obviously gone to great lengths to count! For patients who believe that they need to stimulate the elimination of toxins and/or gallstones out of the bile ducts, a liver flush can be done to greatly increase the flow of bile through the liver and bile ducts. The Standard Method for the Liver and Gallbladder flush is:

1. Freshly squeeze some citrus fruits such as grapefruit, orange, lemon and limes to make 300 mls of juice. This will have a slightly sour taste, which is good, as bitter tasting fruits and vegetables stimulate the flow of bile from the liver and gallbladder. Dilute this juice with 200mls of filtered water.
2. Finely grate 1 to 2 cloves of fresh garlic and half a teaspoon of fresh ginger, and then press both in a garlic press to make juice. Add this juice to the water and citrus juice mixture. Garlic and ginger are liver cleansing.
3. Pour 300mls of good quality cold pressed olive oil into a warm glass.
4. Every 15 minutes swallow 3 tablespoons of the citrus juice mixture and 3 tablespoons of the olive oil. Try to relax in between these 15 - minute intervals. Some people find it beneficial to lie down on their right side with a hot water bottle over the liver area, which helps to dilate the bile ducts to allow the passage of small stones and sludge from the gall bladder. Others prefer to sit in a warm bath, which also helps to dilate the bile ducts.
5. If you desire, collect all your bowel actions (they may be loose and messy) into a bucket and when the flush is over, place them in a large strainer or colander and run tap water over them. You will probably find many greenish stones/gritty sludge around the size of a lentil or slightly larger. There may also be some large soft stones full of fatty cholesterol. Some people may not want to collect their bowel actions and are content to hear the stones clanging as they land in the toilet bowl!

Some people who do this flush may find that they feel very nauseated (bilious), and/or vomit several times. Abdominal cramps and diarrhea may accompany this, before the stones are passed. An Alternative Method for the Liver and Gallbladder flush is:

1. Drink one litre of organic unsweetened apple juice daily for five days. This will soften up the stones to such an extent that they can be squashed with the fingers. During these five days eat only raw fruits and vegetables and no dairy products, red meat or chicken.
2. On the sixth day, skip dinner and at 6 p.m. take a tablespoonful of Epsom salts with 3 glasses of water. Repeat this at 8 p.m.
3. At 10 p.m. make a cocktail of 115ml of olive oil and 115ml of fresh squeezed lemon juice. Shake this very well and drink immediately.
4. Next morning you will pass green stones varying from the size of grains of sand to as large as your thumb nail. You may be amazed at the results, as have many thousands of people who have used this technique to avoid surgery.

Preparation for the flush:

• To prepare for the flushing procedure, it is recommended that during the two days prior to the commencement of the flush, you consume only raw fruits and vegetables and drink 2 litres of water daily. This preparation will lessen the chance of a bad reaction.
• Begin the liver flush in the morning after some brisk walking and deep breathing exercises. Make sure that you drink 2 litres of water gradually by sipping it slowly during the day otherwise the flush may induce dehydration. Some protagonists of this procedure recommend that you begin the flush at 7 p.m. because they believe that the gallbladder is “more active at night”. This may be true; however you will not get much sleep that night, if you decide to do the flush while the moon is shining!
• If you are a person who forms recurrent gallstones you can do this flush 3 times every year to prevent gallstones from building up. Some people do it every month and find that it does not cause any problems or side effects. If you follow the dietary guidelines found in Dr Cabot's Healthy Liver and Bowel book, you should not have to do this procedure very often because a healthy liver manufactures healthy bile, which prevents gallbladder inflammation and gallstones.
• We do know that family history often plays a part in liver and gallbladder disease so if you find yourself with gallstones, have a good look at your family history and take extra special care of your liver.
• Gallstones are more common during pregnancy. If gallstones are recurrent in younger persons, this may be a sign of an underlying blood disease.

Caution Certain people such as pregnant women, young children, very elderly and frail people, insulin-dependent diabetics or those with severe liver disease or an acutely inflamed gallbladder, should not try the liver/gallbladder flush and should discuss it with their own doctor. Ideally a qualified health practitioner should supervise your gallbladder flush. At the very least, never do the flush alone, so that if you do dislodge a large stone and get severe pain, your companion can take you to medical care. Always check with your own doctor before doing the liver/gallbladder flush.

It is important to support the healthy function of your liver and gallbladder.

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