Gallstones and your gall bladder 101: what, why, who (and generally speaking) what to do?

Until this week I had no idea how prevalent gall bladder inflammation (cholecystitis) and gallstones were. And in who. A lovely client of mine had experienced cholecystitis for years. She was actually none the wiser as equally suffered from irritable bowel syndrome too so had lumped the symptoms (upper abdominal pain, particularly after a fatty meal) into the same category as ‘digestive issues’ which we had been working on (and she had been having success with) over the last few months. It wasn’t until this week that she called me to say she was diagnosed with gallstones and was going in for emergency surgery to remove it that I thought – hmm, is that unusual? Turns out it’s not.

The gall bladder is required to store the bile that is required for fat digestion. If a person is experiencing inflammation (systemic or local) this can irritate the gallbladder and cause significant abdominal pain after eating which usually subsides in the hours that follow. Gallstones are a result of reduced gallbladder function, where the bile isn’t released as it should be and can become thick and sticky, forming stones that can be the size of pebbles to the size of golf balls. There are three types of stones; black pigment stones (related to cirrhosis – scar tissue build up in the liver – or haemolytic disorders – breakdown of red blood cells); brown pigment stones (related to an infection in the gall bladder) but overwhelmingly in the western world, the prevalence of the third type of stone – a cholesterol rich one – is increasing, accounting for around 70% of gallstones. Pain occurs if one of these get stuck in the bile duct – this may also subside. However if you experience continual pain, or begin to have more frequent attacks, then it is generally recommended that something needs to be done.

I had always associated gallstones with people of an older age bracket, but that was just because I’d never had a reason to look into it at all. In fact, this week I was bombarded by young, fit women who responded to a post I put on my Facebook page related to cholecystitis and gallstones that had all experienced problems and subsequently had their gallbladders removed. Now not all people suffering from cholecystitis have gallstones, and not everybody with gallstones experience pain – indeed some remain asymptomatic for most of the time. However, there is a surprisingly high number of people that experience problems with either condition and in New Zealand it’s estimated that 20% of people aged 30y – 75y will be affected. Now that is a LOT of people who may be having problems with either cholecystitis or gallstones and potentially not even know it. The pain experienced in an attack may be in isolation of other symptoms, or put down to ‘normal digestive issues’.

The formation of gallstones and cholecystitis is (like most things) possibly due to an interaction between both genetic and environmental factors. Genetically, a mutation in a protein that may be responsible for the delivery of phospholipids and bile from the liver will increase the risk, as will having a genetic predisposition – the latter increasing your risk four-fold. In addition – and this is what sparked my attention from the Facebook posts – the presence of an autoimmune disorder (Crohns disease, celiac disease) or even a sensitivity to gluten increases risk. The first possible reason for this could be from increased inflammation due to the nutrient malabsorption, or a defect in the gallbladder ability to empty – both resulting in a reduction in gallbladder function. Alternatively, it could be that the gallbladder disease is the result of the same immune system attacks that occur with an autoimmune condition. Regardless of the mechanism, there is a very real relationship here.

Other factors that increase the risk of gallstones are taking an oral contraceptive pill, being pregnant, or having had multiple pregnancies. The increased oestrogen levels affect gallbladder motility (delaying bile release from the gallbladder) and increase cholesterol saturation of bile (cholesterol is the backbone of our sex hormones). A high carbohydrate intake in pregnant women (particularly fructose) is also associated with increased incidence, and there is a link between pregnancy, pancreatitis and gallstone risk. Weight loss, weight cycling or fasting can also increase risk of gallstones as fat is being rapidly broken down and there is increased secretion of cholesterol into bile. With these factors in mind, it is no wonder women are at greater risk (two-thirds of those in the US with gallbladder disease are women). Equally a diet that is higher in processed refined food and calories increases the risk with higher circulating insulin and triglycerides as a consequence of the standard western diet. People who are overweight or obese, or have risk factors associated with the metabolic syndrome are at an increased risk – now this may well be due to the previous point, however this has also been found independent of diet; those with a fat deposition around the middle are more likely to experience problems. Indeed this type of fat patterning is related to reduced function of the liver (and non-alcoholic fatty liver disease) which may result in fat build up and cirrhosis also related to gallbladder function.

A question that arose on my Facebook page was whether athletes were at greater risk compared to the general population.I had a good look around the literature and only came across a couple of studies that related a high training load to problems with the gallbladder. As athletes we place ourselves under a lot of training stress – chronically this leads to increased inflammation. Haemolysis can also occur in susceptible athletes who heavily exert themselves which again impacts on inflammatory pathways. This inflammation is in the absence of gallstones but may well lead to gallstone formation as it reduces gallbladder function. If you combine this with an intolerance to certain food (as a number of endurance athletes also experience), then there are certainly links between the two despite an absence of academic literature out there. Changes to liver enzymes after an extreme endurance event may place an athlete at risk, and interestingly, this case study illustrated how inflammation due to higher intensity training led to a thickening of the gallbladder tissue and an increased tension in the absence of stones or bile buildup (‘sludge’). The removal of the gallbladder stopped this tension and the athlete was pain-free. In this instance, surgery was potentially the only route as it wasn’t related to stones. But if you do suffer from gallbladder problems with or without gallstones and don’t want to go down the surgical route, what are your other options?

For those with problematic gallstones, a first approach may be sound wave therapy to break down stones so they can move down the intestine and be excreted without the risk of getting stuck. Similarly, ingesting a naturally occurring bile (in the form of ursodeoxycholic acid) may also gradually break down the stones. However many people continue to suffer symptoms associated with gallstone attacks after these treatments. Though not in the academic/medical literature, I’ve read a lot of people do an olive oil/lemon juice protocol which (it appears) involves fasting/apple juice/anywhere from 1 cup to 3 cups olive oil and lemon juice/sleeping then warm water. I’ve actually just lumped a lot of different components of these protocols to give you an idea of what you can find if you can go searching… not to recommend you try it (it’s not my place to do that!)

For those with problems related to inflammation of the gallbladder, or with gallstones that are symptomatic, an anti-inflammatory diet is the way to go – removal of grains, dairy, legumes, refined processed food and a focus on fruits, vegetables and animal protein. These foods are rich sources of antioxidants and are not going to cause stress on the digestive system, thereby they are your best line of defense. For some, following an auto-immune protocol that also removes eggs, nightshade vegetables, nuts and seeds initially may be required, with further supplementation to help heal the gut. If you have neither of the above and are currently losing weight, research suggests that following a higher fat diet for weight loss is protective against developing gallstones when compared to a lower fat diet. Further, there is limited research that vitamin C supplementation can prevent gallstones by promoting the conversion of cholesterol to bile salts in the gall bladder.

And what if you have the surgery to remove your gallbladder? Is it low fat foods from here on in? This seems to vary a LOT from person to person. Some people can continue to include good amounts of healthy fat in their diet with no noticeable digestive issues. While some notice a vast improvement with the addition of digestive enzymes, others don’t notice any change. It’s best not to drink fluid around meals so you don’t dilute your stomach acid and obviously try to eat as ‘clean’ as possible –following a paleo approach will ensure nutrient intake is optimal.