Gallbladder Blues

Gallbladder Blues

I did an urgent laparoscopic cholecystectomy the other day on a young woman who called the office with a sudden worsening of her gallbladder symptoms. By the time we got her to the OR preop area, she was pale, diaphoretic (cold and sweaty) and writhing in pain. Her gallbladder was sick but not infected and she had a stone stuck tight in her cystic duct, the tube that drains the gallbladder. The stuck gallstone was probably what caused the sudden worsening of her symptoms.

I had originally seen her in the office late in July, just before I went on vacation. She was having episodes of upper abdominal pain once or twice a week and had gallstones diagnosed by ultrasound. She’s an otherwise healthy thirty year old who had stones diagnosed on a pregnancy ultrasound and symptoms that started four months after the recent birth of her third child–pretty typical history. She took no prescription medications but did take a handful of herbal and vitamin supplements daily and told me she stayed away from processed foods in favor of  a ‘natural’ diet. That should have tipped me off, but it didn’t at the time.

The surgery went well, although the stone was wedged pretty tightly and I did an x-ray of the common bile duct, the main tube that drains bile from the liver, just to make sure no other rocks had gotten away from us.

When I talked to her family after surgery, her husband asked if the ‘purge’ had worked. I asked what he meant and he told me she had read about a gallbladder purge that was supposed to get rid of stones ‘naturally’ and had tried it a couple of days before. The increased pain and the stuck gallstone now made sense.

These purges are touted on various websites as a natural cure for gallstones. There are several popular ones, but they all involve a fast of several days followed by a large dose of olive oil or similar fatty meal. The idea is to make the gallbladder ‘expel’ the stones. These purges are at best a bad idea and at worst dangerous.

Why? First, a few words about the gallbladder and what it does. The gallbladder stores bile. When we eat, especially a meal rich in fat, the stomach and intestine secrete a hormone called cholecystokinin (CCK), which causes the gallbladder to contract and push a big slug of bile into the common bile duct and through it into the intestine. Bile acts like detergent to break fat into smaller globs that the digestive enzymes can work on. People have gallbladders because for most of human history, food supplies were unreliable. Especially for our hunter-gatherer ancestors. They might eat a large meal one day and then little or nothing the next. An organ to store bile during fasting and mobilize it in response to a meal prevented crippling diarrhea from poorly digested fat.

When we eat every day, which most people in this country do, and especially when the quantity and quality of our food doesn’t vary much, the gallbladder can languish. It has nothing to do. That may be why some gallbladders form stones. We don’t really know. But we do know that healthy gallbladders don’t allow stones to form in the first place. So if you have gallstones, your gallbladder isn’t working very well.

Purges try to take the normal physiology of the gallbladder and use it to pass the stones out into the bile duct and thence into the intestine. Sounds nice, but in practice, only small stones can pass this way. And, because the bile duct is a low pressure/low flow system, even then they often get stuck. A larger stone will just wedge itself into the duct and jam up there, causing unrelenting pain and setting up the potential for an infection or even a ruptured gallbladder.

I see five or six patients a year who come to my office or to the ER acutely ill after one of these purge attempts. Often they were referred to a website by a helpful friend, or worse, had the purge prescribed by one of those charlatans who call themselves ‘Naturopathic Physicians’. Just because it’s natural, doesn’t make it safe. (Hemlock is a natural substance but it wasn’t very good for Socrates.) You may know a friend or a friend of a friend of a friend’s second cousin who ‘cured’ gallstones this way, but that doesn’t make it a good idea.

On the other hand, it doesn’t hurt my business to have a patient who is convinced in such a graphic way that they need an operation. Olive oil cocktail, anyone?