Whew, that title is a mouthful!
Years ago–more years than I care to count–I had my gallbladder removed. I had gotten gallstones as a side-effect of birth control pills. I had no idea why every month I would get an attack of crippling, writhe-in-agony pain, until it finally landed me in the emergency room. The ER doc was a woman, and I suspect I was fortunate in that regard because I rather doubt a male doctor would have made the connection between The Pill and The Pain, gallstones being one of the rarer side effects. Anyway, I was told my gallbladder would have to come out, and I obediently went along with the plan.
I wish I had known then what I know now.
Having my gallbladder removed (the surgery is called a cholecystectomy) was probably a huge mistake (taking The Pill definitely was) and has almost certainly led to numerous digestive and abdominal complications for me. Collectively, these are known as Post-Cholecystectomy Syndrome (PCS). Sometimes PCS is caused by stones in the bile duct of the liver, or by scar tissue from the surgery, or by the constant drip-drip-drip (and occasional gush) of bile into the small intestine, but it all boils down to problems resulting from there not being a gallbladder to store, concentrate, and control the release of bile.
Post-Cholecystectomy Syndrome (PCS)
According to Wikipedia, anywhere from 5% to 40% of post-cholecystectomy
victims patients suffer from PCS. I’m sure that readers do not particularly want to read a detailed exposition of the workings of my internal organs, but I know from my internet trolling that there are many people out there looking for help with PCS symptoms. Generally, symptoms include:
- pain in the upper and/or lower abdomen, especially the upper right quadrant
- intestinal gurgles (borborygmia)
- abdominal bloating
Wow, that’s quite a symptom list, isn’t it? Hey, while we’re at this, let’s review what the symptoms of gallstones are (note that many people have gallstones without ever having symptoms):
- pain in the upper right quadrant of the abdomen
- in severe cases, pancreatitis or cholecystitis (the GB gets clogged with stones and then infection sets in)
Most of the symptoms of gallstones (the most common reason for a cholecystectomy) are also symptoms of PCS. And we know that PCS is caused by not having a gallbladder.
That means you can have the same symptoms with or without a gallbladder.
So, logically, this would suggest that removal of the gallbladder is not necessarily a great treatment for gallstones with pain, because there is likely to still be pain, nausea, etc. sans gallbladder. (I should mention that the pain from gallstones is beyond-description horrible. I knew a lady who said giving birth to twins was nothing in comparison. Certainly I have never known anything that comes close, except passing a kidney stone, but that wasn’t as bad. The pain I have now is at least bearable. But if I could have found a way of reducing that pain without surgery I would have preferred that. And the digestive upsets I experience now are far worse than what I had with a malfunctioning gallbladder.)
Another way of looking at this is to say that, 5%-40% of the time, removal of the gallbladder doesn’t cure whatever was wrong in the abdomen, or at least not all of it, so the problems continue even after it’s gone. “Cutting out a body part is treating the symptom, not the cause,” writes Mary Ackerley, MD, MDH, ABIHM in this article.
Maybe my gallbladder would have had to come out anyway; I’ll never know. At any rate, it’s gone now and there’s no use crying over its tiny little green body (yep, gallbladders are green). Let us instead turn to treatments for PCS. Bear in mind that this is a work in progress–a topic I am still researching. But here is what I have learned so far.
I work with herbs within the context of European-American traditional herbalism, but I also looked to Traditional Chinese Medicine (TCM) to see what light it could shed on this matter. TCM is a complex science and I know little about it, but this is what I have gleaned so far:
The gallbladder is responsible for the dispersal of yang qi throughout the body. The yang qi warms the body and prevents the accumulation of excessive dampness and cold. Without the gallbladder, qi can not be distributed normally and it “stagnates” in the abdomen, affecting in particular the liver, stomach, and spleen. Moreover, it cannot combat dampness, which then accumulates in the body. The combined effect of heat and dampness in the upper abdomen results in the symptoms of PCS.
Furthermore, when the bile doesn’t flow normally from the liver, “liver qi stagnation” can develop, and this is the root of many ills. Obstructions caused by adhesions and scar tissue resulting from surgery can also disrupt blood flow and result in “blood deficiency.” When the liver qi isn’t flowing through the body as it should, it can flow across to the stomach, kidneys, and/or spleen, interfering with their normal processes.
In a nutshell, not only does this contribute to the symptoms of PCS, but to all sorts of other problems as well, including irritability, moodiness, stress, and depression.
This actually fits pretty well with a traditional Western explanation for PCS. In the Western tradition, there is no concept of qi, but there are the temperature and moisture axes (hot to cold, dry to damp), as well as concepts of energetic excess and deficiency, and of movement, torpor, and stagnation. So the description of heat and dampness in the liver system overflowing into the stomach, kidneys, spleen, and intestines makes perfect sense and fits with the observed symptoms.
Viewed from this perspective, we can see that dampness and heat is a cause of the symptoms cholecystectomy is supposed to cure, and removal of the gallbladder actually worsens the dampness and heat and causes it to spread. Even if your gallbladder really did need to come out (e.g., if it ruptured), you are likely to still have dampness and heat affecting multiple organ systems.
What can we do about it?
We have seen that the gallbladder is intimately involved in the digestion of fat. So we can expect that without a gallbladder, digesting fat is going to be a problem. It seems to me that this is a major contributor to the diarrhea, gas, tummy rumbles, and bloating of PCS. For example, without a gallbladder the bile can’t be stored and concentrated, and that results in:
- bile that drips constantly into the small intestine, irritating its lining
- fat that is not fully digested hanging around in the intestines and bloodstream
…both of which cause diarrhea.
Also, if you’re not digesting fat properly, then it’s not fully available for your body to use as nutrition. One of the ways in which the liver disposes of excess fats/cholesterol is by binding them up with bile salts and sending them on down the intestines to be excreted. But bile salts themselves are derivatives of cholesterol! This means that you need some cholesterol to make bile salts to get rid of excess cholesterol. I’ll be coming back to this point in a bit.
It seems to me the first order of business is to support the liver. There are many herbs that can do that, but my go-to herbs here would be dandelion and milk thistle (which I discussed in my previous post). Mountain Rose Herbs makes a “Liver Care” extract consisting of dandelion, milk thistle, yellow dock, schisandra, and Oregon grape root, which sounds like an excellent blend, though I would use bayberry rather than Oregon grape. One day soon I hope to come up with a PCS-specific blend myself. Anise and fennel are helpful with gas and bloating, but both have a liquorice flavor I’m not terribly fond of. Still, their benefits are such that I can put up with it.
TCM also recommends bupleurum, rose (specifically Rosa rugosa), dried ginger, eupatorium (boneset), skullcap, pulsatilla, fennel, cumin, garlic chives, and liquorice. (Note that dried ginger is very heating.) I would consult with a TCM practitioner since they use very complicated blends of herbs, as well as herbs which are not part of the Western materia medica and I think they will make custom blends.
I find I benefit greatly from an astringent to tonify the intestines; my favorite is agrimony, which also reduces anxiety and tastes good. However there are many to choose from. Astringents sort of tighten up the wall of the intestines and make them less “leaky.”
Alternatively, you may find that you suffer more from irritation in the upper GI tract, and mucilaginous herbs such as marshmallow and liquorice may be of assistance there (though they will increase moisture).
In general, you will want to avoid warming, moistening herbs, because there is already excess damp and heat. Go for cooling, drying herbs and astringents.
Bile salts & fats
Next you are probably going to have to supplement with bile salts. When bile salts are deficient you end up with an overload of fats that cannot be properly digested or stored. Some of it is going to get stuck in the liver. Excess fat in the liver results in insulin insensitivity, which in turn results in insufficient bile secretion. So there is a nasty downward spiral here. Supplemental bile salts help to compensate for the lack of concentrated bile, and in turn helps you digest the fats you eat.
But all fats are not created equal. Naturopath Bruce Fife discusses the difference between long-chain and medium-chain triglycerides:
“When we eat fats composed of LCTs [long-chain triglycerides] they travel through the stomach and into the intestinal tract. It is in the intestines where the vast majority of fat digestion occurs. Pancreatic enzymes and bile are necessary for digestion. LCTs are reduced into individual long-chain fatty acids. These fatty acids are absorbed into the intestinal wall. Inside the intestinal wall they are repackaged into bundles of fat and protein called lipoproteins. These lipoproteins are then sent into the bloodstream. As they circulate in the bloodstream they release particles of fat. This is the source of the fat that collects in our fat cells and the fat that collects in and clogs up artery walls. As the lipoproteins get smaller they eventually go to the liver. In the liver they are dismantled and used for energy or repackaged into new lipoproteins and again sent back into the bloodstream to disperse fat throughout the body.
“MCTs [medium-chain triglycerides] are processed differently. When we eat a fat containing MCTs, such as coconut oil, it travels through the stomach and into the small intestine. But since MCTs digest quickly, by the time they leave the stomach and enter the intestinal tract they are already broken down into individual fatty acids (MCFAs [medium-chain fatty acids]). Therefore, they do not need pancreatic enzymes or bile for digestion. Since they are already reduced to fatty acids as they enter the small intestine, they are immediately absorbed into the portal vein and sent straight to the liver. In the liver they are preferentially used as a source of fuel to produce energy. MCFAs bypass the lipoprotein stage in the intestinal wall and in the liver. They do not circulate in the bloodstream to the degree that other fats do. Therefore, they do not supply the fat that collects in fat cells nor do they supply the fat that collects in artery walls. MCFAs are used to produce energy, not body fat and not arterial plaque” (emphasis mine; source is here).
So medium-chain triglycerides should be more easily-digestible for people who don’t have sufficiently strong bile, and they are less likely to contribute to the fatty liver-insulin insensitivity-even less bile spiral. MCT fats are the exception to the rule that you should strictly avoid saturated fats. Foods with medium-chain triglycerides include coconut oil, butter, whole milk, and palm kernel oil.
For healthy fat metabolism sans gallbladder, you need (a) sufficient bile salts to bind up the fats/cholesterol, (b) something to soothe and protect the intestinal lining irritated by constant exposure to weak bile, and/or to bind up that bile, and (c) something to break up undigested fats in the intestines in lieu of strong bile. In addition to bile salts, choline can help with fat digestion and reduce gas and bloating.
Nutrition & exercise
Third, I would look to nutrition beyond the fats. Many PCS sufferers avoid fat because they find it causes diarrhea (often immediately); but as Dr. Ackerley points out in the article I cited above, this can result in not getting enough healthy fats like the Omega-3s and MCTs. So you might consider a fish oil supplement. (In my case, I did discover that I was deficient in essential fats.)
Meanwhile, leafy greens such as kale, collards, mustard greens, chard, nettles, and dandelion are really good for the liver so try to work more of those in. These help cleanse, help the liver produce and secrete bile, and are full of vitamins and minerals. Based on my experience I suspect that dairy is generally not a friend to the PCS sufferer, since even when non-fat it still contributes to mucus production (dampness); however, I do make sure to eat small amounts of whole-fat milk, butter, and yogurt from pastured cattle. When I can afford it (it costs an arm and a leg here) I get raw milk. These taste sooooo much better than the typical grocery store varieties and are more nutritious. Refined sugar is also probably best avoided because in excess the liver will turn it into fat (not the good kind), and without a gallbladder, whatever fat the liver sends to be excreted through the digestive system is going to cause pain, gas, bloating, gurgles, and diarrhea.
Eating frequent small meals means there will always be something in the intestines to absorb excess bile, but by itself this won’t be sufficient because without a gallbladder, it’s difficult to digest these things correctly to begin with. Eating high fiber foods such as oats, nuts, and legumes (especially peanuts) can help to sequester excess bile.
All I’m going to say about exercise is that TCM says exercise gets stagnant qi moving, and we all know movement is good for us. It can be gentle and still be effective.
According to TCM, liver qi stagnation often results from emotional conditions, such as chronic anger and anxiety. However, the removal of the gallbladder also contributes to emotional states, including anger and depression. Therefore, it’s important to care for yourself psychologically and emotionally. I personally strongly recommend meditation for stress reduction, though I understand it’s not to everyone’s taste. Listening to binaural beats or isochronic tones (I like the ones by FingerprintDiva on YouTube) can get your brain into a brainwave state which is very helpful for promoting good sleep and relaxation–look for alpha waves specifically.
I personally do not endorse fasting “liver cleanses” with olive oil and lemon juice or epsom salts. If you have PCS, your liver is already under a lot of stress. A course of dandelion alone is a safe, gentle detoxifier. Besides, your problem here isn’t a buildup of toxins per se. If you feel the need to detox I would recommend just doing a short fast, supported by herbs, as opposed to fasting + giving yourself a massive case of the trots for no reason.
I’m not a doctor or expert in physiology; what you read here is the best information I’ve been able to compile over the last couple of years. So far as I know, there is no other place on the web that puts all this info together for the PCS sufferer (although the internet is vast and I could be wrong). I hope the info will be useful, but as with anything your mileage may vary. Finally, everything I have suggested here as a remedy should also benefit those who still have gallbladders that are giving them trouble.