It's gratifying that despite my absent posting for many weeks, this blog still gets over five hundred visits and more than a thousand page views daily. This I attribute to the fact that some of my stuff comes up on searches for medical information, which makes me feel as if, whether or not I regain my enthusiasm for bloggery, my work will have been of use. (Or maybe it's just that people like coming by when I'm not around so they don't have to worry about running into me.)
Anyhow, I still get comments and questions; quite frequently on the subject of gallstones, about which I wrote a series (one, two, three, four) of posts many months ago. A recent visitor asked some good questions about non-operative management of gallstones, and I was surprised and disappointed to discover that I hadn't really covered it in my prior series. So this is an attempt to rectify (a term which I used in a punny context -- and one which gets hits now and again, from the perverted and/or the easily amused, ever since -- here, and here.)
Let's start with a gentle statement of fact:
OF ALL THE BOGUS, DISHONEST, DISINGENUOUS AND STUPID BULLSHIT THAT MASQUERADES AS ALTERNATIVE MEDICAL METHODOLOGY, "GALLBLADDER FLUSH" IS AT THE TOP OF THE LIST. THE PURVEYORS OF IT ARE, AT BEST, CREDULOUS; AT WORST, THEY ARE CHARLATANS AND (LITERAL) SNAKE-OIL SALESMEN WHO WILLFULLY DECEIVE AND STEAL FROM THE SICK AND THE VULNERABLE, AND ARE TO BE COUNTED AMONG THE SCUM OF THE EARTH.
OK, let me tell you what I really feel.
Over the years, particularly after the dawn of that series of tubes called the internet, patients have asked me about "gallbladder flush" as a method of eliminating gallstones. They've handed me recipes (which commonly include some sort of oil and something acidic like lemon-juice, with a few plants thrown in), and, in some cases, have proudly presented me with little cartons of their stool, containing what they are certain are stones they have pooped out as a result of drinking their herbalicious and natural remedies.
Fortunately, as a surgeon, I'm well-used to staring at excrement in its many forms, both within and without the confines of the viscera generally expected to contain it. What I saw was curds. I know stones, and I know curds. These was curds, is what they was. Evidently, if you drink some kinds of oils and chase it with certain acidic substances, what you get is curds in your turds. What you don't get -- and trust me, I've seen the proof in pre- and post-glugging ultrasounds -- is change one in the number and nature of stones in your gallbladder.
As with most other forms of medical woo, the pharaohs of phlushes toss around terms like "toxins", and "weak liver," and "detoxify." They make extravagant claims with no proof. Potions of prevention, like methods that keep the elephants away, are hard to disprove. If my writings over the past couple of years confer me with any credibility at all, please trust me: it simply doesn't work, and the proof -- when there actually are stones -- is easy to obtain. If you really believe it, do it. And then get another ultrasound.
There are, of course, those who push these flushes onto the healthy, onto those with no gallbladder problems at all. Generally those are the ones who have something to sell, and, sad to say, they easily manage to separate the credulous from their cash. Like chiropractic on healthy kids and homeopathy on anyone, it most often does no harm, other than to one's economic well-being, and in the situations wherein it delays needed and actual treatment.
A truism: people who produce the kind of bile that can precipitate crystals will, as long as they have a gallbladder (which is where the crystallization occurs), form gallstones. A corollary: treatments that eliminate stones but retain the gallbladder are generally followed by the return of the stones.
Indeed there are pills that can dissolve gallstones. I've prescribed them, for people who really, really want to try everything to avoid surgery, or for people in whom I've thought the surgery would not be tolerated. The main problems are with side-effects (nausea, cramps, diarrhea typically), and the fact that success depends on the nature of the stones (big ones are unlikely to dissolve, as are ones that contain calcium), as well as the tendency for stones to come back again, eventually. Also, it takes months for the stones to dissolve. But since -- as opposed to flushes -- they may work, such pills are an option, and should be part of the discussion for people facing surgery.
You can also smash gallstones. Twenty years ago, extra-corporeal shockwave lithotripsy (ESWL) got a fair hearing, if for no other reason than it was cool to say the phrase. Results have been predictably disappointing. (My hospital contracted a privately owned, trailer-borne machine to occupy the physicians' parking lot once or twice a month, into which the gallstone-bearing were rolled and pounded. I was told -- by the owners, not the hospital -- I could accompany my patients into the unit and sit there while the technicians did all the aiming and calibrating, and then I could push a button and charge a grand or so. I demurred.)
Similarly, you can guide a catheter directly into a gallbladder and irrigate with a form of ether which, in addition to giving you weird breath for a while, has a chance of dissolving stones comparatively instantly. Long-term, the results are as expected. Short-term, there may be the really rare situation in which it could make sense.
Of all the things a person can do to live non-operatively with gallstones, dietary changes make the most sense. Typically, gallbladder attacks happen after eating a fatty meal, so, theoretically, modifying one's diet to avoid fat and any other personal triggers makes sense. Theoretically. In some people it's a very linear relationship: eat fat, have attack. Don't eat fat, don't have attack. But for many, the attacks come in no relation to eating.
Of all the things a person can do to live non-operatively with gallstones, dietary changes make the most sense. Typically, gallbladder attacks happen after eating a fatty meal, so, theoretically, modifying one's diet to avoid fat and any other personal triggers makes sense. Theoretically. In some people it's a very linear relationship: eat fat, have attack. Don't eat fat, don't have attack. But for many, the attacks come in no relation to eating.
On the other hand, by far the majority of people with gallstones who have symptoms (NB: not everyone with stones has problems from them. I was among those surgeons who leaned away from operating in the absence of symptoms) don't go on to have the really serious complications that can occur with gallstones. So for the average person, absent risk factors that could make complications more serious were they to occur (diabetes being high on the list), and absent a crystal ball, trying to live without surgery by judicious dietary behavior -- and, for some, trying pills -- is not entirely unsensible. Just, in the name of all that's holy -- or unholy, if you prefer -- don't waste your time, or your money, or your self-respect, on flushes. Really. It's the poster-child, the sine qua non, the Platonic ideal, the Mona Lisa of quack.
245 comments:
«Oldest ‹Older 201 – 245 of 245Hi Dr. Schwab,
As others have previously stated, thank you very much for exposing such valuable information.
I do have a question. My gallbladder was removed and the surgeon stated there were a couple of gallstones and that my gallbladder had a "layer" of cholesterol.
Please apologize my "ignorance" as I am just starting to learn about the detaiks of this subject but, where does cholesterol go after gallbladder removal? Does not having a gallbladder increases the cholesterol in your blood then?
I am mostly curious because I have been taking a supplement called DIMPRO to balance hormones naturally and I just learned that it also helps to "get rid of" extra cholesterol.
I am concerned as to where would this extra cholesterol go without a gallbladder. Don't even know if the gallbladder has anything to do with it but since the surgeon mentioned about the cholesterol layer I just wondered.
Thanks for your time.
Cholesterol is manufactured in the liver, as is bile, which contains cholesterol. The gallbladder is only a storage pouch and has nothing to do with production of either; cholesterol can be deposited in many areas of the body: the skin, the arteries, the wall of the gallbladder.
Removing the gallbladder has no effect on the amount of cholesterol in the blood, one way or the other. Think of the gallbladder as your lawn, and cholesterol as rain. Removing the lawn won't affect how much it rains.
Thanks for providing all this information.
I was wondering what your thoughts are on diet and gallstones. I understand that changing one's diet won't get rid of gallstones that have already formed, but do you think that it could be worthwhile for people who have stones, not large enough to cause serious symptoms, to alter their diet to slow down or even stop the growth of the stones?
Some of the dietary recommendations I've read about are as follows:
Reducing saturated fat and cholesterol.
There's some evidence that consuming monounsaturated fats can reduce the cholesterol content of bile.
Increasimg fibre should slow down stone growth by binding to food cholesterol and bile in the gut, causing their removal from the body.
As you yourself mentioned, gallstones are hormone related. Too much sugar and refined carbs can increase the risk of gallstones by increasing the secretion of insulin. Elevated insulin can increase the concentration of cholesterol in the bile.
As body mass index increases, so does the risk of developing gallstones, especially if excess weight is carried around the abdomen. Abdominal fat can cause hormonal changes thought to promote gallstone formation.
Very low-fat diets and skipping meals can decrease gallbladder contractions and prevent it from emptying completely.
Vitamin C is needed to properly synthesize bile; without it bile becomes cholesterol-rich increasing the likelihood of stone formation.
Calcium and magnesium bind to bile acids in the gut eliminating them from the body.
Would you recommend any of this to a patient that is not at a stage where surgery is the only option? Or do you think that diet is irrelevant?
Is gall bladder disease genetic, or is it caused by poor dietary habits that are passed down?
As I've written, there are many factors in gallstone formation: dietary, genetic, hormonal, as well as certain blood diseases.
I had an ultrasound done and the report said that I had "sludge" gallbladder sludge. I would like to get rid of the sludge and have not had a lot of luck doing a Google Search and would very much have some personal suggestions if you have any. Please let me know if you have a treatment for my sludge.
Thank you very much.
Mike
"Sludge" is an ultrasound finding of variable significance. Bile gets concentrated (thickened) as it stays in the gallbladder, so it's hard to know when a finding of sludge is just that: normal. In some people it may indicate the kind of bile that goes on to form gallstones. Sometimes it just goes away.
What to do about it depends on whether the person has symptoms suggestive of gallbladder problems. If there's a strong suggestion of biliary symptoms, then, just like with stones, removal of the gallbladder is the generally recommended treatment.
If symptoms are minimal or absent, then there's nothing that needs to be done. Reducing fat intake in your diet might help. Pills to dissolve gallstones are of questionable value for sludge.
If you don't mind me repeating my question: would you recommend dietary changes as an alternative to surgery? I mean for a patient that is not at a stage where surgery is the only option?
I did read your article, and I am aware that you stated that there are multiple factors in stone formation. I am sorry to repeat the question but I am genuinely interested in your recommendations as a specialist in this area.
I have asked specialists about this before (in person) and they declined to answer for some reason. Is this a touchy issue? I would have thought it was quite a simple innocent question.
jeronimus: I see I didn't really give a decent answer. Sorry. If diet is a factor in stone formation then it follows that in those cases where it was, altering diet might affect future growth or formation of stones. I don't know if that's been studied; because, if you have them, it really doesn't matter, in terms of future behavior, whether they get bigger, or increase in number. But it might well be the case that a lower fat diet would have impact.
Diet can, but doesn't always, affect when a person has "attacks," so I've told people in whom it seems to play a role, and who prefer not to have surgery, that it makes sense to avoid those foods which seem to be triggers, which usually means foods high in fat content.
On the other hand, since timing of attacks often has nothing to do with food intake -- or is related to eating anything at all, in some people -- dietary manipulations aren't a panacea.
Dear Doctor,
Thank you for your wonderful blog.
I'm 50 years old and general healthy. I have been diagnosed via ultra sound and CT scan as having gall stones. I have been reluctant to have surgery because my attacks don't appear symptomatically to match the typical symptomatic indicators I've read about. I have no sensitivity in the area of the gall bladder, never have any pain in that area, never experience and pain radiating to the back or shoulder. My pain appears to always be in the chest or around the ganglion just below the sternum. An EKG and stress test showed that the heart is not the problem.
I had an endoscopy which revealed a small hiatal hernia so the doctors aren't sure what's the source of the occasional attacks.
What really scared me even more than the attacks was the fact I began experience, in parallel, fasiculations in my left arm and occasional sharp pains in my legs. These symptoms come and go but tend to be more present should I eat meat or fat.(I'm basically vegan but sometimes I try some meat or fat because I worry about the lack of essential fatty acids which resulted, I believe, in systematic tooth decay).
Question: Have you ever had a patient with fasciculations or pin point pain in the legs due to gall bladder problems? Could an improperly functioning gall bladder result in toxins backing up into the liver or blood manifesting in neurological symptoms? Or maybe..could an improperly functioning gallbladder lead to the malabsorption of nutrients needed for a properly functioning neurological system?
Would so much love to hear your opinion.
Thank you for your blog.
Michael
Michael, I've never had a patient with such symptoms related to gallbladder disease, and am unaware of nor can I think of any physiological way in which they'd be related.
Dr. Schwab,
I am one who still thinks I am passing small, stones ( and one large one) .
40, History of severe ulcerative colitis in active flare. One " attack" had ultrasound. Mostly Full of stones. Gallbladder not thickened or infected. Cholesterol also mildly high
I didn't want surgery. Asked for ursidiol. Have proceeded to lose a ton of weight. No attacks but unexplained weight loss and diarrhea. In stool is often appearance as if someone broke a macadamia nut into hundreds of small pieces scattered when nothing I ate matches it. Also a few black grit bits that are teeny tiny specks. Then recently, I felt a lot of pain for a few days. Looked down and saw a big old yellow thing. Size of a Brazil nut ish. Measured one inch long but narrow and a feeling of tremendous physical relief after days of misery. I also pass more of these little " stones" when I have consumed low chol veggies and a trace amount of salad dressing with oil and avocado. Not totally unlike the " flush" but not the flush. And I have also added niacin and soluble fiber to try to clean out my bile. Karenhurd.com suggested soluble fiber alone can help dissolve. So all this is to say, the one inch stone scared me. If it was one. Because it hurt badly and the fact that it ended up not stuck didn't ease my mind all that much about the future. I have never wanted to flush stones but rather dissolve them and change the dynamics of more cholesterol than bile with dietary changes. So I haven't eaten low fat as much as low cholesterol dietary. And above all, I fear the bile dumping into my already damaged colon and flaring the colitis worse after no gall bladder. Since I am mostly a symptomatic on attacks and infection, I thought the ursidiol was a good stave off surgery ex devour. Now, I am concerned I might actually be passing stones. The large one was yellow. Oval. And hard. One inch long by 1/4 in wide. Most are this trace small broken nut appearance. Nothing like the photos online really. And my colitis is in a severe flare. I had hoped to at least stabilize it before surgery. In this case, is continuing the ursidiol and just looking for signs of pancreatitis as the give up point ok or could I ACTUSLLY be passing stones which may or may not be quite dangerous.
Shelley: The only way you could pass a one inch gallstone out of the gallbladder is to have had a gallbladder infection severe enough that it plastered your gallbladder to your intestine and then ate a hole into it. This can actually happen, but it's pretty rare, and such an episode of infection would hardly have been silent. So, no, I think it's close to impossible that that big thing was a gallstone.
The purpose of ursadiol, far as I know, is to dissolve stones. It doesn't work on large ones, but the small ones that were seen might have dissolved. But I don't know of a therapeutic strategy that involves the long-term use of the drug. Most docs I know would say that if it hasn't dissolved them after a few months, there's no point in continuing it.
The only way to know if those things you describe in your stool are stones coming out of your gallbladder (which I strongly doubt, for reasons I've explained many times in this comment thread, including the fact that passing gallstones is usually not a benign, painless process) is to repeat the ultrasound to see if they're diminished, or to have them chemically analyzed.
I know of no evidence that soluble fiber dissolves gallstones. I don't doubt that there are people who claim it. People who have no idea other than a good imagination.
Finally, as I've also written, having your gallbladder removed has no effect on the amount of bile that reaches your colon. With or without a gallbladder, your liver makes the same amount of bile, about a liter a day, most of which drips steadily into the duodenum from which it ends up in the colon. The few tablespoons that sidetrack into the gallbladder eventually end up there, too. In terms of how much and when bile gets to your colon, the gallbladder is irrelevant.
Hi Dr. Schwab!
I found your blog in the process of looking for answers to the questions I have about my pathology report. I fall into the group of "maybe" patients because my symptoms and scans were not straight forward, as I experienced episodes of vomiting and feeling ill but no pain other than a positive Murphy's sign. My ultrasound was completely normal, but my hida scan (which was not preformed with CCK but they had me drink 12 ounces of heavy cream) came back at 19%.
When I met my surgeon I was under the impression that the surgery was no big deal. He assured me that I would be sore for a couple days but after that I would bounce right back. My main concern was the confusion over IF my problems were actually caused by my gallbladder since there wasn't any clear evidence of WHY it wasn't functioning properly, but the surgeon basically told me not to worry about WHY and that I would be fine without my gb regardless and if I had more problems after surgery then he would run more test. Easy peasy, right?
After I woke up in recovery I assumed something had gone terribly wrong because I was in so much pain that I could hardly breathe. I've had four c-sections in the last 10 years that were a walk in the park compared to the pain I was in. I asked several nurses if I could speak to my doctor and ask if something was wrong and if I was suppose to be hurting like that. Apparently he was already gone, and I would be able to speak to him in two weeks for my follow up.
I could barely get out of bed for over a week. In retrospect I believe if I would have gone into the surgery with realistic expectations (since doing my research on what actually happens during a cholecystectomy, which in my opinion is not so minor) my recovering would have been easier or at least expected.
But back to the problem at hand, I received a copy of my pathology report as I was checking out of my surgeons office (no surprise that he didn't even attemp to explain anything to me) and I'm hoping that you can translate the report in words that I can understand.
Gallbladder is intact with a smooth gray-pink (what color should they be?) serosal surface. The specimen contains yellow-green viscous bile (normal?) and no calculi are identified following formalin filtration. The mucosa is yellow-green and velvety (normal?) with no lesions identified. The wall thickness averages 0.2 cm. The cystic duct is patent and no periductal nodule is identified. The en-face cystic duct margin and respresentative gallbladder are submitted in A1.
Microscopic description: the sections demonstrate a benign gallbladder wall showing Rokitansky-Aschoff sinus formation (what in the world is that???). Chronic inflammatory cells are seen. Negative for dysplasia or malignancy.
Does that sound like my gallbladder was diseased or are those just asymptotic incidental findings? Thank you in advance for any advice/insight you might have.
I'll try to be diplomatic. First, a positive Murphy's sign is useful (or, at least, often present) in the face of gallbladder inflammation. People who have a positive Murphy's sign related to gallbladder disease would nearly universally have an abnormal ultrasound, showing clearcut inflammation. There are other reasons for tenderness in the area, such as a doctor pushing real hard, a sore muscle, something going on with the colon, etc.
As I've written in my other gallbladder posts here, I considered HIDA scans useful when all of the following are true: the patient has pretty typical gallbladder symptoms, ie the sort of colicky pain I've described elsewhere; when the HIDA is clearly abnormal; AND when injection of CCK (or, I suppose, eating fatty stuff) reproduces those symptoms. In that case, surgery has a reasonable chance of helping. But not 100%.
When I saw people where the preceding was not the case, I generally recommended against surgery. I never suggested removing the gallbladder and if that doesn't work we'll look into other things. I sent the patient to a gastroenterologist to try to rule out other possibilities before choosing surgery.
The most common cause of severe pain right after surgery, assuming it was laparoscopic, is retention of some of the gas used to distend the abdomen during the operation. Other causes could include blood or bile, which, if the pain eventually goes away, would not have represented a significant problem.
I'd translate your pathology report as normal. Rokitansky-Aschoff sinuses are microscopic size pockets in the gallbladder wall which can be an incidental and insignificant finding; although they're also associated with inflammation. Doesn't sound like there was significant inflammation in your case, so I'd not consider the finding of concern.
The bottom line, of course, is whether or not you have or will notice improved symptoms. It's easy to recommend surgery when everything is "textbook." When it's not, it's a matter of judgement, and I'm not in a position to judge individual decisions of which I wasn't a part.
Based on the conversations I've read here, you are a respectable MD with prudence, wisdom, experience, more humility than many arrogant and negligent MDs, and a sense of humor. Thank you for those admirable character traits. (Even though you demonstrate a slight medical prejudice and towards chiropractors, in ignorance of what they actually accomplish, which is forgivable. I have benefitted greatly from their care for 4 decades, in maintaining my overall health.)
I am a 60 yr-old male. In excellent health. (Sensitive gut, however.) I exercise regularly, sleep well, and eat a real food/plant-centered diet with occasional eggs, meats, fish and cheese. No alcohol. Low sugar. Low fat. Plus, good fermented foods regularly for bowel health.
But----I have been experiencing infrequent, apparently random GB flare-ups, and one particularly disconcerting episode which ruined my Christmas Day. I have been on the Internet for 2 days researching, while my symptoms have subsided. Being a health-food kind of guy, I gravitated first towards the cleansing approach, hoping that would be my cure for this distress and prevention of a future episode. I have come to agree that the so-called Liver/GB flush is anatomically and physiologically bogus, but what should I do now? Just have an ultrasound and decide if i have stones to either live with them and curb my dietary oils and fatty foods or consider surgery? You must admit, the gall bladder is an important organ, or God wouldn't have designed it. Same for appendix and tonsils which are so frequently (sometimes carelessly) yanked out when inflamed. (I am glad they removed my inflamed appendix at age 12, in an almost emergency situation, but my gut's never been the same since; prone to continual irritability. Your suggestion on my "possible" GB situation would be appreciated.
Thanks for a thoughtful comment, Mr Crooker. I'll try to respond in kind.
Congratulations for doing enough research to realize that gb flush makes neither anatomic nor physiological sense. I'll refrain from much commentary on chiropractic, other than to repeat what I've said before: for specific spinal situations, manipulation makes sense. But the theory on which the rest of it is based has no basis in physiology. "Legitimate" chiropractors, meaning ones that limit themselves to what amounts to physical therapy for known conditions, have a role to play. But those that wander into treating medical conditions, or who convince people they should have regular manipulations for prevention are, in the first instance, dangerous and in the second, charlatans. Keeps the elephants away, though, right?
As to your specific issue. I infer you haven't yet had gallstones diagnosed, in which case it's a little speculative that your gallbladder is your problem. Assuming you do have stones diagnosed at some point, and that there's good reason to believe they're the cause of your symptoms, you indeed have the choices you laid out: live with the symptoms or attempt to control them satisfactorily with dietary measures, or have surgery. (You can try medical [legitimate] stone dissolution but, as I've written, the results aren't uniformly good.) I rarely tried to talk someone into gallbladder removal if they didn't want it; just tried to lay out the possible consequences either way.
As I've written, the vast majority of people who have their gallbladder removed, assuming it was done for the right reasons, are happy and suffer no side effects. I've written about why that is, in the other posts on the gallbladder in this blog. In brief, it had a role when man was a hunter/gatherer, eating sporatically, gorging on a greasy meal every few days. In modern humans who eat regularly, not so much. It's only a storage pouch for bile, not a manufacturer.
There's very little evidence that the appendix serves an important function in humans; I've written here about that, too. As to "design," well, to me it speaks loudly of evolution: the appendix, in humans, is vestigial, a remnant of a once-useful function in our progenitors. It'd be hard to show that your current intestinal issues have anything to do with having had appendectomy. Post hoc/propter hoc, dontcha know?
I would be remiss if I did not first extend gratitude for this amazing blog. Your knowledge, time spent, sense of humor and thoughtfulness have been a true blessing. I have read every post. Thank you.
Not sure if you are still posting, but.....I did not come across in your blog what happened to me. I had the most excruciating pain recently in my abdomen just after eating, combined with extreme sweating. Lasted between 30-45 minutes. Pain only subsided after I forced myself to vomit. My mother and sister have gallstone issues, and their GB attacks mirrored mine. Runs in family. Doctor appointment this week for initial consultation. I am 57. Can throwing up ease the pain from a GB attack? If so, why?
Thanks for your kind words, Leo.
What you describe is consistent with a gallbladder attack, so it makes good sense to be seeing a doc. As to vomiting and pain, I don't know of a reason why vomiting would end a gallbladder attack, but they can certainly be associated with vomiting, and they generally last in the range of time you describe. So if it was a gallbladder attack, it might just be coincidence.
Thank you for this blog, Dr. Schwab. I have a question regarding my situation. I'll try to keep the background brief: Two attacks in January of last year, X-rays, CT, and ultrasound revealed nothing unusual at the time. One attack in January of this year, but this time, the ultrasound revealed a 15mm gallstone. Outside of these 3 attacks, I feel great. I'm a 43-year-old male who is active, athletic, healthy, and otherwise loving life. I have surgery scheduled for April 7th, but I am still agonizing over this decision, given how good I otherwise feel. Can you comment on any experience you might have with patients who tried to save their gallbladders with diet, herbs, etc. only to eventually end up giving up the battle and having the surgery? This may be a better question for a general practitioner, but I thought maybe you may have some insight to share, given your extensive experience. Thanks!
I've said here many times, but by now it's all buried in many posts and countless comments, that I rarely tried to talk people into having their gallbladder removed if they really didn't want to. I found it to be true, and I think others with experience generally agree, that people who have gallbladder "attacks" generally keep having them. It's usual to feel fine between them; and no one can say if you'll have more for sure, or, if so, when and how often.
It's also true that it's uncommon for a person to go from having stones with no symptoms, to having the more severe complications that can occur from stones, without first having a period of intermittent milder symptoms. That's the argument for not doing anything if one is found to have stones but is having no symptoms from them.
Similarly, the majority of people who do have episodes like yours don't evolve into the dangerous complications. So if a person chooses to live with occasional attacks, and recognizes there's some chance of having more severe problems such as infections or jaundice or pancreatitis, I've generally felt it's their choice to make. The ones on whom I exerted more pressure were those who'd had infections, etc, and recovered, or those with higher risk of severe infections, such as diabetics. OTOH, even if a person gets a severe complication, as long as they get timely treatment, they're likely to be okay. Likely. Not certain.
Long answer, eh? In short, yes, I had many patients who chose to defer, trying diet, medication, etc, who eventually chose surgery. No crystal ball here.
Hi Dr. Schwab. A follow-up to my recent post. I just received GB ultrasound results; no stones but there are polyps? I would very much appreciate your experience with that, and opinion on necessity for GB removal. Can polyps cause a GB attack? Thank you so very much.
Oh, boy, Leo. Gallbladder polyps are yet another gray-zone issue in terms of gallbladder management. Do they cause symptoms? Maybe. Sometimes. Or not. Do they represent a risk for other issues, specifically cancer? Maybe. A very low risk most likely.
At what point is it reasonable to have surgery for polyps? Some say if they're big enough, ie a centimeter or so, the risk of cancerous change increases. It's not really known for sure. If a person is having classic biliary colic and the only finding is polyps, can they be the cause? Maybe. Sometimes.
Can small stones be mistaken for polyps? I've operated on people in the above circumstances an found that in fact there were stones.
In your specific case, best to talk it over, I guess, with a surgeon. Meanwhile, here's a link:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3359430/
Thank you, Doctor, for your blog. I just read through all of the comments in this thread and I will be reading your complete info on gallstones next.
I've had many very painful episodes with my gallstones over many years. I tried a few flushes when first diagnosed 20 years ago. I tried eating better but find I yo-yo back and forth from eating very well to very poor. Over the years I went to the ER several times due to the pain and was always advised to pursue gallbladder removal. But then I would go to the Internet and read all of the stuff that says I shouldn't do that and that I should do flushes instead. So, I've avoided surgery all of these years. I'm 52 now.
I've had two attacks in the past year and a half, one was mild and the other was quite intense but not enough to get me to the ER. The last attack was months ago but I recently decided to see a doctor about by gallstones.
I had an ultrasound last week that noted the many stones in my GB. I'll see a GI doctor tomorrow to discuss that result. I'm sure surgery will be recommended again.
I was considering trying more flushes and was doing research about this idea when I found your blog, which has gone a long way on convincing me to finally get the darned surgery.
I've been struggling with this decision, so I just wanted to thank you, very much, for taking the time to provide this information.
I do have one question. If oil, apple juice, etc. can not get to the stones in the gallbladder due to the physiological structure, how do the bile acids medicine get there? Through digestion and bloodstream or ?
Well, you've made me flush with pride that my blog is helpful. I may not be right in all things, but the bogosity of flushes has been established beyond doubt. Which make it puzzling, at best, that so many still believe in it. Those bits of curdled oil are pretty convincing, I guess.
As to how such meds as ursadiol work, this says it better than I could:
DRUG CLASS AND MECHANISM: Ursodiol is a naturally-occurring bile acid that is made by the liver in humans and is secreted in small quantities into bile. It is used to dissolve and prevent cholesterol gallstones and to treat primary biliary cirrhosis, a disease of the liver. Ursodiol blocks the enzyme in the liver that produces cholesterol and thereby decreases production of cholesterol by the liver and the amount of cholesterol in bile. It also reduces the absorption of cholesterol from the intestine. By decreasing the concentration of cholesterol in bile, ursodiol prevents the formation and promotes the dissolution of cholesterol-containing gallstones.(http://www.medicinenet.com/ursodiol/article.htm)
Like most other meds, it gets absorbed from the gut into the bloodstream. From there, as with all thing absorbed from there, it goes to the liver.
Dr. Schwab,
Thanks for the response to my question about how the bile acid medicine gets to the stones. I sign in as Anonymous because I don't have a Google account, but you can call me Mark R.
I saw my GI doctor yesterday and, yes, he referred me to a surgeon. That will have to wait because my insurance is changing from Blue Cross to Kaiser starting July 1st, so I'll have to start over with a new primary care physician.
Like I said in my last post, I just had an ultrasound of my abdomen on June 11, 2015. I've got a copy of the report and the images. You can see the stones in my GB. There appears to be several big ones that are about 10mm in size. Hard to imagine how those would be expected to pass through my 2.5mm common bile duct. That's a bit on the small side of average.
I think you are right when you say that the stones can't be flushed out, but I find myself tempted to give the castor oil packs and olive oil/lemon juice flushes a thorough test just the same. I think it would be good to have someone (me?) who is willing to provide some "proof" for others to consider.
I could do the flushes for a few months and then get another ultrasound through my new insurance provider. That would provide proof as to whether or not the flushes did me any good. Then I could share the results on your blog if you like.
Do you see any risk if I do that? I mean other than the risk of delaying surgery. Could there be a risk of the flushes causing me a problem?
I don't know if I'm actually willing to do this or not. As I recall, oil packs and oil/juice cocktails aren't a lot of fun. But I am thinking about it.
Mark R.
P.S. Reading your blog really did strongly sway me toward finally having the surgery. But then I had to go out on the Internet and read a bunch more from the advocates of gallbladder flushing and a bunch of the comments from folks who continue to suffer pains and bad digestion after having the surgery. And I found my self uncertain of my decision once again. That is what we gallbladder patients are faced with and it makes it very difficult to decide what to do.
I understand your frustrations, Mark. And, of course, it's impossible to sort through internet information to cull out that which is meaningful and that which isn't. In my experience, those people who had the surgery when symptoms were clearly related to stones, and had documented stones, were uniformly happy with the outcome. Sadly, there are people in whom it's not as clear that the gb is the problem, who've had surgery anyway, with less than great results. And, yes, it's true that some people will have digestive changes after removal. Remember, though, that it's about the most commonly done operation, and the 99% who're satisfied have no reason to be posting complaints. I did well over a thousand cholecystectomies in my career, and can count on one hand those that had issues; and of those, the solutions were simple dietary adjustments.
As to your idea of being an experiment of one, I'd love to see the results, although I'm absolutely certain, in terms of the stones, what the result will be. The main risk, as you said, is of having intervening complications from the stones. Who knows if it'd happen? As to risks of the flush itself, I suppose it depends on the exact recipe you follow and for how long. I'd guess if you do one that causes lots of diarrhea, for example, there could be problems from that. I suppose there could be risks from ingesting lots of oils, too, in terms of blood lipid levels and the leeching out of certain vitamins; but I have no direct knowledge nor experience on which to base it.
Good luck.
Good thoughts, Doctor. You have given me much to consider, and your comments have helped me to feel very reassured that having the operation would have a positive result.
I'll think things over a bit and decide how to proceed. At least I am finally resolved to deal with these stones and to do so within the next few months.
I'll let you know how things go.
Thank you for caring enough to be here for us.
Mark R.
Not sure if you still check comments, but in the hopes that you do: Your blog has been extremely helpful as I try to make my surgery decision, so thank you so much for that.
Question: Regarding Post Cholecystectomy Syndrome, what is your theory for its occurrence? Do you think the gallbladder was never the real issue, or do you think it was and these people are just unlucky enough to not live well without one?
I'm a 43-year-old woman, and I've known I have gallstones for at least 15 years. I thought they never gave me trouble, but am now wondering if the occasional gnawing, clenching pain I felt in my upper abdomen, right in the center below where my ribs meet, was actually my gallbladder acting up when I was eating poorly. I assumed it was an ulcer or heartburn. At least one doctor told me years ago it was my gallbladder, but since I could eat a pretty high-fat diet with very little problems, and my pain was never directly on my right side, I ignored it.
I had my first classic attack last Thanksgiving (before I ate), ending up in the ER thinking it was a heart attack. The pain was unbearable but only lasted between 30 and 40 minutes. But I was able to go home and eat Thanksgiving dinner with no problems. My second attack was about two weeks ago, on an empty stomach, and consisted of severe stabbing pains throughout my abdomen and back. The pain lasted four days - nothing I took relieved it - and became so bad on the fourth day I went to my doctor. She felt around my abdomen and I yelped when she pressed on my gallbladder, even though the pain seemed mostly on the left side (but certainly there was plenty on the right, and everywhere else). An ultrasound showed a gallbladder "virtually filled" with stones and walls thickened to 7 mm. Blood tests showed slightly elevated white blood cells and liver enzymes. I couldn't eat solid food for nearly a week because of the pain.
The surgeon I was referred to said it was a no-brainer to take it out. But, like most other people here, Ive seen far too many negative experiences to take it as cavalierly as many doctors seem to. And I know of at least two people who have had it done and now have to cope with urgent and unexpected diarrhea after eating certain things. As of now the pain is mostly gone, but just enough little cramps and stabs (incredibly minor) remain for my gallbladder to let me know it's still not happy.
I know there really aren't any studies on the ability of the gallbladder to heal or to reverse disease. But I'm still in agony over this decision. When I think of scheduling surgery, I break out into a cold sweat and think, but what if?? I already canceled surgery once, but I know I need to make a decision.
Well, Erin, I have to agree with your surgeon. Whereas there are situations, as you've read here, where it's unclear if the gallbladder is the culprit, in your case you've described both biliary colic (pain episodes without evidence of inflammation) and cholecystitis, where the gallbladder is inflamed. The former, if that's all there was, is only a matter of choosing to live with episodes or not; the latter is potentially more serious. In your case, having stones, story, and evidence of inflammation, unless you have other medical issues that make surgery risky, I doubt you'd find any surgeon who'd suggest otherwise. (Disclaimer: I base my comment on what you've written, and without access to all the relevant info, of course.)
No one has a crystal ball; we base recommendations, to a large extent, on what's known about large groups of people. You're in a category where it's highly likely to be a recurring thing, and where more serious complications might occur. Maybe you've already had all the trouble you're gonna have; maybe next week something dangerous could happen. There's no way to tell, individually.
I think "post-cholecystectomy syndrome" is a very capacious and mixed bag; ie, it includes people who didn't need the surgery because their symptoms were due to something else, and it includes a lot of vague issues that might or might not be due to the absense of the gallbladder. As I've written, the vast majority of people who have the surgery for the right reasons (which, based on your information, would appear to include you) are happy to be rid of the symptoms and note no adverse after-effects. I won't rewrite here my take on why that is, but you can find it in my several posts on the gallbladder.
It's true that some people have diarrhea after the operation. The number, in my experience, is small. I've taken out a couple thousand gallbladders and have had only a couple of people with diarrhea that wasn't easily controlled. By far the most never had it at all; or if they did, it went away within a short time after surgery. As you probably surmise, people post their horror stories online. People who sailed through, ie nearly all of them, have no reason to.
Good luck with your decision. If I had that crystal ball, I'd tell you exactly what you want to know. But I'm pretty sure I know anyway.
I cannot thank you enough for your thoughtful response. It is so appreciated as I try to navigate this new world of information. I have seen some horrifying things on SOD - and the fact that it's more likely to affect women - that still give me pause, but your words have been incredibly helpful and reassuring. So thank you so much for taking the time to respond, and thank you for all that you do here.
Hello Doctor,
Mark R. here. I first commented here in June 2015.
Well, I decided to not do any more flushes and chose to go a different path. I've spent the past year getting acupuncture and taking Chinese herbal medicine. Those seemed to help my psoriasis condition somewhat but did not help my gallstones at all. I just had another ultrasound and my GB is still packed full. To be fair I must admit that I wasn't at all consistent in following the Chinese Doctor's dietary advice, so I don't want to judge the efficacy of his treatment on my experience alone.
So, I decided to go for surgery. I'm scheduled for November 21st, 2016, unless a cancellation can get me in sooner.
I haven't had any symptoms for almost two years. My GB looks ok with just a little bit of wall thickening. Prior to these past two years I had many attacks over a 20 year period. Several of those attacks drove me to the ER seeking relief from the pain. I know that no one can predict if I will ever have another attack or not. I just don't really recall a time where I would go so long without any discomfort or symptoms of my GB acting up.
I think getting the surgery now is a good idea to avoid the possibility of needing the surgery in an emergency situation sometime down the road. I'm 54 now and in good health. I wouldn't want to go through this when I'm much older and perhaps less healthy. Do you feel I'm making the right choice now, or does the lack of symptoms for two years and the good condition of my GB in the ultrasound test suggest that I should not have surgery at this time. Perhaps, just wait and see if my GB acts up in the future?
Thank you,
Mark R.
I really can't (well, I could, but I choose not to) make specific recommendations to individuals in this venue. All I can say is that in my practice if people had stones and had had symptoms, I recommended surgery. I also said no one can predict what'd happen with or without it. And unless the person had complicating factors like diabetes or immune system disease, either of which could make a gallbladder infection more dangerous, I generally didn't try to talk them into it. The main reason is to relieve symptoms, and the secondary reason (how far down the list is a subjective thing) is to prevent future problems.
So, as a general approach I'd say that a person who has stones and who's had symptoms is making an easily supportable decision to have surgery.
Hi Doctor Schwab, and thank your for your response.
I do understand why you can't give specific advice here, and I really do appreciate how you try to give all of the facts and options that are available.
As I said before, I have not had any symptoms from my GB in over two years, so I hate to have the surgery if I'm not really in need of it. However, I had many, many attacks over many years and my GB is still very full of stones, some of which are very large. And I suppose I will just keep making stones as time goes by, so there is probably a good chance of future attacks.
I will still go ahead and have my GB removed as a preventative measure. I really don't want to ever have to go through that excruciating pain again. However, no one wants to undergo surgery, ever. Understanding that you can't give me specific advice, can you tell me if you would get the surgery if you were in my situation? Or am I trying to cheat here? :-)
In any case, thank you for the wealth of information you have provided here.
God bless,
Mark
If I had symptomatic gallstones I'd have my gallbladder removed.
Dr. Schwab,
Yes, I'm going to have the gallbladder removed on Nov 21st. I'll be glad to be done with it after all of these years.
Thanks again for the valuable information you provide here, and thanks for your responses to my questions. You make a difficult decision easier to process.
Sincerely,
Mark R.
Hello again Dr. Schwab,
Mark R. here. Well, I had my gall bladder surgery a little over one month ago. The surgery was done laparascopically, so I only have four little scars that have been healing up very well.
I am feeling great and have not had any problems since having my gall bladder removed. In fact, I am greatly relieved to not have to deal with the little bugger anymore.
I just wanted to come back here to thank you very much for your blog and responses to my questions. Thank you! You truly helped me to finally decide to do what I should have done over 20 years ago, get that darned thing out of me!
Let me say to anyone else who is struggling with their decision about gall bladder surgery that I wish I had done it many years ago. I put myself through much needless suffering and wasted a lot of time, money, and energy pursuing alternative treatments (oil/lemon juice flushing-many times, acupuncture and herbs, controlling my diet, etc.) None of this worked at all! I had many terribly painful attacks over many years, but I was stubborn and wanted to believe I could find another path. I was very wrong in that belief.
My surgery went very well. I experienced very little pain. In fact, I only took one dose of the painkiller prescribed. I even returned back to work six days after my surgery (desk job). And now knowing that I will never have to worry about this again is very, very satisfying. That's my testimony. Good luck with your decisions out there.
Again, thank you very, very much Dr. Schwab! Enjoy your holidays and happy New Year!
Thanks for taking the time to follow-up, Mark. Glad (and unsurprised) it worked out well.
I learnt I have a calcified 2.5cm gallstone in the gallbladder from a CT scan. Given the gallbladder does play an important role I too have searched for options to be able to remove the gallstone but retain my gallbladder. Why isn't the percutaneous endoscopic-laproscopic cholecystolithotomy procedure available as an option for those who wish to retain their gallbladder?
I would appreciate your advice.
As you've no doubt learned, alfredo, a 2.5 cm calcified stone won't dissolve medically. And, as I've written, people who form stones tend to keep forming them as long as they have a gallbladder, even if the original stones were made to go away. I'm not sure what you mean by "percutaneous laparoscopic-endoscopic cholecystolithotomy." I haven't heard that combination of terms, since they sort of preclude each other.
To remove a one-inch stone would require either a sizeable hole in the gb, or the breaking up of the stone by lithotripsy. The latter leaves fragments inevitably which might or might not pass and might or might not cause complications if they do. Lithotripsy fell out of favor not long after it began, because of complications and low long-term success.
The good news is that stone as large as yours is virtually impossible to pass out of the gb to cause serious complications such as cholangitis or pancreatitis. Assuming there aren't any smaller ones hiding in the shadows. So if you're set on retaining the gallbladder your future complications are likely to be limited to episodes of colic and the possibility of cholecystitis. And, as you may have learned, the long-term risk of gallbladder cancer which pretty much only occurs in people who've had gallstones for many years. While relatively rare, it's an aggressive one.
The bottom line, as I told my patients, the main reason to remove the gallbladder is to relieve symptoms. Preventing future complications is an issue, but a crystal ball sort of thing. So if you're having symptoms and they're tolerable enough that you prefer to live with them and you're okay with possible future risks of unknown likelihood, it's not an unreasonable choice. But there really isn't any viable "between" option.
Thank you for your reply. The minimally invasive cholecystolithotomy procedure using a laproscope and cholecystoscope has become a routine gallbladder (GB) preserving procedure in China in recent years. An incision is made in the fundus of the gallbladder and a soft or rigid cholecystoscope introduced into the GB cavity and the gallstones removed using stone baskets and suction. The incision in the fundus is the sutured. The operating time is comparable to laproscopic cholecystectomy. Stone recurrence rate has been shown to be significantly decreased (4% over 6 years) with this procedure but is dependent on lifestyle and diet following tx.
Although I presently have an asymptomatic gallstone discovered during CT scan a year ago, I am concerned about cancer risk the longer I keep the stone and desire to retain my gallbladder as it does play an important function in regulating bile release etc.
My question is why to the best of my knowledge is the procedure only available in China (Yang Zhang et al)when outcomes have been demonstrated to be superior to removal of gallbladder in benign cases?
I don't know.
Sid,
Found your page while looking up the efficacy of the gallbladder purge. You seem to have confirmed what I suspected. Now let me get to my question(s). Hopefully these weren't all answered because I did scan for a while but didn't read everything.
Background: I had a bout of pancreatitis that landed me in the ER. Lipase was up above 20k. The bout lasted a few/couple hours. By the time they had ruled out more serious issues, it had passed. I did have an ultrasound done right after the bout passed which showed no gallstones or other abnormalities. I also had a CT scan done now a couple weeks after the event which also showed no abnormalities. I would assume it was gallbladder related because I have dropped weight relatively fast over the summer (30 lbs at about 2lbs/wk but finished a month prior to the episode). I also generally eat a low fat diet. However, my doctors didn't see any liver enzyme elevation they would expect with gallstones. I've been on various bland/low fat diets since the event 2 weeks ago. I've felt mostly fine but my stomach is off digestively (milk is giving me severe gas).
Now my first question is: Does one need to keep "exercising" the gallbladder to prevent gallstones? My diet typically is 30 grams fat or less I'd guess (since the bout it's been lower I'm sure because I haven't been eating normally). Should I be shooting for more fat, and does it matter what type? I guess I'm worried that if this was gallstones or sludge, that by sitting on this low fat/bland diet I'm going to cause another episode.
Second: my doctor wants to do an ERCP test to further investigate. I'm a bit hesitant to be sedated unnecessarily (it would include intubation). Opinions on the necessity of this test?
Thanks.
Intuitively, the idea of "exercising" the gallbladder makes a little sense: making sure it empties regularly would lower the likelihood of sludge formation. I don't know of studies that address it, however. There are recent studies, however, suggesting low-fat diets aren't as healthy as once thought. (Seems that dietary recommendations change with the weather, doesn't it?) Since I'm no expert in nutrition, I'll leave that decision to you and your docs. Low-fat diets are usually recommended, though, after pancreatitis. As you know, I assume, avoiding alcohol is important, too; and I assume your episode wasn't related to an alcohol binge, and that you're not taking medications associated with pancreatitis.
As to the ERCP, I don't like to make specific recommendations or comments on therapies or interventions from so far away. I prefer to provide general information. I'd say though that unless there are specific medical or anatomic reasons, general anesthesia with intubation isn't common.
Thanks for the input.
Not alcohol or medicinal as far as I know. Also not sure why it's intubated but that seems to be the doctor's preference. I do not think I have any medical factors that make that necessary. I guess I'll try to discuss that with him.
One final question I think: My research seems to indicate gallstones are best detected with ultrasound. If there were any gallstones lurking in my gallbladder, would the ultrasound most likely detect them or is it mainly geared towards ones that are trying to pass?
Thanks again.
Ultrasound is, indeed, the best modality for finding stones. It doesn't really distinguish those "trying to pass" from others in the gallbladder.
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