Your Gall Bladder & Gut Health

Your Gall Bladder & Gut Health

Cholecystectomy is the removal of the gallbladder.  In the later stages surgery is necessary but I’ll talk about how to avoid this and why.  A few years ago my dad had symptoms of a serious gall bladder attack.  I urged him to call the ambulance immediately.  I know how dangerous it can be if left untreated.  He was living out of town and was unable to drive because of the pain.

Surgery Doesn’t Treat the Underlying Cause

Surgery keeps people alive which I am so grateful for.  Now that his gallbladder is gone, bile flows from my dad’s liver to his small intestine via the common bile duct.  The liver continues to produce bile but an accumulation can still occur. Bile secretion directly into the small intestine has been shown to effect the microbiome and function of the gut negatively (1).  Also, those who have had a cholecystectomy can still have  gallstone issues if the underlying cause has not been addressed (2).

Gall Bladder Physiology

Bile is produced in the liver and travels via the common bile duct to the gallbladder. When dietary fats enter the small intestine, the gall bladder contracts to release bile. Bile is made up of mostly water, with only 3 percent consisting of a mixture of bile acids, cholesterol, phospholipids, bilirubin, inorganic salts, and trace minerals. Bile acids act like a detergent, helping to emulsify lipids in food. Without bile, these lipids go undigested, resulting in fatty stools. Bile is also crucial for proper absorption of cholesterol and the fat-soluble vitamins A, D, E, and K.

Gallbladder symptoms vary.  Initially pain in the upper abdomen that radiates into the back is common especially on the right side.  Nocturnal onset along with jaundice or yellowing of the skin, nausea and vomiting usually are involved (3).

Gallbladder diseases include:

  • Cholestasis: the backup of bile flow in the liver or in the biliary ducts.
  • Gallstones: stones form from the components of bile. 10-15% of adults are affected (4).
  • Cholesystitis: prolonged cholestasis characterized by inflammation of the gallbladder. 6 to 11% of patients with gallstones develop Cholecystitis (5).
  • Cholangitis: a complication where the flow of bile is blocked. The infection can also spread to the liver, so quick diagnosis and treatment are very important (6).

Leaky Gut

The connection between leaky gut and gall bladder problems is largely missed in conventional medicine. However, studies demonstrate a clear link between gluten intolerance (both celiac disease and in non-celiac wheat sensitivity) and inflammation of the gallbladder. Gluten damages the intestinal lining compromising the intestinal barrier function.  Largely this is due to zonulin.  Gluten increases this toxin resulting in a break down of the tight junctions.  Microbes and dietary proteins from the gut then ‘leak’ into the bloodstream (7).  The immune system sees these microbes and their microbial products as foreign invaders, and launches an immune response. The biliary system is affected by this inflammatory signaling. It has been shown to alter the gene expression and bile secretion in the liver (8).

Sure enough, research has linked gluten intolerance and celiac disease to increased prevalence of gallstones and biliary cirrhosis (9,10). Patients with autoimmune hepatitis are often also celiac (11). A study found that 42 percent of adults with celiac disease had abnormal levels of liver enzymes and I certainly see this in my practice. A gluten-free diet normalized liver enzyme levels in 95 percent of these patients (12).

Treating the gallbladder functionally

A low-fat diet may alleviate symptoms over the short term which is what conventional doctors often suggest.  But a long-term reduction of fat intake prevents gallbladder contractions which leads to more sluggishness and an increased risk of gallstones. Interestingly, a higher fat diet has been shown to protect against gallstone formation. Use it or lose it applies.

Gallbladder flushes are recommended by some natural health stores.  I learned long ago these have the potential to be dangerous as the bile duct can become obstructed. I typically stay away from extreme approaches that lack scientific evidence. I have yet to find a clinical trial on gall bladder flushes. I focus on treating the root cause.

Testing: markers like ALT, AST, bilirubin, LDH, GGT, ALP, and 5ʹ-nucleotidase can help discern what is going on.

Diet:  removing inflammatory foods like gluten, processed foods, and sugar are a great starting place.

Gut:  beak the cycle of gut inflammation leading to biliary stasis and lack of bile causing more gut inflammation.

Stimulate bile: with bitters like dandelion, milk thistle, and curcumin.

Reduce gallstones: with beet root, taurine, phosphatidylcholine, lemon, peppermint, and vitamin C.

Take bile: if you are having trouble with digestion of fats supplement with ox bile for a therapeutic period.

 

Want Your Life Back?  Autoimmune Paleo Could Be It

Want Your Life Back? Autoimmune Paleo Could Be It

Digestive health was what got me into studying medicine so when new research comes out I get really excited.  Its fairly often that I have a patient with irritable bowel disease.  Until now the dietary intervention that I see work clinically hasn’t had research to back it.  This particular study is therefore a landmark and I definitely suggest glancing over the abstract.

New Research Backing the Autoimmune Paleo Protocol (AIP)

The participants of this study were all in an active flare of either Crohn’s or Ulcerative Colitis.  All were symptomatic and need to have received an endoscopy.  Labs included tissue biopsies, gut testing to assess the changes in the microbiome and 6 weeks of an autoimmune paleo diet.  This was followed by 5 weeks of maintenance and monitoring.  Their medications remained unchanged during the study.  Quality of life surveys were included. The average age of participants was mid 40’s and most had the disease for roughly 20 years.

The results were incredible: 73% went into clinical remission!  This is based on the standard indexes for each disease taken at 3 different intervals during the research.

Average Mayo score (disease activity) in ulcerative colitis patients

  • Baseline: 5.8
  • Week six: 1.2
  • Week eleven: 1.0

Average Harvey-Bradshaw index (disease activity) in Crohn’s disease patients:

  • Baseline: 7.0
  • Week six: 3.6
  • Week eleven: 3.4

These results are encouraging given that most others treatments for IBD come with multiple side effects.  An increased risk for infection is common.  These drug have mixed results with high variability.  But in this study four participants were able to discontinue some or all of their meds.

People who develop one autoimmune disease often develop more.  So this kind of dietary intervention is actually saving people’s lives.  I see it in my clinic and I hear the same from colleagues in Functional Medicine.

Treatment in conventional medicine usually includes suppressing the immune system with pharmaceuticals and invasive surgery which doesn’t get to the root of the disease.

What causes IBD?

Genetics:  231 single nucleotide polymorphisms (SNPs) within 200 different genes are associated with IBD risk. But genetics only account for a small proportion of the variance in disease.  In Celiac Disease only 8.2% can be linked to genetics and 13.1% in Ulcerative Colitis)

Environmental Factors: include gut dysbiosis, environmental toxins, and diet, among others play the biggest role.  Increased risks from eating a Standard American Diet (SAD) are well know whereas anti-inflammatory diets like AIP are known to offer relief.

Food Sensitivities: 65% of people with IBD have known food sensitivities. Some patients may not know which foods might be harming them.  An elimination diet like AIP is the gold standard for assessing food sensitivities. Alternately testing is available.  For my patients I always start with an elimination diet.  Once people start feeling better these dietary changes are really not as difficult to make as people think.

Making The Leap and the Commitment

When he was 3 years old, I took my son off of egg whites and gluten after he developed unrelenting eczema on his legs.  Both these foods are excluded in AIP.  I used both an elimination diet and serum blood testing.

His skin cleared up immediately.  Yes he wants to eat gluten sometimes and he has egg whites occasionally in baked goods but I monitor him.  Skin and lungs are connected and this is the first winter he hasn’t had a persistant cough.  He did have an asthma attack in the fall but so far this is the only one and it wasn’t severe. He doesn’t need to be on steroids.  This may be due to the herbs and other interventions I’ve implemented.

Having a limited diet is not always easy socially.  We both have to make the commitment for it to work.  The pay off is that he is thriving.  I’m pretty convinced that if I had followed the doctor’s suggestion to use hydrocortisone on his eczema and make no diet changes he would have multiple more serious concerns to manage instead.

Conventional medicine does a great job monitoring his lungs.  We are lucky to have met with an excellent pediatrician who we happen to know personally.  He is curious and open about what other treatments we’ve explored.  I know its not always like this.  Patients tell me every week how they don’t feel this level of respect from their care provider.  Functional medicine is holistic meaning it’s inclusive of allied professionals.  Its also evidence-based meaning we stay on top of current research and are always looking for more effective ways of treating patients.

Looking to the future I see an integrative model of medicine where lifestyle and diet are primary interventions for chronic conditions.  This kind of research is an important step in the right direction.

 

 

 

 

Do you have Candida? Or is it SIFO?

Do you have Candida? Or is it SIFO?

What’s the Difference?

Symptoms like chronic yeast infections, brain fog and sugar cravings can indicate dysbiosis or an imbalance in the gut microbiome. About 20 years ago candida albicans began receiving a lot of attention. Some said to cause a long list of ailments. We’ve learned a lot since then and continue to learn more all the time. Endoscopies are not perfect but can show fungal overgrowth occurring in the small intestine. (SIFO).   In out patient settings, we test the gut using stool and breath tests.

Candida albicans is one strain of bacteria residing in the colon and is part of a healthy colon when in balance. It can get out of balance. This can happen when there is a dybiosis of insufficiency meaning a lack of other bacteria. Often it occurs after antibiotics used especially if several rounds were used.

Keep in mind that high stress, poor diet and reactions to foods also trigger an imbalance in gut flora. Similarly a parasitic infection like giardia can trigger the onset of Celiac disease and non-celiac gluten sensitivity. This is why people go traveling and say their gut was never the same afterwards.

So what causes SIFO?

If you are on a very limited diet to manage symptoms that appear to be fungal overgrowth but your labs come out looking good we have to consider SIFO. There isn’t a breath test available for SIFO and it won’t show on stool tests. Certain antibodies can be used to detect it but this is not yet widely used. An organic acids test has markers that are more telling. This is what I end up using because it has a variety of other markers that are helpful for assessing the patient’s health status in general. Knowing what triggered the symptoms is important so reinfection can be avoided. There is a strong correlation between long-term use of proton pump inhibitors and SIFO.   Low stomach acid means more pathogens make it into the small intestine.

Treatment can include both pharmaceuticals and botanicals.   As far as botanicals go I use monolaurin, a concentrate of coconut oil, oregon grape root, berberines, caprylic acid or allicin and biofilm disruptors like NAC or Interfase Plus. Cycling antibiotics followed antifungals is what gastroenterologist Dr. Satish Rao suggests. This is because onset of fungal infection occurs after the good bacteria is killed off whether its in the small intestine or the colon.

Can diet help?

A lower carb diet rich in nutrients is a good starting place. There is some indication in the research that ketones can feed the overgrowth so use caution with this approach. Often people will know what triggers symptoms and these need to be avoided. Following treatment a period of rebuilding is key to ensure that the colon is functioning optimally. A prokinectic like 5-HTP or bitters encourage the migrating motor complex to prevent reinfection in the small intestine. If the ileocecal valve between the two bowels is inflamed we want to address this. Bacteria collect around these valves and take up residence where they shouldn’t. So inflammation and any immune issues also need to be addressed.

Keep in mind that candida albicans is different than candidiasis, which is a serious condition occurring in immune compromised people. Candidiasis requires immediate medical intervention.