The gallbladder is a small sack located under the rib cage on the upper right side of the abdomen that stores and releases bile. The gallbladder releases bile during a meal to help absorb fats by emulsifying the fat (mixing the fat with watery secretions of the intestines) in with the chyme (the churned food masses in the stomach). A high-fat meal causes the release of more bile, and a low-fat meal causes less. When too much fat and cholesterol is consumed, gallbladder complications arise.
Gallbladder problems are divided into three categories: gallstones, acute gallbladder inflammation or infection (acute cholecystitis), and chronic gallbladder dysfunction (cholecystopathy). Gallstones can be present or absent with either of the last two conditions.
The gallbladder plays a unique role in the complex process of digestion, yet almost a million people in the United States alone have their gallbladders removed each year. Although surgery is necessary in some acute and severe cases, most gallbladder disorders can be treated successfully with lifestyle modifications.
SYMPTOMS
Gallstones can be “silent” which means they are asymptomatic. 75 to 80% of people with gallstones (which is about 10-15% of the population), although they may experience non-specific digestive symptoms like bloating, nausea, or mild abdominal discomfort, have no symptoms that are a direct result of their gallstones.
However, about 20% of those with gallstones will develop symptoms because of a gallstone slipping into the bile duct, causing blockage, and disrupting the flow of bile. In these instances, the gallbladder becomes symptomatic and may cause:
- Pain in the upper right quadrant or center of the abdomen, that intensifies and seems to come out of nowhere
- Pain between the shoulder blades or in the right shoulder
- Pain caused by gallstones usually comes and goes and may last for as little as a couple of minutes or as long as many hours.
Depending on where the gallstones end up, they can also block the ducts that drain the liver and pancreas, causing jaundice and pancreatitis. If the flow of bile from the gallbladder is obstructed, the gallbladder can become swollen and tender, like a large, pus-filled pimple—a condition called cholecystitis.
Symptoms of acute cholecystitis include:
- Fever
- Gallstones
- Chills
- Nausea
- Vomiting
- Itching
- Light colored stool
- Loose stool
- Pain, including severe or cramping abdominal pains, and/or pain radiating to the back or beneath the right shoulder blade
- Jaundice
- Bloating
- Unstable vital signs
When the gallbladder undergoes repeated bouts of inflammation, it can become scarred and chronic gallbladder dysfunction, or cholecystopathy, can ensue. Symptoms of cholecystopathy are usually chronic and non-specific and include:
- Fullness after eating
- Bloating
- Indigestion
- Gas
CAUSES
Dietary Cholesterol
Most gallstones are caused by an over-abundance of cholesterol in the diet. Cholesterol is only present in animal products, and if there’s too much in your diet, it crystallizes in bile, causing gallstones. A small percentage of gallstones are caused by bilirubin and calcium forming pigment stones, which are common in conditions like sickle cell anemia.
Risk Factors
Although an over-abundance of dietary cholesterol is the main cause of gallstones, certain lifestyle behaviors, diseases, conditions, and genetic and demographic characteristics can lead to a predisposition of gallstone formation in some individuals. These risk factors include:
- Age
- Alcohol
- Bile duct strictures
- Birth control pills
- Cholangitis (brown pigment bile duct stones)
- Cirrhosis
- Crohn’s disease
- Diabetes
- Diet (high fat/low fiber/high carbohydrate)
- Ethnicity (Pima Indians)
- Female gender
- Genetics
- History of abdominal surgery
- Hormone replacement therapy
- Ileal resection (black pigment stones)
- Infections (Helicobacter species, malaria)
- Medications (calcineurin inhibitors, cholesterol-lowering drugs, octreotide, ceftriaxone)
- Metabolic syndrome
- Obesity
- Organ transplantation
- Physical inactivity
- Pregnancy
- Rapid weight loss/surgery for obesity
- Sickle cell anemia
- Spinal cord injury
- Total parenteral nutrition (intravenous nutritional therapy)
- Vitamin B12/folic acid deficient diet (black pigment stones)
Cholecystitis is caused when a gallstone obstructs the bile duct, blocking the flow of bile, which can cause the gallbladder to become swollen and tender. Repeated occurrences of cholecystitis can lead to cholecystopathy where the gallbladder becomes scarred, causing chronic dysfunction.
DIAGNOSIS
Tests
The best and most non-invasive way to diagnose gallstones is using an abdominal ultrasound, in which images are taken of the gallbladder to look for gallstones. CT scans are sometimes used for the same purpose.
A hepatobiliary iminodiacetic acid (HIDA) scan in which a dye solution is consumed to highlight the gallbladder and bile ducts, is administered to assess gallstone blockage as well as bile duct ejection fraction to test for a poorly functioning gallbladder.
An endoscopic retrograde cholangiopancreatogram (ERCP) is sometimes administered and uses an endoscope to look for gallstones blocking the bile duct. If blockage is found, gallstones can be removed during the procedure.
Misdiagnosis
Gallbladder problems are sometimes misdiagnosed, and unfortunately, some individuals only realize this after surgery, when their gallbladder is gone, yet their symptoms remain. The following conditions can mimic the signs and symptoms of a poorly functioning gallbladder, causing nausea, bloating, and abdominal pain:
- Dysbiosis or bacterial overgrowth
- Acid reflux
- H. pylori
- Stomach ulcers
- Gluten sensitivity
- Lactose intolerance
- Delayed stomach emptying or gastroparesis
If you suspect your gallbladder as the culprit of your symptoms, be sure to investigate these conditions to rule them out before considering irreversible treatment options like surgery.
TREATMENT
Surgery
In the absence of a gallbladder condition indicating a clear need for surgery such as acute cholecystitis, gallstones that keep obstructing the ducts, or severe symptoms from a poorly functioning gallbladder, try to hold on to your gallbladder if possible. Symptoms like bloating, abdominal discomfort, and nausea may not be resolved by simply taking out the gallbladder, because even when it’s functioning poorly and causing those symptoms, removing it doesn’t address the fundamental problem behind why it’s not working. The biggest problem after gallbladder surgery is the continued presence of original symptoms, reported in some studies in almost half of all patients who have their gallbladder removed. Even worse, in addition to the original symptoms, which were mistakenly attributed to the gallbladder, new symptoms may develop when the main organ responsible for bile secretion and fat absorption is gone. Without the gallbladder to store and secrete just the right amount of bile after meals, there’s either too much or not enough being circulated. If you thought you had problems with fatty meals before your gallbladder was removed, you may have even more difficulty after. The focus should be on figuring out where things went wrong and why, and fixing the underlying problem, instead of just removing the organ and hoping for the best. You need your organs. Try to hold on to them if possible.
Endoscopic retrograde cholangiopancreatogram (ERCP)
If a gallstone is blocking your bile duct but you’re not as acutely ill, it may pass through on its own, or you may need a procedure called an ERCP where the gallbladder is left in place, but the bile ducts are swept clean with small pipe cleaner-like wires.
Diet
The food industry has gone to great lengths to set up complex hierarchies of good, better, and best when it comes to cholesterol, with fish at the top of most people’s pyramids and red meat at the bottom. But the truth is there’s not a huge difference between beef, chicken, or fish when it comes to cholesterol:
A small serving of:
Lean ground beef has 78 mg of cholesterol
Beef sirloin has 89 mg of cholesterol
White meat skinless chicken has 85 mg of cholesterol
A pork chop has 85 mg of cholesterol
Salmon has 63 mg of cholesterol
Of course, if you’re eating wild fish there are additional benefits, like omega-3 fatty acids that have anti-inflammatory properties. But the idea that one kind of animal flesh is significantly better for us than another is a construct that leaves us scrambling for chicken breast over hamburger when we really should be thinking about plants versus animals. For most of us, simply increasing the number of plants in our diet, especially the green leafy kind, and cutting back on animal products will take care of whatever gallbladder issues we have, give us enviable cholesterol levels, and help prevent a host of other problems, including heart disease and cancer. The Academy of Nutrition and Dietetics (formerly the American Dietetic Association), recommends that we consume less than 300 mg of cholesterol daily. The difference between an 85 mg chicken breast and an 89 mg piece of sirloin pales in comparison to the fact that fruits, vegetables, nuts, seeds, beans, yams, potatoes, rice, and grains have zero cholesterol. It makes the math a lot simpler.
Integrative Solutions for Gallbladder Issues
If you suffer from gallstones and/or a poorly functioning gallbladder, the following lifestyle modifications can not only put you on the path to recovery, but may stop recurrent gallstones and gallbladder inflammation altogether:
- Increase your vegetable and fruit intake bite by bite, one fruit/one vegetable a day: Changing your diet can be scary and challenging. Start with eating one fruit and one vegetable a day. Not only are fruits and vegetables cholesterol-free, but some of them can help to lower your cholesterol. Plant sterols block the absorption of cholesterol in the body, and studies show that vegetarians and people who follow a plant-based diet have much lower cholesterol levels.
- Trim the fat, specifically fat from dairy: Decrease your fat intake, including dairy. Dairy is the biggest contributor to fat in the American diet, which is why even vegetarians who eat a lot of it aren’t immune from developing gallbladder problems. The amount of dairy you consume daily can really start to add up, and your GI tract may have a hard time digesting it. Try replacing your yogurt breakfast with steel-cut oatmeal, substituting your turkey and cheese sandwich with butternut squash, lentil soup, or a large salad, and adding cooked green veggies and sweet potatoes to your regular dinner of meat, chicken, or fish.
- Move your body: A European study published in 2010 revealed that people with gallstones who were physically active had fewer symptoms than their sedentary counterparts, and the overall risk reduction was as much as 70% in the most active group. These beneficial effects seem to be synergistic with nutritional modifications like a high-fiber, low-fat diet. Studies also show that exercise can both prevent gallstones from forming and reduce symptoms if you already have them. Instead of driving to work, commute by metro or bus, which involves more walking. If you live close to work, consider biking or walking, and no matter where you work, take the stairs! Another way to move more is to take your calls on the go; instead of talking at your desk or on your couch, go for a walk.
If you think your gallbladder may not be working quite right, seek the advice of a doctor and get an ultrasound, HIDA scan, or whatever tests or blood work they recommend. If your problems are more pressing—fever, severe pain, tenderness, abnormal lab values—and you’re told that your gallbladder needs to come out, that’s probably sage advice. But if you’re one of the millions of people with symptoms like bloating, feeling full after meals, mild nausea, and abdominal discomfort, consider the possibility that your gallbladder itself may not be the culprit, even if you have gallstones, and that the problem may be elsewhere. And even when it seems like your gallbladder is the problem, make sure it’s not an innocent bystander caught up in a tangled web of other problems like too much high-fat foods and not enough physical activity. Changing what you eat and how you live is hard but take it one bite at a time. It’s worth it. Particularly when it allows you to hold on to important digetsive organs like your gallbladder.
