Sunday, November 17, 2013

An Honest Discussion Concerning the Gallbladder

(Picture: University of Minnesota )

  In nursing school when we were told about gallbladder dysfunction, gallstones and the like, I didn't worry too much.  Neither of my grandparents or my parents had ever had such problems, and since I was slim, I didn't think I would ever be afflicted.  However, I had not received the entire story in college, and even now, a lot of information concerning gallbladder disease is not widely disseminated to the public.
Nine years after graduation from college, I was the young parent of two small children, born a year apart, and a nurse in a critical care unit every evening for eight hours, after I put my children to bed.  I had been having episodic pain just below my breastbone. My doctor sent me to a gastroenterologist, and I had been scoped. Their operational theory is that my "epigastric pain" was probably ulcer related and that I did have a stressful job.  Since most people with gallbladder disease have pain in the upper right quadrant of the abdomen noted generally after rating, this was not actually on my doctor's radar at the time.
          The gallbladder is an organ which is connected to the liver via the common bile duct. The liver manufactures bile which is intended to be held within the gallbladder and sprayed onto digesting food in the small intestine anytime the person eats a fatty or a sugary food. The bile aids in the proper digestion of fats.
Gallbladder disease encompasses a number of issues, not simply gallstones.   For example, someone with ulcerative colitis or Crohn's disease often experiences chronic irritation of the gallbladder and potential infection there.  People who have experienced salmonella infection, often have irritation of their gallbladder for a time.  Stomach flu can inflame the gallbladder also. Most of the time, this is a transient issue which resolves, but sometimes this becomes an issue of chronic irritation or chronic infection.   Gallstones are another issue.  80% of gallstones are made of cholesterol and some people simply turn cholesterol into stones. Cholesterol stones can also defy being seen by some of the more sophisticated scans of the gallbladder including the nuclear medicine variety.  Other stones may be made of bilirubin, and can be visualized on the aforementioned scans.   Some people can live for years with a few stones occupying their gallbladder. Bile comes in and out around the stones and the gallbladder still functions.  However, sometimes the gallbladder fills with stones, or the stones clog the common bile duct and a surgical emergency results.  In this event, the gallbladder must be removed.  If it is not, the bile refluxes up to the liver and begins to digest it. This is exceedingly painful, dangerous, and can result in death.
             Generally, the persons most physicians consider being at risk for gallbladder disease are those who are:

fair skinned,    fat,     female,     forty-ish,    fertile

However, this is quite misleading.

A slim blond male radiologist who had his gallbladder removed on an emergent basis once told me that all he had noticed was that he could no longer eat a McDonald's Big Mac without indigestion.  He suggested that it become an annual gallbladder test for adults.

Other people who actually are at risk and may not realize it are:

1. Anyone who has concluded a pregnancy in the last year.
2. Anyone with inflammatory bowel disease. (Crohn's or UC)
3. Anyone who experienced a severe episode of food poisoning, especially salmonellosis,
    at any time, but especially in the preceding year.
4. Anyone who has received a Rocephin injection or intravenous infusion in the prior year. (I have not seen evidence that this particular cephalosporin does the same thing if given orally.)
5. Those with a documented case of Lyme Disease, particularly in the past year.
6. Those who have had babies in rapid succession.
7. Those who have lost a large amount of weight for any reason.
8. Those being treated for anorexia nervosa.
9. Diabetics may have an altered use of triglycerides which sometimes results in gallstones.
10. Women who take birth control pills are also at higher risk for gallbladder disease because the estrogen in the pills may slow the passage of bile.
11. Those who take some cholesterol lowering drugs may also begin to make gallstones.
12. Those with American Indian or Mexican heritage may also be at risk, even though they don't fit the commonly conjured image of "fair skinned stomach pain equals gallbladder problems".

Healthline's Gallbladder

It is theorized that many of the above situations cause "gallbladder sludge" and can precipitate gallstones. However, infections alone may cause dysfunction.  Pregnancy or pregnancies in rapid succession are theorized to cause a positional decrease in available circulation to the gallbladder, which contributes to dysfunction and disease.

This is important because a huge number of people are therefore at risk for gallbladder dysfunction and disease.  These factors can lead to inflammation, and an acute inflammation of the gallbladder is called cholecystitis.

A Frenchwoman once told me of her family's "treatment for gallstones".  It involved olive oil, lemon juice and some black olives.  Anyone with true cholecystitis or known gallbladder inflammation would be unwise to try such a thing.

 Once you have known irritation of the gallbladder or known stones, you should make arrangements to have the gallbladder removed on an elective basis.  This way, the procedure can be done when you are as well as possible, and when this is a reasonable process with adequate follow-up.   To put off the procedure for too long can and does result in the following.

1. A clogging of the gallbladder or common bile duct with leakage of bile to the liver.   This can cause pain, and icterus, a yellow discoloration of the sclerae (whites of the eyes) and the skin.  Digestion of the liver with bile if untreated can be fatal.
2. An unattended diseased gallbladder can become gangrenous, rupture and spill its contents throughout the abdomen causing peritonitis, and potentially death.
3. An unattended diseased gallbladder can become gangrenous, rupture, and infect the abdomen causing abdominal abscesses which resist resolution.
4. An unattended diseased gallbladder which spills its contents can cause an infection which damages and destroys the beta cells of the pancreas and leaves the patient a Type I insulin dependent diabetic for a lifetime.
5. Chronic gallbladder disease can result in gallbladder cancer, though this is rare.  Gallbladder cancer often metastasizes quick quickly to the liver and causes death.  I have had patients for whom this has happened.

I have had several patients during my career who spent more than a year in a critical care unit as a result of a ruptured gallbladder.  If you believe you may have a failing gallbladder, then this should be mentioned to your physician.  It should be watched.

One of the reasons that Russia's Far East has so many children in orphanages is that they have lost parents to simple gallbladder disease. In some places in Russia's Far East, there are no surgical services and no manner by which those with gallbladder disease can be treated, and those people, simply die.  This knowledge was horrifying for me.

          One evening while at work my pain became so severe that they dropped me into a wheelchair and took me to the ER.  I was only 28, slim, and I had an excellent diet.  (I did and do have fair skin.)  My blood pressure was extremely low and I was admitted to the hospital. I was found to have extremely high liver enzymes, but negative tests for hepatitis.   Finally, it dawned on my physician that it had never been a stomach issue.  I had a failing gallbladder and now bile was digesting my liver.  I received an emergency removal of my gallbladder, which was found to be gangrenous.  I had complications and was kept in the hospital for three weeks for a procedure which if done early enough, is possible to do in a Same Day Surgery setting.

        With Obamacare's potential for dismantling the quality health care the United States has enjoyed, and with potential financial collapses coming, this is a good time to consider the health of your gallbladder. Consider also any other procedures you have been considering having done.

        My parents and my grandparents, who have all now passed, never did need their gallbladders removed. This week I was reminded of how insidious a failing gallbladder can be when two of our friends had emergent gallbladder surgery, and one of them had an emergent appendectomy.  I wanted to make sure that everyone here was armed with this information, and could recognize cholecystitis.

       The symptoms of a failing gallbladder or of gallbladder dysfunction may well be the severe upper right quadrant pain up under the right ribcage, that we are all taught about.  It might seem to occur after eating fried or fatty foods.  Or it might not.  You might experience GERD symptoms which could still be gallbladder or early gallbladder symptoms.  You might have nausea or new food intolerances.  Cream cheese might make you sick.  You may feel nauseated after sugary foods but not have noticed that fatty foods bother you. You may have abdominal pain at intervals, which sometimes occurs after eating and sometimes doesn't. Gallbladder pain often travels from the abdomen all the way through to the back. This is something to tell your doctor if you have pain which does such a thing.  It is my hope that someone here may better recognize these and intervene better than they would have otherwise.

   May all of you be well.


Sunnybrook Farm said...

Thanks, now I know something about it. My wife's son had his taken out in his late 20s he is fair skinned and eats pizza and fast food, very picky eater. I don't know about the big mac test, that may give a lot of false positives!

JaneofVirginia said...

Thanks for posting ! Yes, I think the "Big Mac test" probably would detect those with a failing gallbladder, but many people would be a bit nauseated anyway. (Like me, who is gallbladderless.and still find a Big Mac too much fat to eat !)

Gorges Smythe said...

Thanks for posting this.

JaneofVirginia said...

Thank you Gorges. A lot of people go through life without ever losing their gallbladder. However, for those who have a problem with it, it eventually becomes such an issue that it threatens life. For this reason, everyone should know about it and have it attended to BEFORE financial collapse or before some socialist loony snares the US presidency and dismantles our quality health care system to below that of the Third World. It's probably never happen, but oh.....wait !!!!

Sandy said...


I had read a while back women going through menopause when put on HRT they should also take fish pills to prevent problems with increased cholesterol which in turn could also cause gall bladder issues.

JaneofVirginia said...

Yes, if a woman has to take HRT during menopause then because this is estrogen, it will make her more prone to gallbladder dysfunction, just from the estrogen standpoint. The fish oil tablets would probably cause an increase in the amount of bile flowing because even modest increases in oil intake with increase bile flow. It might work.

BBC said...

Geez, don't make it so complex, it can happen to anyone.

Linda said...

I have been having this pain and nausea since I was at least 37 and am now 67. I have taken premarin since I was 45 and went through menopause. I am sitting here in pain as I read. Tomorrow, I will be calling my gastroenterologist again. He wants the colonoscopy done. Is there any value in doing that first instead of solving the gall bladder problem. I will not quit taking estrogen!

I cannot have all the surgeries done that I need before the end of the year. Doctors have told me I need back surgery, work on torn meniscus in both knees, surgery for several issues in six inches of my lower spine. Which are likely to be halted at the beginning the year. Oh, yeah. I have a torn rotator cuff and do not want to even think about that surgery. I am falling apart. Thursday, I will have a D&C because obgyn fears I may have uterine cancer.

I don't stall these surgeries out of fear. I just have no support system, so I feel fragile.

Linda said...

I forgot to ask. So, I should take fish oil pills?

BBC said...

Sally had hers taken out last week, at 77 she isn't bouncing back as fast as she thought she would. I'm 70 and have only had one minor knee operation in all my years, after trying to shove my leg up my butt with a motorcycle. Been lucky I guess.

JaneofVirginia said...

If you already have nausea and pain of uncertain origin, then adding fish oil will likely heighten the nausea as it will definitely increase the amount of bile produced. If the gastroenterologist agreed, then you could do a short term trial, but I would rather have a diagnosis and deal with that, rather than be stabbing in the dark, at least at this time.
Linda, my intention for writing this post was to make readers aware of the potential for gallbladder illness in all people. It certainly wasn't intended to frighten you. You are doing what you can, which is to deal with one medical issue at a time, selecting the most disruptive or potentially dangerous issues first.
There is value in havng a colonoscopy done, and this is why it's one of the first things they do. It rules out a great deal.
Many people absolutely cannot have everything they need from a medical standpoint done before the end of the year, or even the end of next one. This is why those of us who can and could, should get what we need done, clearing the way for those who did not have a choice about waiting.
If someone genuinely needs a number of procedures, then these need to be scheduled gradually. There needs to be adequate recovery between procedures, and recovery from things like anemia which can occur following surgeries.
Linda, of course you feel fragile. You are dealing with many of these things alone and this makes them even larger than they are. Please take one step at a time. Do you have a medical social worker at your local hospital who can help you prioritize these needs ? This is what they are for ! Best wishes.

JaneofVirginia said...

Quite true, the post just gives the background as to why that is true.

JaneofVirginia said...

Sometimes it takes some time to recover from the surgery, and that's true of young people as well as older ones. Every once in awhile we have someone in the hospital who is in their eighties and has never been in a hospital before. My friend who died recently whom I mentioned in an earlier post died in her sleep at 86. She had never been in a hospital overnight in her entire life. She had three babies while her husband was serving in a foreign job and they were delivered in an outpatient maternity hospital. Then she and her husband adopted two more. She raised her children, buried her husband, and was never ill other than an occasional cold. Of course, she could outwalk ME no matter what the weather or the conditions. There are people like you and she, out there.

BBC said...

" You may feel nauseated after sugary foods but not have noticed that fatty foods bother you."

Hum, really? Cuz I love fatty foods but often feel weird after my morning dessert. Oh hell, it doesn't matter, I'm getting old, my death isn't going mean a fucking to the universe.

JaneofVirginia said...

This IS a family blog and so I need to ask you not to use profanity in your post responses. However, I must disagree. During our time on Earth we often underestimate our importance while here. Sally needs you, and I would miss your curmudgeonly commentary, as I'm sure would others. When my youngest son died, I was surprised as to how many people knew him and had been touched positively by his short life. I am sure that the same is true of you, and of all of us. We just don't always realize this while we are here. My son Daniel often said that "The real work of the world and of God is most done by ordinary people". That would be true.