Amie: Yes. So, the webinar that I’m gonna be covering off, which includes gallbladder stuff, it’s all about the importance of detoxification and the different aspects of detoxification, but a lot of people understand the role of the liver, and the gut, and the kidneys, and so this particular educational piece is really going to be focusing on the importance of the gallbladder, and how to support it, why it often runs into trouble, and what to do about it. And the reason I wanted to chat with you today is gallbladder disease is on the rise. In fact, when you look at the statistics, it’s terrifying how much of a problem it’s becoming. And I say that in part because the main remedy for that tends to be just to cut the gallbladder out. But there are some significant consequences to that, so I thought you and I better need to have a chat, and share with everybody why looking after your gallbladder is so important, and why you want to try and avoid having it removed if you can.

Andrew: Well, let’s talk about some statistics. What are we talking about here with regards to incidence, prevalence, and indeed different types of gallbladder disease?

Amie: Well, just focusing on having the gallbladder taken out for a second, we know that over about 15 years, so, between 2004 and 2019, here in Australia, there were almost 1.1 hospital admissions from symptomatic gall bladder-associated disease. And more than three-quarters of those resulted in the gallbladder being cut out. In New Zealand, it was, you know, not too dissimilar. So, proportionately speaking, over that same time period, there were 163,000-plus admissions to hospital with gallbladder issues, and just over 98,000 of those resulted in the gallbladder being removed. And we know when we look at statistics from other countries, for example, England, the number of gallbladder surgeries happening there between 2000 and 2019 have actually increased by 80.4%, annually increased by 80.4%. And we also see other reports where, you know, gallbladder issues, in particular gallstones, were more an issue for someone in their 40s, 50s, or 60s, and now it’s more prevalent in those in their 30s and 40s. And even teenagers are having their gallbladders removed now. That was unheard of.

Andrew: It’s just, it’s amazing how, you know, back in my day of nursing, and I’m going to be politically incorrect here, because there’s an acronym, and that’s the acronym. And so, forgive me, but the acronym back in my day of nursing was fat, 40, female, fertile, and flatulent. Right? And that was this, you know, very probably misogynistically-designed acronym. But the 40 has now gone down to 20s. That’s what I think is really interesting.

Ami: Mm. Yeah.

Andrew: It’s just amazing how time progresses. And I understand, you know, COVID lockdown, things like that, people are more sedentary, but it’s not just that we’re talking from, you know, the 2000 way, before COVID.

Ami: Mm. That’s right.

Andrew: So, something else is happening.

Amie: Yeah, definitely. There are a lot of things happening, and I think it’s a tricky one to unpack, although, in the webinar, I’m certainly gonna go through a lot of that. But I guess to point towards what you said, like, in naturopathic college, it was “fair, fat, and 40s.” So, like, light-skinned, is typically, is certainly where I was from at the time, a condition that affected Caucasians more predominantly. But certainly, for female and fertile, I think, touching on that, we know that estrogen is a risk factor of that. So, elevated levels of estrogen. And that can happen because of poor estrogen metabolism. It can be a result of xenoestrogen exposure, which, of course, we’re getting increasingly more so through, you know, pesticides, herbicides, foods, personal care products, and of course, a lot of women are opting for, you know, the combined oral contraceptive pill as a form of contraception, or for other reasons, and then HRT at the other end of their fertile window, in terms of a life chapter.

So, those are definitely increased risks. Certainly, age is an increased risk, but I think age is partly an increased risk because one of the things that contributes to cholestasis, or sticky bile, sluggish gallbladder function, is toxicants. So, whether that’s from personal care products or from agricultural industry, or, you know, from any of the other hundreds of sources that we get that from, we know that those things, especially the lipophilic ones, that are eliminated through the gallbladder, accumulate over time, and they accumulate also with an increase in weight, which is often something that occurs alongside aging. So, you know, those are issues. We know there are also dietary components that need to be addressed. You know, the increased risk factors of things like diabetes and insulin resistance, any issues with cirrhosis, or even liver infections, and parasites. And one of the other areas I’m gonna be touching on in the webinar is the impact of mycotoxins on the gallbladder, and how that contributes to cholestasis as well.

But, certainly, for women, if all other, you know, confounding factors are equal, women are more at risk than men because of the estrogen factor. In fact, women are diagnosed three times more often than men, with gallstones, once, like, before the age of 40, but by the time they’re 60, the risk is actually starting to draw closer, unless, of course, they’re on estrogen therapy, like HRT. And certainly, anyone who’s carrying extra weight, male or female, will have increased estrogen levels. Ironically, though, rapid weight loss also can trigger issues with gallstones and the gallbladder as well. So, you know, you have to really treat it with such respect, and consider it to be, you know, a partner of the liver, as opposed to just a sac that sits there behind the liver, collecting what the liver creates.

Andrew: Absolutely. I’m so glad, back at the beginning there, you were talking about toxicants. And one of the sort of issues I’ve been pondering myself is, we always, as humans, we tend to go, “that equals that, that to that,” rather than “that to that, to that, to that, to that, to that.” Right? So, now, forgive me. Those people, those of our listeners can’t see me pointing around the room, to various points before, you know, instead of A to C, it’s A to Z. So, for instance, in Australia, we still have, on our shelves, an endocrine disruptor chemical, called triclosan. And it’s been shown to affect thyroid function. And thyroid function, if it’s decreased, can lead to high cholesterol. And high cholesterol can lead to a seed in the gallbladder. And, do you see? And so, there’s this whole thing about, with the toxicants, it might not be a direct that equals that. It might be around the sort of board a bit, still has an issue in gallbladder disease.

Amie: Totally. You’ve got direct influences, you’ve got indirect influences, and then you’ve got the cumulative effect of multiple influences. You know, we don’t live in a pristine toxicology lab, where we’re exposed to one thing at a time. We’re being assaulted from multiple sources in the air and our water and our food and our personal care products and our home cleaning products, with, you know, all kinds of toxicants. And some of those are willingly onboarded, and some of them aren’t. For example, pollution, if you’re living in a big city, or near a main road, and your liver, and of course, all of your detoxification organs have to deal with that. But as you so eloquently pointed out, sometimes it’s a direct inhibition of the autonomic nervous system, and gallbladder contraction, or an increase in, you know, the viscosity of bile, or, in the example you gave, there’s this domino effect, that are, you know, multiple steps removed, that ultimately also influences the health of the gallbladder.

And this is what makes functional medicine so wonderful, and also so tricky to practice, because you have to be such a great detective, and actually really put all of those, like, elucidate, all of those variables, and address them all to have a successful result. And I think that’s why removing the gallbladder seems to be such a popular choice in allopathic medicine, because all of the other methods that address gallstones, and of course, gallbladder disease is not just gallstones, but just using this example, you know, tend to reoccur. And that’s because the underlying causes haven’t been addressed. And so, they’re like, “Well, what’s the point in removing the stones and leaving the gallbladder, because they’ll just come back?” Sure, if you don’t deal with the underlying cause, and, you know, I tell my clients, “surgeons can cut out everything but the cause,” and I guess the sad reality is whatever was contributing to those gallbladder issues also doesn’t get addressed when you remove the engine oil light that’s indicating, “hey, we’ve got a problem here.”

Andrew: Yeah. I have to disagree with you on one point. I explained it in the most fumbling way possible. You explained it eloquently. So, but notwithstanding that, just a point I’m pondering is, I wonder if one of the possible, I don’t know if to what degree, but I wonder if one of the possible factors involving why, sorry, leading to why women, more women have gallbladder disease than men is simply because of the size of the tube, of the common bile duct, in men versus women. Bigger bodies, bigger aortas, bigger vessels, bigger common bile duct. I don’t know. But I just pondered that, and I don’t know

Anyway. So, when we’re talking about, you know, why not cut it out? Like, I totally understand that if you’ve got a blocked common bile duct, it’s not a medical emergency that you’ve got on your hands. It’s a surgical emergency. Having said that, we should be taking care of an important, I’m not gonna say necessarily vital, but an important part of our bodies, that, due to our normal function. You know, it’s kind of like we used to just think, “Ah, cut out the appendix.” Now we don’t.

Amie: Mm-hmm. Mm. Yeah.

Andrew: So, is there any movement in the thinking of the importance of the gallbladder?

Amie: It does vary country to country, and I think it varies also depending on the patient population and how educated they are, and perhaps also resources. You know, every medical system is set up differently, and there’s, you know, likely in other countries, like it is here, things that are covered by, you know, Medicare, and then other options, you’ve gotta pay out of pocket. So, I think it’s a combination of things, but I really think, ultimately, what it comes down to is people are presenting in an acute state of distress, that needs to be addressed, and they are not getting appropriate care, either pre or post, to address how they ended up in there. And that’s not the surgeon’s job either. And so, I can absolutely appreciate why a surgeon, when given the choice of just removing the stones and clearing out the common bile duct, and leaving everything there, versus… Because, actually, by the way, you don’t actually, you know, end up without gallstones after gallbladder removal. In actual fact, in some of the stats that I looked at, only 18% of patients who’ve had their gallbladder removed remain free of symptoms, and up to 72% of patients can end up with gallstones in the common bile duct after the gallbladder’s removed, because the source of them wasn’t addressed.

And so, I know, if this was to happen to me, depending on, you know, when it was discovered, if you’ve got the luxury of time, and you’re not in so much pain, you can obviously use things like lithotripsy, or oral medications to dissolve the stones, or both, whilst you’re addressing the underlying cause. If I was to, say, present at an emergency department with an acute gallbladder attack with gallstones, I would be begging to have the stones removed, and everything else left intact. But the current, you know, state of medicine in the Western world is such that, you know, the people who are presenting to emergency for acute treatment don’t know where to go to actually get the underlying causes dealt with, because they think that medical system is one and the same when it’s not.

Andrew: Is there any advancements in medicine to preserve the actual bile… Sorry, gallbladder, whilst expressing, if you like, the gallstones? Or is it…

Amie: Yeah.

Andrew: Is it that the endothelial lining is so impacted by whatever, you know, it is, whether it be inflammation, whether it be infection, that they just go, “No, let’s take it?”

Amie: Yeah, look, I think there are variables there that sometimes, you know, a surgeon isn’t going to know about it until they get in there, and as you pointed out, endothelial tissue damage, with a risk of infection, can certainly present problems, make it more complicated, require antibiotic use, and may end up resulting in the gallbladder being, you know, needed to be removed anyway. But, look, in terms of, like, the different options you’d have medically, there are oral medications that have been shown to dissolve some gallstones, and these are classic compounds found in bile. And so, bear bile acid is another, I guess, natural version of that to thin the bile and allow the gallstones to dissolve. And, you know, those medicines are really well-tolerated, but they can be slow to work, so, totally not appropriate in an acute gallstone attack. And of course, isn’t treating the root cause either, but someone with a grumbling gallbladder, that could certainly be part of their treatment plan. But as you just alluded to, there is something called a percutaneous cholecystostomy tube, which actually is essentially a drain where they can use it to move gallstones out of the area, and kind of massage it out.

If the gallstones are bigger, so, as you said, they can be anything from the size of a grain of sand all the way through to a golf ball. Now, in terms of passing a stone, like, the common bile duct isn’t big enough to pass, you know, anything too large. And essentially, if it’s over 1.5 centimetres, typically, they’ll use lithotripsy, which is a type of, you know, ultrasound [inaudible 00:17:24] shockwaves, that breaks the gallstones into smaller pieces, so you can pass it.

But there’s also a, I don’t know if I would opt for this one, but they can also inject a solvent, which, of course, is highly toxic, but in this case, as a one-off, to actually dissolve the gallstones. It can cause a lot of pain. It can cause serious side effects as well, so, you know, and it’s also a bit risky for the doctor administering it as well. So, it’s probably not anyone’s top choice. But certainly, endoscopic drainage, you know, a tube to actually move them out, or using ultrasound would be options that I would consider before going for surgery. And ideally, I think recognizing gallbladder issues earlier on is really kind of the way to go, and this is where preventative and naturopathic and functional medicine comes into its own, like, you know, where when someone gets to a point when they’ve got a gallbladder full of gallstones, like, it’s been potentially decades of, you know, earlier red flags and earlier signs that have been pointing to that their gallbladder’s in need of help. So, maybe we should have a chat about some of those.

Andrew: I think that’s… I mean, this is obviously where we need to go. I was gonna say, before we move over to that, with regards to the solvents that are used, I was gonna make a glib comment about the degreaser that you get from the cheap shop. But I could understand the surgeons’ issues, safety issues regarding that, with leakage around the insertion point into the gallbladder. Obviously, that would be Obviously, that would be also dependent on the type of stone. Most of them are cholesterol, but there may indeed be, forgive me, salts that are in there as well. And so, that requires a different approach. So, I’m really interested in lithotripsy, because that was, used to be reserved for renal disease, but that’s interesting. I wonder if they’re using it for

So, moving on, with regards to symptoms, we talk about the classic shoulder tip pain and things like that. That’s more of a grumbling gallbladder. If you have a gallbladder attack, it’s…you’ll know it. But let’s talk about these nuanced symptoms. What are we looking at here?

Amie: So, I guess, as you mention, that pain, there’s a couple of places people can experience pain, and it kind of depends if there’s stones there, and also what size they are. So, one of the classic places to experience discomfort is underneath the bottom of the right shoulder blade, and that’s really sort of directly over where the gallbladder sits. But we can also see pain radiating, or actually presenting as a primary, like, the top of the right shoulder. For some people, if there’s issues with stones in the common bile duct, it can be a bit more central, so, sort of, right at the bottom of the sternum, like, behind the stomach, where it sort of crosses over towards the pancreas.

But there are other signs of poor gall bladder function or poor bile flow. So, number one would be the colour of your stools. So, if you’re having what we would call a perfect poo, it has a particular texture, a particular shape, a particular size, and also a particular color, which is a dark brown. And a dark brown is, the dark brown is caused by the bile and the changes in the pigments of the bile through the, like, the metabolism of digestion. Anytime we see any of those lighter colours, we know that we’re either not producing good-quality bile or there’s something impeding the flow of bile, and therefore it’s not coming through and colouring the stool in the same way. And so, that would be one big hint.

A second big hint would be if the stool, or, like, after a bowel motion, you’re seeing a greasy film on the water, in the toilet bowl, so, obviously, undigested or mal-digested fats, in particular, stools that are high in fat will often float rather than sink. Now, that’s not a definitive point, because we can also see that with microbial fermentation, but, you know, if it’s floating and you’re seeing some of those other things, they’re red flags. Other red flags are, you feel unwell after fatty food. So, you might feel nauseous. You might even vomit. You might feel a bit headache-ey or a bit off. You might find it really just sits in your stomach really awfully, and affects your digestion and your bowel motions. And if that is you, it’s likely that you now avoid fatty foods and fatty meals, and eat more on the low-fat side, to avoid triggering those symptoms.

So, those would be sort of the big ones there. But also, we can see issues with fat metabolism appearing on the skin. So, we can see sclerosis in the sclera of the eyes. We can also see lipomas, often around the eye area, but sometimes elsewhere on the body, and are just, you know, technically a tumour, but they are basically just fatty tissue, so, fat coming out of your body because it’s not coming out through the gallbladder, where it’s meant to come out. They would be sort of the main ones. There are other things, like, often, you know, chemical sensitivity, alcohol sensitivity. We can see on blood tests bilirubin being elevated, ALP being elevated. You know, there’s a few other bits and pieces that we can sort of see occurring, clinically speaking. And I will go over all of that inside the webinar, for clinicians that will be attending, but, you know, if you’ve noticed that maybe your liver enzyme’s a little bit wonky, but there’s no other real reason, or your bilirubin’s, you know, over 10, I know the reference range is a bit more generous than that, but anything over 10, to me, would be, you know, indicative of some sort of sluggishness. And, you know, these types of signs appear often decades before you end up with, you know, in the emergency room with a gallstone attack. So, you know, I certainly, as a clinician, wouldn’t be allowing a client to write that off as acceptable.

Andrew: No, no. But with regards to bilirubin, and raised… I mean, sorry, ALT, wasn’t it? So, alkaline phosphatase.

Amie: Well, actually, AST and ALP. But also, yeah, alkaline phosphatase too. Yeah.

Andrew: Right. So, with regards to raised LFTs, right? So, is that early or late-stage? Like, how early can we pick this up?

Amie: Look, it really depends, because as you know, you know, it’s not one variable that tends to be driving it. And so, you know, if there is toxicant accumulation, would we see LFTs go up first, and bilirubin come later? Sure. But sometimes I see LFTs looking fine, but bilirubin starting to sneak up to 12, 13, 15, 16. And they’re not having, you know, not having jaundice symptoms yet, they’re not having light-colored urine yet, but that, to me, is a sign that there is difficulty with elimination, which of course is predominantly through the bile

Andrew: Yeah. So, unconjugated bilirubin. Okay. And I’m just trying to think about patient pictures here. So, when we’re thinking about therapies, how heroic do we start off here? Do we go gently, gently, or do you go, “Nah, let’s go

Amie: Well, if you would like all of the juicy details, you can come to the webinar. But what I would say is you do wanna take a very systematic and considered approach, because the last thing we wanna do is trigger a gallbladder attack. And I know there’s a lot of, you know, gallbladder flushes online, but for every person who’s found that helpful, I know someone else who that triggered a trip to the emergency department. So, again, if you’re not in acute pain, but you’ve got grumbling pain, or maybe you’ve got some of these earlier signs, and perhaps you’re gonna go have an ultrasound and just see what’s happening, and you discover something, but your asymptomatic, really, you actually wanna start with the gut, because 25% of all detox starts there, and any gastrointestinal inflammation downregulates detoxification in the liver. And so, you can’t really come from a liver, or a top-down approach, if you haven’t already done some gut work and support.

And given the state of most people’s guts, skipping that part wouldn’t be advisable, even though it feels like an extra step, and maybe not such a necessary one. I really do think it is. And then from there, withdrawing anything…well, alongside that, withdrawing anything that’s contributing to toxic body burden, inflammation. You know, for some people, these issues can actually arise because they don’t eat enough fat, because fat actually stimulates the gallbladder to contract. And so, you know, if someone’s not eating enough fat, increasing dietary fat, to start moving the gallbladder along. There is a lot around the autonomic nervous system and the vagus nerve, and how that splenic branch actually operates. And so, you know, is there anything structurally a chiropractor needs to address through the thoracics? Is it a nervous system communication problem? Is it that they lack, you know, bitters in their diet, because that’s a primary stimulant of the gallbladder as well. You know, there’s so many moving pieces that you wanna take a holistic approach. But I would also be including, if stones have been identified, or I’d actually be encouraging clients to ask for an ultrasound to see whether they have them, or whether it’s just viscous bile, I would then be applying things that help to dissolve the gallstones before we do anything to try and stimulate the gallbladder to eject its contents.

Andrew: So, I know we don’t want to give too much away because of the seminar, but can you give us a couple of hints and tips here?

Amie: Sure. Yeah, of course.

Andrew: So, we’ve got things like, for instance… Well, we’ve got things like, there’s the cholesterol triad, where you look at the level of cholesterol, the amount of lecithins, and the amount of bile salts. So, we can do certain simple things there, like lecithins, and taurine, and vitamin E, tocotrienols. What else?

Amie: Well, I mentioned bitters. So, bitters and dietary fat help to stimulate the gallbladder. So, you know, even just really gentle things like lemon juice and water, or apple cider vinegar and water before foods. Increasing your bitter green vegetable intake would be helpful. We know that dietary lecithin and choline helps to emulsify those crystals. What else would I consider? I would also be checking someone’s fibre intake. We know that only 1.5% of Australians eat the recommended amount of fruit and vegetables. And so, whilst we’re all meant to be getting around 30 grams of fibre a day, most people are getting roughly 9 to 12 grams. And then, what we’re seeing there is reabsorption of a lot of these things back into the liver, which is kind of double-handling everything.

So, you know, these things sound kind of flimsy and weak in the face of, you know, say, a gallstone attack, but these can all be, you know, contributors to, the absence of them, contributors to why you ended up with, you know, a sluggish gallbladder. Obviously, for women especially, making sure they’re not being exposed to endocrine-disrupting chemicals, in particular xenoestrogens, making sure estrogen metabolism is operating as designed. Supporting gut health, of course. And then, there are bitter herbs, that a herbalist might use. Dandelion root’s a really popular one, and certainly you can get dandelion root tea from the supermarket. But herbalists might call on things like gentian or globe artichoke. But again, those things, you wouldn’t touch until you knew there weren’t gallstones, or that they were small enough that they could be passed safely through the common bile duct. And you would use other manual therapies to help with that, like lymphatic drainage, Castor oil packs. You know, enemas might be called upon as well.

Andrew: Right. Okay. You know, one herb that I totally take your point about, confirming, without a doubt, that their gallstones are less than… I had to cut off at 1 centimetre. So, anything over a centimetre, I wouldn’t touch. Go off. See ya. But, particularly if it was gravel or sludge, but they were getting contraction pain, that sort of griping pain after meals, particularly a fatty meal… I used to love the use of wild yam. You know, it was popularized back in the day as a sort of phytoestrogen. Eh-eh. But I used to use it for liver. Because it’s a smooth muscle relaxant. It was brilliant. I loved it. It’s fantastic.

Amie: Yeah, beautiful. Yeah. So, anytime you were doing some sort of active flushing or gallbladder stimulation, something like that would be imperative to use alongside that. And certainly, you know, there are essential oils, like caraway and peppermint, that also can relax smooth muscle, that you could consider. So, you know, as you can see, it does require a very coordinated and holistic approach, and sort of in the right order, as well, to avoid causing more problems.

Andrew: Yeah. Beautiful. Amie, look forward to this seminar. As usual, I know it’s gonna be comprehensive. But thank you so much for taking us through just some of the finer points, some of the more practical points, where we can help patients today. Thanks so much.

Amie: Yeah. Thanks, Andrew.

Andrew: And thank you, everyone, for joining us today. Remember, we’ll have all the show notes and every other podcast up on Designs for Health website. I’m Andrew Whitfield-Cook. This is “Wellness by Designs.”