ERCP Archives - Hormones Matter

Problems after Gallbladder Removal: Postcholecystectomy Syndrome

Published on May 18, 2021

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Obviously, you can survive without a gallbladder. Otherwise, gallbladder removal (cholecystectomy) would not be such a common surgery. In fact, over 600,000 people in the U.S. have their gallbladders removed yearly. However, surviving without an organ and living a healthy life without it are two very different things.

Following a cholecystectomy, you are more prone to developing certain health problems. For example, you are at greater risk of developing a fatty liver, diarrhea, constipation, biliary issues, indigestion and developing deficiencies of essential fatty acids and fat soluble nutrients. Bile, which is necessary for digesting fats and proteins and metabolizing fat soluble vitamins and minerals, is no longer stored and concentrated in the gallbladder. This can lead to unpleasant symptoms.

When your body is void of a gallbladder, bile freely flows from the liver to the bile duct, exiting through the sphincter of Oddi into the duodenum (the first part of the small intestine). The high-water content of bile is no longer removed and overly concentrated bile is not conjugated in the gallbladder.

Change in bile chemistry isn’t the only thing that occurs after cholecystectomy. Surgeries are never perfect and fool-proof. Therefore, human error can bring about injury to the ducts. Adhesions (scar tissue) can form following surgery and some people are more prone to developing them. A remnant cystic duct (the duct that once connected the gallbladder to the common bile duct) may cause problems. Also, dramatic changes may occur within the liver itself due to the absence of a gallbladder.

Any health issues or symptoms arising because of gallbladder removal is called postcholecystectomy syndrome. Postcholecystectomy syndrome describes the appearance of symptoms after cholecystectomy. It is widely estimated 10-15% of the population experience some form of postcholecystectomy syndrome, but Merck Manual estimates anywhere from 5-40% of cholecystectomy patients are afflicted. Isn’t it interesting that a seemingly disposable organ could wreak such havoc on our bodies once it is removed?

The most common causes of postcholecystectomy syndrome relate to the change in bile flow and concentration, complications from surgery (i.e. adhesions, cystic duct remnant, common duct injury), retained gallstones or microscopic gallstones (biliary sludge), effect on sphincter of Oddi function, and excessive bile that is malabsorbed in the intestines. Jensen, et al described in their research paper, Postcholecystectomy Syndrome, over 60 different etiologies of postcholecystectomy syndrome.

Diagnosing Postcholecystectomy Syndrome

If you are experiencing troubling symptoms following a cholecystectomy, talk to your gastroenterologist or primary care doctor. He/she will likely order blood work, specifically liver function tests. In addition, you may want to ask that your vitamin and pancreatic enzyme levels be tested, since bile is required to metabolize fat soluble vitamins like vitamins A, D, E and K; and some postcholecystectomy issues affect pancreatic enzyme output.

Depending on the results of your bloodwork, your doctor may order an imaging study (x-ray, ultrasound, MRI, or CT scan), a functional test (gastric emptying study or small bowel follow-through) or a procedural test (endoscopy, colonoscopy, barium enema). If these tests are inconclusive, your doctor may want to conduct a more in-depth procedural test like an endoscopic ultrasound or Endoscopic Retrograde Cholangiopancreatography (ERCP) to get a better look at the ducts, liver, and pancreas. In rare cases, your doctor may recommend exploratory surgery.

There are also alternative tests a naturopath or functional medicine practitioner could offer, i.e. comprehensive stool analysis, or hormone and nutritional tests. Keep in mind that for some postcholecystectomy patients, the answers to your symptoms may not be revealed in typical bloodwork, scans, or procedures. Tests are not fool-proof for all patients. Many patients have disabling symptoms and their bloodwork and scans are normal. “Normal” test results can come as a relief. However, when you do not get an answer to your woes, it can be quite frustrating. This does not mean, though, you can’t treat your symptoms.

Treating Postcholecystectomy Syndrome

The most common postcholecystectomy issue is bile acid diarrhea. Because bile is being dumped and no longer processed, the intestines receive an excess of bile or bile that is difficult to reabsorb. This may cause moderate to severe diarrhea in some people, especially after eating.

Ask your gastroenterologist or primary care doctor about prescribing cholestyramine, a bile acid binder. It will bind the bile acids and, in most cases, reduce this form of diarrhea. Always pay attention to side effects like constipation, bloating, or flatulence to gauge how much cholestyramine is appropriate for your individual situation. If the cause of your diarrhea originates from bile, cholestyramine will likely help you. If the cause of your diarrhea is from irritable bowel syndrome (IBS) or another cause, this therapy will not be effective. For other forms of diarrhea, you may need an IBS-specific medication or natural therapy.

Another postcholecystectomy issue, mostly affecting women, is Sphincter of Oddi Dysfunction (SOD). SOD symptoms are upper right quadrant pain, nausea/vomiting, bowel, and other issues. For more information on this condition, read my article, Sphincter of Oddi Dysfunction, or go to the SOD Awareness and Eduction Network website. In addition, I published The Sphincter of Oddi Dysfunction Survival Guide this past summer.

Microscopic gallstones and biliary sludge can cause problems too, but is difficult to diagnose unless you have an ERCP. If you have constipation, upper right quadrant pain, and nausea, you may have biliary sludge. If you and your doctor suspect this, he may want to prescribe ursodeoxycholic acid, which reduces the cholesterol content in bile. Alternatively, an ERCP can clean out the duct.

Consult with a natural health practitioner if you’d rather go the holistic route. He/she can prescribe the essential fatty acids Omega 3 and 6 (bile is needed to convert these fatty acids), digestive enzymes, a bile replacement supplement, homeopathic remedies, and/or herbs (ex. dandelion, milk thistle, turmeric, peppermint, and bitters). In addition, chiropractic, acupuncture and Chinese medicine, and other natural therapies have helped people with postcholecystectomy syndrome.

General Diet and Lifestyle Remedies

After I had my gallbladder removed, I had to change my eating habits to avoid unpleasant symptoms. Overeating spelled disaster for my strained liver, pancreas, and ducts. It is best to try to eat several small meals a day or eat smaller portions at breakfast, lunch, and dinner. Going too long without eating is also bad as our bodies signal bile to be released at certain times of the day. Not eating can lead to bile acid diarrhea and intestinal discomfort.

Don’t eat fast. Instead, chew your food thoroughly and take your time. This will benefit your entire digestive tract and organs so they don’t have to work as hard. Your digestive system starts in your mouth where enzymes are released to start the digestion process. Taking the time to allow these enzymes to mix with your food is essential for proper and thorough digestion.

Eat a low-fat diet. This does not mean you should avoid all fats. Instead, be mindful of the amount of fat grams you ingest, especially saturated fats. The Mayo Clinic recommends keeping fat intake under 3 grams per meal and snack. Greasy, fried food may no longer be your friend. It is wise to hold off on re-introducing fatty foods high in saturated fats. If you don’t, you may experience pain, gas, or diarrhea. Some of the worst offenders, besides fried foods, are cheese, fatty luncheon meats or sausages, hot dogs, fatty pieces of steak, dark meat portions of poultry, butter, and all oils except medium-chain triglycerides (MCT) oils. MCT oils, i.e. coconut and palm kernel oil, do not require bile for digestion.

The juice of certain vegetables can do wonders for the liver and biliary system. Beets, apples, and ginger all support bile formation. Beets are probably the best vegetable for your liver as they contain important liver healing substances, including betaine, betalains, fiber, iron, betacyanin, folate, and betanin.

Betaine is the substance that encourages the liver cells to get rid of toxins. Additionally, betaine acts to defend the liver and bile ducts, which are important if the liver is to function properly. Additionally, beets have been linked to the healing of the liver, a decrease in homocysteine, an improvement in stomach acid production, prevention of the formation of free-radicals in LDL, and the prevention of lung, liver, skin, spleen, and colon cancer.

Apples contain malic acid which helps to open the bile ducts that run through your liver and reportedly soften and release the stones. Apples are also high in pectin. Ginger is reported to increase gut motility and bile production. You can add ginger to food dishes or eat it raw. I prefer to juice ginger and drink a small amount of the extract. The extract can also be added to juiced fruits and vegetables. Be careful, though, as it is spicy and pungent. You only need a small amount.

Other foods reported to protect the liver and increase bile production are bitter foods such as dandelion and mustard greens, radishes, artichokes, fruits high in vitamin c, and cruciferous vegetables such as broccoli, cauliflower, and cabbage.

Stay tuned for my next book, Living Well Without a Gallbladder: A Guide to Postcholecystectomy Syndrome, which will be published Summer 2017.

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This article was published originally on January 30, 2017.

Sphincter of Oddi Dysfunction (SOD)

by Brooke Keefer

Published on October 3, 2017

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I have Sphincter of Oddi Dysfunction or SOD, a female-dominant health condition that caused me to give up a successful career as a not-for-profit director, lobbyist, and advocate. I could not parent and spent a year vomiting, in severe pain, and on a feeding tube. I was 90 pounds and the emergency and hospital rooms became my second home. On several occasions, my gastroenterologist said postpartum depression and stress were causing these extreme symptoms. As I was dying I was told to shake it off, just eat, and reduce my stress. Not only was I very ill, I was blamed and shamed for being ill. Though my tests were normal, I knew my body and this was definitely not psychological in nature.

Fortunately, a surgeon friend of my mom’s suggested I be tested for something called Sphincter of Oddi Dysfunction. Having never heard of this disorder, I scoured the Internet for information and bingo! Everything finally made sense.

Gallbladder Removal and Sphincter of Oddi Dysfunction

The year was 1998. I had my gallbladder removed and soon after developed a severe and constant pain in my right side under my rib. After a few tests proved negative results, I was diagnosed with IBS and given a medication that did not work. Since pain medication barely touched the pain, I went without and learned to live with it. Avoiding certain food triggers, breathing exercises, and mindfulness/awareness techniques helped me function each day.

Fast forward to September 2011, three months after giving birth to my third son. I could not keep food down. The pain shifted to the area below my sternum. Later identified as pancreatic pain, it was searing and relentless. Weight was flying off of my 135 pound 5 feet 4 inch frame. For a year, I suffered; until I took matters into my own hands. I traveled from New York to the University of Minnesota to put a name to the mystery condition slowly killing me. There, I had an endoscopic retrograde cholangiopancreatography (ERCP) with manometry—the gold standard diagnostic test for SOD. Sure enough, the doctor told me I had a terrible case of SOD. The frustrating part of this was my doctors back home could have performed this test but insisted on the psychiatric diagnosis.

What is Sphincter of Oddi Dysfunction?

So what is Sphincter of Oddi Dysfunction or SOD? SOD is a condition where the sphincter valves controlling the flow of bile and pancreatic fluids do not open and close properly. SOD occurs most frequently following gallbladder removal (post-cholecystectomy). Symptoms include (but are not limited to):

severe upper right quadrant pain
pancreatic pain
nausea
vomiting
diarrhea
constipation
malnutrition
unintended weight loss

Sufferers often go undiagnosed or misdiagnosed as it is common for SOD patients to have normal bloodwork, scans, and procedural workups.

SOD and Women

SOD is most prevalent among women for unclear reasons. A culmination of studies published on the NIH website estimate this prevalence to range from 75-95%. However, surveys conducted in 2013 and 2014 by the Sphincter of Oddi Dysfunction Awareness and Education (SODAE) Network showed an astounding 98% of SOD sufferers are women.

I oversee The Sphincter of Oddi Dysfunction Awareness and Education Network (SODAE Network) website, Facebook page, and support group. As such, I read and listen to countless stories of doctors telling SOD patients not only that their symptoms are psychological, but that SOD does not even exist! Patients either exhaust their savings to travel far and wide to see a doctor who will help them (yes, there are some fantastic SOD doctors out there) or, those who cannot afford that option, are left with no treatment options and in time deteriorate physically and mentally.

Confusion amongst Physicians: Is Sphincter of Oddi Dysfunction Real?

At the center of this “SOD is not real” movement by some gastroenterologists is the National Institutes of Health study—The Evaluating Predictors and Interventions in Sphincter of Oddi Dysfunction (EPISOD) study, which I happened to be a participant in. The treatment at the center of the study, sphincterotomy, showed it did not relieve symptoms in all participants—not that SOD could not diagnostically be proven. The sphincter is cut so it will provide greater access for fluids to flow rather than get backed up. I had this and it did not work for me either. Two months later I had a transduodenal sphincteroplasty–a major abdominal surgery to sew my sphincters permanently open. I am happy to say I am doing well for the most part and consider myself in remission.

Theoretically, if the treatment did not relieve the patient’s symptoms, then the problem could not originate in the sphincter, which was now cut wide open. This makes absolutely no sense. Would we say other diseases measured by symptomology and/or diagnostic methods do not exist when a treatment is found to be ineffective, i.e. cancer, multiple sclerosis, Alzheimer’s, etc.? As we know, many diseases cause secondary conditions. It is quite possible SOD began as a primary condition, but as it precipitated (it often takes years to obtain a diagnosis), it spawned secondary issues like ductal spasms, nerve and/or visceral hypersensitivity, pancreatitis, malnutrition, or gut dysmotility. The original disease did not change. It was always there. However, once the sphincters were cut, the body still had these secondary issues.

Sphincter of Oddi Dysfunction is Real

Rather than spending valuable time recklessly slamming women with SOD and questioning SOD’s existence, researchers, policymakers, and the medical profession should be investing in women’s health, funding research to identify the cause of this condition. By learning the exact nature and cause of SOD, we can then move on to identify and develop effective treatments and preventative measures. Of particular note, is the need for investigating the possibility of a genetic and/or hormonal cause to SOD, since so many sufferers are women. No such study has been initiated, outside of a prairie dog study conducted in 1994 determining estrogen inhibited sphincter of oddi motility. That is a narrow bit of research on which to base medical opinion.

This article was published previously in January 2015.