Postcholecystectomy Syndrome Archives

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.

Living Well Without a Gallbladder: A Resource for Treatments

by Brooke Keefer

Published on October 24, 2017

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In July, I published my second book, “Living Well Without a Gallbladder: A Guide to Postcholecystectomy Syndrome,” to help patients suffering from symptoms following gallbladder removal (cholecystectomy). As a regular contributor to Hormones Matter, I have written two articles about the gallbladder, The Gallbladder: An Essential Organ Influenced by Hormones, where I discussed the importance of the gallbladder, the gallbladder/hormone link, and ways to avoid a cholecystectomy; and Problems after Gallbladder Removal: Postcholecystectomy Syndrome, where I described conditions and issues that arise following cholecystectomy, and information on obtaining a diagnosis.

In this article, I will complete the gallbladder trilogy with treatment resources for people suffering from symptoms following gallbladder removal due to postcholecystectomy syndrome.

Dietary Basics Postcholecystectomy

Regardless of your postcholecystectomy symptoms or diagnosis, it is very important to follow certain dietary rules now that your body no longer has a gallbladder. The foods your body will have the most difficulty digesting are fats, even healthy fats, due to the change in bile consistency and flow, since bile is necessary for digesting fats. Therefore, a low-fat diet is always recommend postcholecystectomy.

You may have difficulty digesting proteins and high cholesterol foods like dairy and eggs as well. However, I don’t recommend limiting your protein intake. Instead, space proteins out and eat them several times a day and not with a fatty meal. Frequent, small meals will be easier on your digestive system after cholecystectomy. In other words, do not overeat!

Postcholecystectomy patients will have a more difficult time digesting long-chain triglycerides (LCTs) as opposed to medium-chain triglycerides (MCTs). The fats in our food are composed almost entirely of LCTs. When we consume fats composed of LCTs they travel through the stomach and into the intestinal wall. It is in the intestines where most of fat digestion occurs. Pancreatic enzymes and bile are necessary for the digestion of LCT fats.

MCT fats are processed differently. After eating a fat containing MCTs, such as coconut oil, it travels through the stomach and into the small intestine. However, since MCTs digest quickly, by the time they leave the stomach and enter the intestinal tract, they are already broken down into individual fatty acids and do not need pancreatic enzymes or bile for digestion.

Therefore, as your bile output and consistency may be compromised as a person without a gallbladder, stick to MCT fats like coconut oil and palm kernel oil. Butter, whole milk, and cheese all contain MCT fat but they also may contain a high amount of LCT fat. Limit these. Otherwise “healthy fats” may not be so healthy. Foods touted as healthy fats like avocado, olive oil, nuts, and fatty fish may not be so healthy for a postcholecystectomy patient.

Keep in mind that although MCT oils are great alternatives for cooking and acquiring fat for energy, it is well-known that MCTs are not a good source of essential fatty acids. Therefore, if your diet is high in MCTs, you will want to supplement essential fatty acids like Omega 3 and 6. Supplementing with an Omega 3 supplement like fish oil will likely benefit all cholecystectomy patients.

If you are experiencing unexplained symptoms and suspect certain foods may be the culprit, I suggest starting a food and symptom diary. Food diaries are easy tools to identify trigger and safe foods. The most common problematic foods for postcholecystectomy sufferers are: fried foods, spicy foods, fatty and oily foods, coffee and anything with caffeine, chocolate, red meat and pork, alcohol, some fruits especially acidic fruits, and difficult-to-digest raw vegetables.

Along with a low-fat diet, gastroenterologists and dieticians often recommend trying a FODMAP diet. It is usually reserved for irritable bowel syndrome, but some with other postcholecystectomy conditions find it helpful. FODMAP stands for Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols. These foods contain difficult-to-digest sugars and fibers that can cause bowel problems like excess gas, painful bloating, and constipation or diarrhea.

Liver-Healing Vegetables and Fruits

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 are a high-antioxidant vegetable that contain important substances like betaine, betalains, fiber, iron, betacyanin, folate, and betanin.

Pectin, which is a fiber found in beets, can also help clean the toxins that have been removed from the liver, allowing them to be flushed out of the system instead of reabsorbed by the body. 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. This substance is also said to decrease the risk of coronary and cerebral artery disease.

Apples contain malic acid which helps to open the bile ducts that run through your liver and reportedly soften and release gallstones. 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 ginger is spicy and pungent. You only need a small amount.

Lemon is purported to benefit the liver as well. The high citrate content in lemon increases the liver’s ability to remove toxins. In addition, lemon contains a bioflavonoid called hesperidin, which protects the liver from damage, assists with digestion in the stomach (enhancing the effect of stomach acid), and inhibits fat synthesis.

Natural Treatments Post Gallbladder Removal

Natural treatments will depend on your postcholecystectomy symptoms and condition. What may work for one condition may hinder another. It is also important to keep in mind that with almost every “remedy” you must give it some time to see if it will help you. I recommend seeking a consultation with a natural health practitioner who can “prescribe” the right natural remedies for you and monitor your progress or side effects.

The most common natural remedies for postcholecystectomy syndrome are:

Bile Acids—to supplement lost bile acids and help bile flow.
Digestive Enzymes that contain protease, lipase, amylase, and lactase.
Herbs—be careful with herbs as they can increase bile flow and can spell disaster if you have a blockage from a stone or biliary sludge. In addition, drug-induced liver injury has been linked to herbs. Therefore, seek a consult with a natural health practitioner to ask about these most common herbs used by postcholecystectomy patients: dandelion root, Oregon grape root bark, gentian root, and wormwood leaves, artichoke leaf extract, milk thistle, gentian root extract, and valerian.
Turmeric—purported to protect the liver and reduce cholesterol levels, inflammation, fibrosis and bile duct obstruction.
Choline—aides in the absorption of fat and cholesterol and helps your liver create lipoproteins.
Betaine—helps your body breakdown and absorb fats.
Lecithin—keeps cholesterol from solidifying in your body and helps support your digestion of fats.
Soluble Fiber—may benefit patients experiencing bile diarrhea or bile reflux.
Magnesium—possesses natural antispasmodic qualities for intestinal and biliary/pancreatic sphincter spasms.
Fat Soluble Vitamins—since bile helps your body absorb fat-soluble vitamins such as vitamins A, D, E and K, you may need to supplement some or all of these to reach optimal levels.
Probiotics—some studies have shown probiotics benefited fatty liver disease and biliary cholangitis infections. Raising the level of “good gut bacteria” can be helpful to overall digestion.
Betaine HCL with pepsin—raises stomach acid levels, which is needed to properly digest food and absorb vitamins and minerals. It is especially helpful for those with bile reflux, which can alkalinize the stomach environment.
Chinese Medicine—can be helpful in balancing the digestive system and improving qi—the circulating life force whose existence and properties are the basis of Chinese philosophy and medicine.
Castor Oil Packs, Ayurveda, Essential Oils, Yoga, Breathing Exercises, Meditation, Biofeedback, Reiki, Visceral Massage, Bioidentical Hormones —are all said to benefit a variety of digestive conditions. Information can be found online and through YouTube videos.

Medications

Medications are typically used to treat specific symptoms, rather than as a preventative measure. It is important to not only thoroughly discuss your symptoms with your doctor, but to also educate yourself on prescription medications.

The most common medication for postcholecystectomy syndrome is a bile acid sequestrant (ex. Cholestyramine, Colesevelam, Colestipol) which binds to bile and reduces cholesterol. It is mostly used for bile acid diarrhea. Another commonly prescribed medication is ursodeoxycholic acid (ex. Ursodiol, Actigall). This medication may be used to dissolve microscopic gallstones and “thin” the bile.

Other medications are:

Prescription pancreatic enzymes (Creon, Zenpep)
Anticholinergics/antispasmodics (hyoscyamine, chlordiazepoxide (clidinium), dicyclomine, scopolamine, glycopyrrolate, amitriptyline, nortriptyline, atropine and combinations of these generics with phenobarbital and belladonna)
Muscle relaxants (cyclobenzaprine, carisoprodol, baclofen and buscopan)
Calcium channel blockers (nitroglycerin, nifedipine, diltiazem, amlodipine and felodipine)
Anticonvulsants (gabapentin and forms of gabapentin)
Antidepressants (any, but most commonly prescribed for digestive disorders are serotonin uptake inhibitors)
Low dose naltrexone—an immune modulator that has been effective in treating autoimmune disorders
Medical marijuana—seek professional medical advice on the best formula ratio of THC/CBD (the active medicinal ingredients in marijuana) for your condition.
Hormone therapy/birth control—hormones play a vital role in digestion and medications containing estradiol and/or progesterone have been helpful to some postcholecystectomy patients, particularly women.
Medications to specifically treat nausea, irritable bowel syndrome and gut motility may also be helpful.

In some cases, the only helpful resolution to postcholecystectomy symptoms is surgery. Your gastroenterologist or a Hepato-Pancreato-Biliary surgeon can help guide you in whether surgery could be helpful or is necessary.

Disclaimer: All material in this article is provided for your information only and may not be construed as medical advice or instruction. No action or inaction should be taken based solely on the contents of this information; instead, readers should consult appropriate health professionals on any matter relating to their health and well-being.