The Functional Medicine Approach To Gallbladder Disease

Mark Hyman, MD

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Dr. George Papanicolaou: Everybody says a lot of people know, "Oh, yeah, it's my gallbladder. I'm going to have to get it taken out." Your thought is the only cure for the gallbladder is to take it out. There's no thought to their lifestyle, their nutrition, and the impact that bile is having on the gut microbiome, which might be causing some other symptoms in their GI tract. Dr. Mark Hyman: Welcome back to The Doctor's Farmacy, and that's Farmacy with an F, a place for conversations that matter. If you have ever suffered from gallstones or gallbladder disease, this is going to be a great conversation for you because it's going to help you figure out why you got them and how to get rid of them and how to actually deal with this problem, which affects so many people. And today our guest on a special edition of The Doctor's Farmacy, called House Call, is none other than my friend and colleague at the UltraWellness Center, Dr. George Papanicolaou. Welcome back, George. Dr. George Papanicolaou: Mark, it's always a pleasure. I love talking about functional medicine and how we work with our patients at the UltraWellness Center to get to the root cause of what's keeping them from optimal health. Dr. Mark Hyman: Of course. Gallbladder is such a common problem. It's one of the most common surgeries, it's such a common problem in America. Tell us about gallbladder disease and what is it, who gets it, how many people have it and now what are the symptoms and why is it such a big deal? And what do we know about who's getting it and all that? So take us down the hole. There's a whole rabbit hole of gallstones. And then we're going to get into how conventional medicine treats it and what functional medicine approach might be that might be worth trying. Dr. George Papanicolaou: Yeah, sure. It's almost so common that it's invisible. And what I mean by that is that people don't really think about it, don't think about their gallbladder. Why would they think about the gallbladder until it hurts? So gallbladder disease affects 6% to 9% of adult aged people between 20 and 70. And all of those people they've either had gallbladder disease or have the gallbladder taken out. So it's a pretty large problem. It's a huge healthcare expenditure. It's a fairly expensive surgery. So it has a big drain on our system. In gallbladder disease, people really don't know that there's anything going on with the gallbladder until they have the symptoms, which is going to be what we call biliary colic. And that's when you've eaten a meal and then within half an hour to an hour, you begin to feel really bad pain in your right upper quadrant. Dr. George Papanicolaou: And then where's that? That's going to be below your ribs to the right. And it's going to be really, really painful and you're not going to like it at all. You're thinking you're having a baby and it's not coming out. It's really painful. And then you're going to end up in the emergency room and then you're going to be given some medications that will hopefully relieve your pain. And if it is a gallstone, then hopefully it will pass on itself and hopefully there will be no complication. And then you'll leave the emergency room, you'll see your primary care. Your primary care will confirm that you're feeling better and then tell you take a statin and send you on your way. And then we're missing so much. We've just lost, like okay, it's not just that you had a stone that didn't pass and you had pain, get to the root cause. Dr. Mark Hyman: What is the root cause? Dr. George Papanicolaou: Why did the stone end up there in the first place? Right? And so where does it come down to? It comes down to what we always start almost every conversation you and I have, it starts with diet. It starts with the foods that you eat. Yes, there's genetic predisposition. Yes, you can be a female, you can be overweight, you can be pregnant, you can be 40, you can be a diabetic. You can have other chronic underlying diseases that predispose you to gallbladder disease, particularly gallstones. But when it comes down to it, a lot of it's going to have to do with your diet. Are you eating a high fiber diet? Are you eating a nutritious diet where you're getting all of the... Are you drinking? Are you getting all of the nutrients that actually keep your gallbladder healthy? Dr. George Papanicolaou: Are you drinking enough water in your day? Because the bile that's in the gallbladder is 95% water. And then it's made up of bile acids, bilirubin, fats, amino acids, proteins, enzymes hormones like estrogen, toxins. Your bile plays a very important role in the detoxification process in your body. And so if you're not getting what you need to make good bile, then you're going to put your gallbladder under pressure. And so if you're not drinking enough water, here's what happens. Where's the gallbladder it's first place? It sits right under the liver on the right side. Your liver makes bile and then that bile goes into the gallbladder where it's stored. And then when you're eating, when fat that you've eaten enters your small intestine, it triggers something called cholecystokinin, which then sends a message or is the messenger to the gallbladder to the release the bile. The bile is released and it will then start breaking down your fat so that you can get all the nutrients that you need out of your fat. Dr. George Papanicolaou: And so that's what happens, that's the gallbladder does. You need healthy bile to then do its job to breaking down the fats. And so where does the problem become? These stones are actually the compounds that are in the bile, in the gallbladder, that begin to precipitate out. So they start to connect to each other and form crystals. And then these crystals can get really big. So when those crystals get big enough and they become stones, or they become hundreds of thousands of little crystals that sit in your gallbladder and on an ultrasound that will be done, they just look like sludge. It's sand at the bottom of the hourglass, sitting in your gallbladder. And so that's how you get the gallstone. Dr. George Papanicolaou: Interestingly, this is very interesting, what's the other thing we talk about all the time? The immune system. The immune system. So when you start creating these crystals because you're not supporting a healthy gallbladder or you have a disease process that slows the gallbladder so it doesn't empty, it gets filled up a bile, the bile can't get out, and that's going to trigger again, the precipitation out of these compounds that are in your bile and they'll form the crystals. But here's the interesting thing. There's been research that shows that you have an immune response to these crystals. Your immune system actually sees them as foreigners and sends eosinophils, which are white blood cells, to attack the crystals. Eosinophils get broken down in the acidic environment. And when they become damaged, they begin to form this matrix around the crystal that exponentially increases the precipitation and the formation of the crystals. And then you can get these huge stones that won't pass or get stuck in the duct that leads from the gallbladder into the intestine. Pretty fascinating. Dr. Mark Hyman: Amazing. Dr. George Papanicolaou: That's how we get there. Dr. Mark Hyman: From a functional medicine perspective, we see a lot of this in diabetics. A lot of it has to do with insulin resistance and poor metabolic health, which affects 88% of Americans. So that's why gallbladder disease is such a big deal. And the problems that people suffer from are miserable, pain, vomiting, nausea, just severe issues. They can't digest their food. And often the traditional treatment is just surgery. But from a functional medicine perspective, what do we think about how do we begin addressing this? What are the ways that we support these patients and how we get them better? And sometimes they do need surgery, but talk about the approach you would take in terms of what diagnostics we would use and how you would help people. Dr. George Papanicolaou: Yeah, sure. Just for sake of contrast, I would say that, just doing my research for this podcast, it was really fascinating that the gallbladder and bile play a really important role in the body. I think this is the one of the classic examples of the differences between functional medicine and conventional medicine, because in conventional medicine, it's the stone, it's the pain, it's the complications of the stone. And so if you continue to have stones, we'll take your gallbladder out. If you have a complication to the stone, you have an infection, then we're take your gallbladder out. That's it, that's it. There's absolutely no thought as to the role, what got you there and what the role of bile is in the rest of the process, because it just doesn't break down fat. Dr. George Papanicolaou: Because of the contents of bile, which spills into your intestine, it can have a huge impact on your gut microbiome. So I just want to emphasize that that's why I said earlier, it's like it's so common, it's invisible. And because we just take it out, there's even more reason to not think about it because everybody says, a lot of people know, "Oh, yeah, it's my gallbladder. Now I'm going to have to get it taken out." Your thought is the only cure for the gallbladder is to take it out. There's no thought to their lifestyle, their nutrition and the impact that bile is having on the gut microbiome, which might be causing some other symptoms in their GI tract. Dr. Mark Hyman: Talk about that. Talk about that connection between the microbiome and the gallbladder. Dr. George Papanicolaou: I can enter that highway from multiple routes. I will go at it from this perspective that when the bile, now if it's too acidic, if you have too many toxins in it and your nutrition's poor, so you don't have enough amino acids in it, you don't have enough proteins or enzymes that actually can be of aid to the bacteria in the gut microbiome to do their job. Then it will start to alter environment of the gut microbiome. And then you'll end up with what we call dysbiosis. The bile will cause damage to the gut microbiome. When that happens, then the organisms that are really healthy start to decline, they become destroyed. Then you start to develop some organisms like candida that will alter the gut microbiome even more. Dr. George Papanicolaou: And some of those commensals that live there, they've been hanging on in the poop party where it's nice for bacteria to grow. They will start to grow. Now all these bad bacteria taking over, you get inflammation, you have a breakdown of the mucosal lining that plays a very important role of protecting your immune system and allowing for the bacteria, the healthy bacteria in your gut microbiome, to communicate to the immune system in a very precise way, because that happens and it's very important. And when that communication system breaks down, because the gut mucosa has been damaged, then the immune system begins to be overwhelmed and starts to have inappropriate responses, leading to autoimmunity and leading to inflammation throughout the body. And so that then triggers this inflammation, then it affects the gallbladder. The gallbladder then will be affected. Dr. George Papanicolaou: I'll give you an example. Let's say you have a gluten sensitivity and you don't know it, and you eat gluten. Gluten is a real strong potentiator for creating autoimmunity against your thyroid. And it can create Hashimoto's thyroiditis. And there have been studies that show a very strong connection between Hashimoto's and gallbladder disease. Dr. Mark Hyman: Interesting. Dr. George Papanicolaou: Right. So what happens? Well, gluten, it has antigens on it very similar to the thyroid. So in the immune system makes antibodies against the gluten. It also can confuse and those antibodies can attack the thyroid. Okay. What happens? Well, now that's called Hashimoto's, and Hashimoto's in its end game, stops your thyroid from working. Your thyroid loses function. We call it hyperthyroidism. Hypothyroidism slows down the gallbladder's ability to move the bile out. And that becomes the first step in your stones developing, because if you can't get the bile out and sluggish gallbladder, then the bile builds up. And now you set up that environment for all those compounds to precipitate out. The threshold for that precipitation to occur lowers as you have more and more bile sitting there under pressure. You can see there's a cycle there. That's why I said you can't just ignore the fact somebody's got a stone. You've got to look for root causes. You've got to look for other disease processes that may have predisposed them to form that stone. The stones just [inaudible 00:15:08] of the process. Dr. Mark Hyman: And the disease process, things like insulin resistance and diabetes is a big one, which is such a big factor that we deal with. And often, it's not really addressed as a way of treating stones. We also deal with the whole gut issues. What have you seen in your patients with this? You had a patient who was over 40, a woman, she was gaining weight, had gut issues. Tell us about her and your approach. What did you do diagnostically? How did you treat her? What was the outcome? Dr. George Papanicolaou: Sure. And as we learned in medical school, it's the four or five F's, depending on how you think about it. But unfortunately it has a lot to do with women. And it has to do with the fact that they're pregnant, they're fertile, they're 40, those are two things that they're associated. Dr. Mark Hyman: And overweight, right? Dr. George Papanicolaou: And overweight, yeah. I don't want to say. Fertile, fat. Dr. Mark Hyman: That was back in medical school. We learned all those, fertile, fat and 40. That was what we learned. George didn't want to say it. Dr. George Papanicolaou: So this woman came and her concerns were that she was really feeling fatigued, she had sudden weight gain. She had gone to her PCP. She was told that her thyroid looked fine, the numbers are okay, not to worry. You still got kids, the same old, you're getting older, you have kids, you're running around, you're busy. And so she was just living with this fatigue and this weight gain. And then she started having gut issues. She started having bloating and distension, and so she just couldn't take it anymore and she came to visit us. She had, I think, one episode of pain that sounded like it was gallbladder disease. It had lasted for an evening, it was after having a really fatty meal and she hadn't gone to the doctor, suffered through the night. And so that, she never really dealt with it. Dr. George Papanicolaou: So part of after her first visit, I told her, "I really want you to go get an ultrasound of your gallbladder." I said, "You have a lot of things going on. But one of the things I need to really find out is if you do have gallbladder disease." So it turned out that she did. She has some stones and she probably did have an episode of a stone that passed and caused her some pain. So the complete workup for her involves looking at her hormones, looking at her thyroid and looking at her gut microbiome and food sensitivities. And so when I got her fibroid numbers back, her TSH was 3.9. Okay? Doctors will look at that and say, "That's within the normal range," because traditionally we've been taught that anything from 0.45 to 4.5 can be considered normal. Dr. George Papanicolaou: But we've learned more and more that that's not the case. When you see a 3.9, you see a 4.2, you start to think, I don't think that that thyroid really is at optimal function. I also, when I check the thyroid, I also check for antibodies and wouldn't you know, her antibodies against her thyroid were sky high. She had Hashimoto's thyroiditis. On her food sensitivity panel. She had food sensitivity. She did not have celiac disease, but she had gluten sensitivity, Hashimoto's hypothyroidism, which then set her up for a couple different things. But certainly it slowed her gallbladder down and set her up for having a stone, by the mechanisms I've already explained. And she was estrogen dominant, meaning that relative to progesterone, she had more estrogen than she needed. And she had a history of a cycle that had been irregular, a cycle that she had a lot of breast tenderness. Dr. George Papanicolaou: She had a lot of water retention around her periods. She had PMS throughout her period. That just screams estrogen dominance and she's had that most of her life. So what did I do? Step by step. We just started to deal with the underlying issues. I started to treat her thyroid, treat her Hashimoto's thyroiditis. She had SIBO by the way. First thing we did, we stopped the gluten. So she was off of gluten and you definitely want to do that because if you have sensitivity to it and you get one autoimmune disease, like Hashimoto's, then you're going to set yourself up for more. It's more likely that you'll get another one. [inaudible 00:20:11] her gluten stopped and then we addressed her SIBO. SIBO is small intestinal bacterial overgrowth. We put her on a low FODMAP diet, which helped address that. I used some anti-microbials that were botanicals that addressed that. Dr. Mark Hyman: How did she do? Dr. George Papanicolaou: She did great. Obviously, it took a while to get her hormones under control and balance those out. It took a little while to get her SIBO under control. But once we had the SIBO under control, we got her thyroid function down from 3.9, got it down to 1.2. Her energy was back. She felt great. And then as we worked with her diet and we cleaned up her SIBO, she was back to normal in a very short course of time, within three months. Dr. Mark Hyman: It's amazing. So we really can affect people's course and she really didn't need surgery then? Dr. George Papanicolaou: She did not need surgery. And I said this before, and I explained this to her. I said the stones are just enigmatic of the bigger problem. They're the canary in the coal mine of your nutrition not being where it needs to be. And you may be having excess toxins in your system. And the estrogen dominance, estrogen needs to be metabolized. And it is in the liver and it ends up in the gallbladder. But if it's in too high a concentration, it can have a very negative impact on gallbladder function. So estrogen dominance, her SIBO, her thyroid, it was a matter of time before she... If she had had that stone and gone to the emergency room and hadn't passed it, she would have her gallbladder taken out and nobody would have ever addressed these other issues. Dr. Mark Hyman: Absolutely. I've seen patients who really have been able to turn things around by correcting them and correcting their diet and their lifestyle and taking the right supplements. And it's not an easy condition for sure, because if you already have big stones that's blocking things, you need to have it dealt with. And after people have surgery, are they restricting what they can eat? Often people say, "Well, I can't eat fat." Is that true? Can they use enzymes? What is the consequence of actually having the surgery? Dr. George Papanicolaou: The consequences of surgery is that now the gallbladder can no longer store the bile. So the bile can freely flow into the small intestine. And so, in regards to the ability for the bile to do its job, it's not going to be being triggered appropriately. So it's really important that if you've had your gallbladder out, that you take something called Ox Bile with your meals, so that you can appropriately break down your fats. It can have a significant role because you may not break your fats down completely, and you need as important fatty acids, your omega-3s, your DHA, your EPA, that you get from your fat. And if you can't get them, then it's going to have a huge impact on you. In regards to foods you can eat, it's more of what you should eat. I think there are restrictions, but they're not always necessary. Dr. George Papanicolaou: It's really making sure that you're getting a higher fiber diet, you're getting foods that going to be favorable to your gallbladder, celery. What are some of the other ones? Help me out here, Mark. Bitters. So bitters. Green leafy vegetables, things that they can be very helpful. Dr. Mark Hyman: Absolutely. Dr. George Papanicolaou: Then the key thing becomes staying away from all the processed carbohydrates, staying away from meats that are not organic, that have lots of toxins in them. And if you do that, you take your Ox Bile, increase your fluid intake, add in some bile salts, which you can do through supplementation. You should be able to live pretty healthy after that. Even more healthy because we're going to change your diet because we're going to say, look, these are the things that got you to the stones and now you're going to have a really good leverage point in getting people to start to eat a healthier diet. Dr. Mark Hyman: That's fantastic. The truth is that there's so much we can do. And it's such a hopeful message for those who have gallbladder disease and can actually make a difference in the course. Maybe they'll need surgery, but maybe they won't if they try some of these other things that we use in functional medicine. And we take care of all sorts of patients like this at the UltraWellness Center in Lenox. We have a great team of five docs and five nutritionists and a great support staff, and really love to see you. So come visit us. And of course, we have a long waiting list, but hopefully we'll get you in soon. And if you like this podcast, please share with your friends and family on social media. If you have gallbladder disease, and you've learned something about it that you want to share, please leave a comment. Subscribe wherever you get your podcasts, and we'll see you next week on The Doctor's Farmacy. Announcer: Hi everyone. I hope you enjoyed this week's episode. Just a reminder that this podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. This podcast is provided on the understanding that it does not constitute medical or other professional advice or services. If you're looking for help in your journey, seek out a qualified medical practitioner. If you're looking for a functional medicine practitioner, you can visit ifm.org and search their find a practitioner database. It's important that you have someone in your corner who's trained, who's a licensed healthcare practitioner and can help you make changes, especially when it comes to your health.