Dr. Amy Nett: Great questions, and I want to just do a very brief review in terms of the gallbladder physiology so that we understand because it’s very straightforward. Once you understand what the role of the gallbladder is, what the bile is doing, you can sort of think through the potential complications. It’s always nice to be able to think through things. That way you don’t have to memorize.
We know that bile formation begins in the hepatocytes. The hepatocytes then actively secrete bile into the biliary ducts for further modification. Principally you get the addition of a watery bicarbonate-rich fluid that makes the so-called hepatic bile. You get somewhere in the order of about 900 milliliters of the hepatic bile produced daily. When you’re between meals, about half of that bile gets diverted to the gallbladder, so the gallbladder can effectively act as a storage organ for the bile. You get about 450 milliliters per day going into the gallbladder. In the gallbladder you have this relatively dilute hepatic bile that’s stored there, and then you get an isosmotic removal of the salts and the water, so you get a much more concentrated bile fluid. Then that bile fluid—so a combination of both the “hepatic bile” and gallbladder bile—is delivered to the small intestine, specifically to the duodenum, when you eat.
So the bile has two major important functions. The bile is going to provide both an excretory route for several solutes that don’t enter the renal glomerular filtration system, or otherwise just saying toxins and compounds that aren’t removed by the kidneys, so this might be cholesterol, bile pigments, plant sterols, lipophilic drugs, toxins, heavy metals—those sorts of things.
The second role of bile is that it’s required for normal lipid digestion and absorption. That absorption piece is particularly important for absorption of the fat-soluble vitamins. What happens when you eat is you have both hormonal and cholinergic mechanisms involved in gallbladder emptying. The dietary lipids, in particular, are going to stimulate the release of cholecystokinin, or CCK, from neuroendocrine cells that are located in the duodenal mucosa. Generally, these are the I cells, but it’s not too important. In response to a meal, you get release of CCK with a five- to ten-fold increase within about 10 to 30 minutes of eating. The most potent stimulator of CCK is going to be dietary lipids and some of the digestive products of proteins, namely amino acids. Carbohydrates really don’t stimulate CCK. The increased CCK then leads to a coordinated response where you get release of bile into the duodenum.
Hopefully by understanding how the bile salts function and the physiology behind that, you’ll know that if you don’t have a gallbladder, you’re not going to be able to excrete the higher volume of bile into the duodenum, or small intestine, and you’re not going to have that concentrated form of bile. You’re going to have the “hepatic bile.”
We know, then, that the primary concerns are going to be fat malabsorption, so a decreased ability to digest fat. That can lead to diarrhea. Most often that’s a steatorrhea, where you see a lot of fat in the stools. The stools may look oily, so people may actually be able to tell just by looking that they have undigested fats coming out in their stools.
The other problem is we said that bile salts help us absorb fats as well, so that means that we’re potentially going to see problems with fat-soluble vitamin absorption when you don’t have a gallbladder and don’t have that more concentrated bile production and release into the duodenum.
Those are the main problems that you need to think about after cholecystectomy. That said, each individual is so different that some people actually seem to do pretty well even after a cholecystectomy. Other people have to experiment with their diet a bit to figure out which foods are affecting them differently compared with prior to surgery. If someone is struggling and they haven’t figured out how to tweak their diet, I’m going to give you a few tips that we sometimes use with our patients who have already had a cholecystectomy.
Before moving on to those, it’s important to mention that there is a connection between gluten intolerance and celiac disease and gallbladder dysfunction. If you have a patient and they’re having some gallbladder dysfunction and they’re being pushed by their surgeon or, otherwise, their conventional medicine physician to have a cholecystectomy, I would absolutely do testing first. Do Cyrex Array 3. We’re going to be talking about that panel in much more detail, but do testing for celiac disease and non-celiac gluten sensitivity, and if the patient has either of those, they need to be on a strict gluten-free diet before you can really assess whether or not they even truly have gallbladder dysfunction because just being on a gluten-free diet may resolve that dysfunction.
Patients who have already had a cholecystectomy and are figuring out how to manage their changes postcholecystectomy, one thing you can start with is just using digestive enzymes that contain lipase. They might just need help digesting their dietary lipids, so try digestive enzymes with lipase. You can also try lipase … they sell supplements that are just lipase.
You can also try ox bile supplementation plus or minus HCl. The ox bile is just what it sounds like. It’s essentially bile, and it’s going to performing the functions that the bile from their gallbladder would otherwise perform, so it should help with that digestion and absorption of dietary lipids. That would be particularly important when meals are higher in fat content. If someone’s eating a heavy-carbohydrate meal, these aren’t going to be as important. They should be able to digest those a little bit better, so they may need to tweak the dose of ox bile and/or HCl depending on the macronutrient composition of the meal.
Patients might also want to limit fluid intake at the time of meals, meaning don’t drink that much with meals, because that’s going to dilute the digestive enzymes and the bile that is getting into the small intestine.
You could also suggest that patients consider more frequent mealtimes. Intermittent fasting, which can be a great strategy for certain conditions for some people, tends to lead to larger meal sizes when you do eat, and it may be that people can’t tolerate those larger meals. Sometimes people who have had a cholecystectomy do better with smaller meals and just more frequent eating, so that could help, just meal timing and size of meals.
Also watch fat intake. Bile primarily affects lipid digestion and absorption, so a ketogenic diet is normally not a good option in someone who has had a cholecystectomy. More of a moderate-fat intake, and you can also think about the types of fats that they’re eating. For example, if you aren’t tolerating fats well, think about leaning more towards coconut oil because the medium-chain triglycerides tend to be more rapidly absorbed and metabolized and therefore tolerated a little bit better.
Then you would also want to consider supplementation with fat-soluble vitamins. Depending on the degree of malabsorption, you might use a combination of cod liver oil and butter oil primarily for vitamins A, D, and K. You could even also consider tocotrienols if you want some additional vitamin E support.
Those are the tips I would consider for sort of optimizing health and nutrition after someone has had a cholecystectomy. Hopefully that answers those two questions.