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Gallbladder Blues

Gallbladder Blues

“Toe in, toe in!  Come on, retract, I can’t see what I’m doing!”
These were the commonly heard urgings by gallbladder surgeons when I was a med student nearly thirty years ago.  Gallbladders were removed through large incisions followed by long recovery periods.  We students would scrub in and stand for a few hours in the OR pulling on wound retractors to keep open the incisions so the surgeons could have good visibility.  Boredom or fatigue occasionally caused us to slacken at our duty and the surgeon would quickly chide us. Happily for med students, surgeons, and especially for patients, most gallbladders are now removed laparoscopically through small incisions with much more rapid recovery and far less suffering.
Some things haven’t changed though – when there’s pain in the upper abdomen, especially if it’s the right upper abdomen, the gallbladder is still one of the suspects considered.  This isn’t surprising since in the U.S. about 20 million people have gallstones, and each year about 700,000 patients have their gallbladders removed to relieve troublesome symptoms.  The gallbladder follows the appendix as the other sack-like organ next most frequently removed due to disease or malfunction.
So what does the gallbladder do when it’s working correctly?  The gallbladder is a 3 to 4 inch long pouch-like organ tucked up into a pocket of the liver in the right upper abdomen.  Bile and other digestive enzymes are secreted and stored by it.  When we eat a meal, especially a large fatty one, this little sack contracts, squirting its digestive enzymes through a little duct or tube into the intestine where the enzymes help digest the meal.
So far, so good.  But things can go wrong.  The gallbladder can develop gallstones of varying sizes.  Then when the gallbladder contracts one of these stones can become wedged in the duct leading to the intestine.  Depending on where the obstruction occurs, this can sometimes also block off the pancreas causing still more problems.  Either way, there is tremendous crampy pain, usually in the right upper abdomen or upper mid abdomen and sometimes radiating through to the back.
The pain typically starts shortly after a meal and may last for a couple of hours or more, until the stone passes into the intestine or falls back into the gallbladder after it finally stops contracting.  Occasionally the pain persists and a trip to the emergency department, sometimes followed by emergency gallbladder removal (cholecystectomy) is the only solution.  An ultrasound of the gallbladder and lab work are usually able to diagnose this problem.
Gallstones are not the only problem that can arise in the gallbladder.  A situation can arise in which it excretes less and less effectively even though it has no stones.  In this condition, the gallbladder may look OK on ultrasound and a special scan is needed to identify the problem. Or, even more dangerous, the gallbladder can become infected with bacteria, often due to one of these other malfunctions already mentioned.   This requires urgent treatment with antibiotics and eventual surgery.  And like most organs in the body, cancer can occasionally occur in the gallbladder.
Anyone can have problems with their gallbladder, but certain groups are more at risk.  The most common group would be Caucasian females around their forties who are overweight.  Also, during weight loss there is a temporary increase in gallbladder attacks as the person processes their own fat.
For these reasons and more, the gallbladder may sometimes have to be removed.  Often this affords a huge amount of relief for the person.  However, besides infrequent complications of residual stones, infection or problems with wound healing, about 10-15% of people have ongoing symptoms after the gallbladder is removed.  This has been given the long name post cholecystectomy syndrome (PCS).  This is not surprising since God puts things in place for a reason; when we have to remove them, sometimes there are issues to deal with.  The loss of the gallbladder can cause symptoms such as heartburn, indigestion, loose stools or cramping.  These can be managed but are certainly a nuisance.
So if you’re getting symptoms that make you wonder about this little 3 inch sack, see your doc and get it checked out.  It’s helpful when it’s healthy; but if it’s betraying you, it just might have to go.
Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville.  Contact him at 982-0835


Low fat, plant based nutrition study causes a lowering in HDL

Here’s a link to an interesting 30 day dietary intervention study out of Australia where over 5000 people were self selected to participate in a standard program which advocates a low fat, plant based diet.

Here’s the study’s description of the nutrition intervention:

The CHIP intervention, previously described, encouraged and supported participants to move towards a low-fat, plant-based diet ad libitum, with emphasis on the whole-food consumption of grains, legumes, fruits and vegetables. Specifically, the program recommended less than 20% of calories be derived from fat. In addition, participants were encouraged to consume 2-2.5 litres of water daily and limit their daily intake of added sugar, sodium and cholesterol to 40 g, 2,000 mg, and 50 mg respectively. Furthermore, the program encouraged participants to engage in 30 minutes of daily moderate-intensity physical activity and practice stress management techniques.

All the biometrics measured were lowered including HDL. HDL dropped 8.7% on average and was worse if the individual started out at a higher level. Of note the LDL and Triglycerides dropped some too. They changed more than the HDL typically so the ratios of LDL:HDL and Total Chol:HDL improved.

Interestingly, 323 participants resolved their diagnosis of Metabolic Syndrome because of their changes but 257 participants acquired the diagnosis of Metabolic Syndrome typically because of their lower HDL numbers.

The study didn’t disclose percentages of fat, protein, and carbohydrates that the participants were eating nor do we know if they measured them. So it leaves the question of what exactly caused the changes. A diet with a lower fat intake, in my experience, is replaced with higher carbohydrate intake with a relatively stable level of protein. Think about yogurt. All the yogurt is low fat but plain yogurt is not very palatable so they add fruit and flavorings (ie, carbohydrates). However this is my speculation only.

From experience, I see HDLs routinely rise as patient’s carbohydrate intake drops. We know that a low HDL is one of the most risky signs of cardiovascular disease, too.

Remember that humans can’t eat a zero protein or zero fat diet and live healthy nor long. They can, and many do, eat zero carb diets and remain very healthy. That puts carbohydrates in a different category as proteins and fats.



Who Needs An Antibiotic?

Let me tell you a little cautionary tale. Once upon a time (roughly twenty years ago) a strong new antibiotic came forth uniformed in a handy little green 6 pill, 5 day pack. Emblazoned across his uniform was the catchy swashbuckling name, Z-pak. For doctors, easy to write; for patients easy to take – dosed just once a day for five days. And man could he fight! All the common thugs feared him: bacterial sinusitis and bronchitis, skin infections, middle ear infections, strep throat, and even some of the more common community-acquired pneumonias – all of them seemed to melt back into the shadows at his presence.

And so the popularity of Z-pak grew. After a couple of years patients would often ask, not just for any old antibiotic, but for Z-pak by name: “Hey I’ve had a cough and congestion for a couple days. I really can’t afford to be sick. Could you prescribe Z-pak? It always clears me right up.”

But alas as the years went by something else started happening – Z-pak started to fail in his mission. I’d get a call back that the sinus infection was weakened but not gone – could they have another round of Z-pak? Over the course of the next 5 to 10 years those failures went from rare to somewhat common to rather predictable. Increasingly, Z-pak was losing the battle with the bad guys. After repeated battles with Z-pak, the “weak” bacteria were being killed off, but the strong, resistant ones were surviving and multiplying. Soon much of the community of bacteria was resistant to the once-mighty Z-pak. In short, he had become a victim of his own popularity. And we haven’t even mentioned the whole pack of viruses over whom Z-pak never held any power.

What can we learn from this little tale? First of all Z-pak is not alone. Any antibiotic that is frequently used tends to select out more and more resistant bacteria. And so, when an effective antibiotic is really needed, sometimes it’s hard to find one that still works. Indeed there are now some super-bugs out there showing resistance to nearly every available antibiotic.

So who needs antibiotics? Legions of sufferers of serious bacterial infections do. How can we maintain the effectiveness of antibiotics so that when we need them, they still work? There are several vital steps needed:

  • Avoid treating viruses like the common cold with antibiotics. They are simply of no use at all in fighting viruses and they only add expense, side effects and resistance problems.
  • Don’t be too quick to throw an antibiotic at every ear infection, sinusitis or bronchitis. Many of these are either viral (where the antibiotic is useless) or a mild enough bacterial infection where the body can fight it off without the antibiotic.
  • When you really need an antibiotic, take all of it at full strength. Otherwise you may kill off only the weak susceptible bacteria while leaving the partially resistant ones to multiply and re-infect yourself and others.
  • Get appropriate immunizations against common infections so that your own immune system can kill infections before they really take hold, thus reducing the need for antibiotic treatments.

Who needs antibiotics? We often do, and if we can get better at calling them out to fight

for us only at the right times, they’ll be there to help us when we really need them.

Andrew Smith, MD is board-certified in Family Medicine and practices at 1503 East Lamar Alexander Parkway, Maryville. Contact him at 982-0835


Insulin: MVP of hormones

Here’s another great article from Dr Peter Attia describing the various actions and functions of insulin. It describes so much of what we teach in our nutritional counseling visits. Our version doesn’t require a biochemistry or physics degree to understand though.

He uses the same example of insulin deficiency, Type I diabetes, and insulin excess, a insulinoma that I have used: without insulin one cannot store nutrients in cells and with an unregulated excess of insulin one only stores nutrients in cells.

Definitely worth the read and retread to try and understand it all.

Making Fat Cells Less Not Thin