The Link Between Gallbladder Disease and Gluten Sensitivity

December 1, 2012 in Categories: , by

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(Created as a guest post for Paleo Parents.)

Celiac disease is estimated to affect approximately 1 in every 100 people, but only 5% of these people receive a positive diagnosis 1.  This is, in part, because celiac disease often doesn’t present with what are thought of as the classic symptoms (abdominal pain, bloating, intermittent diarrhea, weight loss).  In fact, more often, celiac disease presents as a collection of symptoms that many physicians don’t associate with the disease (irritability or depression, anemia, stomach upset, joint pain, muscle cramps, skin rash, mouth sores, dental and bone disorders such as osteoporosis, neuropathy, and/or micronutrient deficiency) 2.  However, the recognition and understanding of celiac disease is improving and more and more people with the disease are receiving positive diagnoses.

The same is not so true of gluten sensitivity, which includes immune reactions that are currently tested for (IgE, IgG or IgA antibody formation against gluten), immune reactions that are not currently tested for (IgM antibody formation, T-cell activation and/or immune complex formation), and non-immune reactions (increased zonulin production and/or gut dysbiosis resulting from deficiency of appropriate digestive enzymes).  Gluten intolerance (where antibodies are formed against gluten) is thought to affect upwards of 20-40% of the general population 3-4.  There are no estimates of the percentage of people who are sensitive to gluten in other ways.  Genetic tests (HLA-DQ, DR, etc.) exist but it is still unknown if current genetic tests accurately identify all individuals who are gluten sensitive 4.

A wider and wider range of health issues are being linked to gluten sensitivity and/or celiac disease.  This is a positive development in medical research because it is starting to bring more focus on how detrimental these grain proteins are in the human diet.  One such health issue is gallbladder disease, although the link between gallbladder disease and gluten sensitivity/celiac disease has not permeated through the public knowledge.  Because so many people are unaware that their gallbladder problems might be linked to gluten in their diets, it seemed like a good idea to write a post about this topic!

Let’s take a step backward and first talk about what exactly a gallbladder is.  The gallbladder is a little pear-shaped sac, nestled toward the front and a little underneath of the liver.  It has a very simple job:

  • store bile (which is produced by the liver) between meals
  • concentrate bile by reabsorbing water
  • release bile into the small intestine when there’s food that needs to be digested

Bile is composed of water, bile salts, bile pigments (products of red blood cell breakdown that are normally excreted in the bile), cholesterol, and various electrolytes.  Bile salts are the only components of bile that actually have a digestive function.  Bile salts are not the same as digestive enzymes (which are produced by the cells that line the stomach and by the pancreas).  Instead, bile salts aid the actions of digestive enzymes and enhance the absorption of fatty acids and fat-soluble vitamins.

The most important action of bile salts is that of an emulsifier.  In essence, bile salts break up fat globules in the small intestine into tiny droplets that are able to mix with water.  The enzymes that break fat up into fatty acids (lipases) can then perform their function more effectively.  Bile salts also aid in the absorption of fatty acids and cholesterol (some of the cholesterol released into the small intestine in the bile is reabsorbed).  Fat-soluble vitamins (such as A, D, E, K1 and K2) are also absorbed.

If the gallbladder is not functioning properly, fats cannot be properly digested (fats are essential for survival and health) and fat-soluble vitamins cannot be effectively absorbed, leading to micronutrient deficiencies.  Gallbladder health is critical for digestive health and overall health.

As is so often the case with research linking gluten sensitivity to other health complications, the research is strongest in the context of celiac disease.  Approximately 60% of celiac disease sufferers are known to have liver, gallbladder, and/or pancreatic conditions 5.  While some of these conditions may be a result of the malnutrition and/or directly linked to the gut damage that occurs in celiac disease, others are thought to share common genetic factors or have a common immunopathogenesis (i.e., the condition originates from the same immune system attacks on the small intestine also attacking these organs) 5.  Specifically, primary biliary cirrhosis, primary sclerosing cholangitis and autoimmune forms of hepatitis or cholangitis are thought to have a common immune system/inflammation origin as celiac disease itself—and that means gluten.

What does this mean?  In celiac disease (and in non-celiac gluten sensitivity, albeit to a lesser extent or perhaps just in a slightly different way), gluten triggers an autoimmune response.  The body’s own immune system attacks the cells that line the small intestine, resulting in the characteristic shortening or pruning of the intestinal villi (microscopic, finger-like projections of small intestine wall tissue made of columns of gut epithelial cells).  As you can imagine, this creates a very leaky gut, which also stimulates the immune system, causes inflammation, and allows toxins and foreign proteins into the body.  In the majority of celiac disease patients, the immune system does not limit its attack to the cells that line the small intestine.  This is why second and even third autoimmune conditions are so common in celiac disease.

When you eat, the cells that line the duodenum (the first segment of the small intestine) detect the presence of fat and protein and react by releasing a hormone called cholecystokinin.  This hormone stimulates both the release of digestive enzymes from the pancreas and bile from the gallbladder.  It also signals to the stomach to slow down the speed of digestion so the small intestine can effectively digest the fats.  When the gut is damaged (whether from celiac disease or other gut pathology), the cells that line the small intestine (called enterocytes or gut epithelial cells) are less able to secrete cholecystokinin.  This means there is not enough signal to the gallbladder that it’s time to release bile salts into the duodenum.  Reduced cholecystokinin release is reported in celiac disease and may be one of the key causes of the gallbladder malfunction that occurs concomitantly with celiac 6-8.

Importantly for this discussion, the dominant gallbladder symptoms that might be caused by gluten sensitivity is cholecystitis (inflammation of the gallbladder) or malfunctioning gallbladder, and not gall stones (reported in 20% of elderly celiac patients, but only 2.5% of the more general celiac population).    The frequency of liver and gallbladder conditions suffered by celiac disease patients has allowed researchers to make the converse argument.  It is now recommended that those with unexplained liver and/or gallbladder symptoms be evaluated for celiac disease 9-11If you have been diagnosed with gallbladder disease (especially if it is not gall stones, but don’t rule out this possibility if it is), it is important to investigate gluten sensitivity or celiac disease as the possible cause.  No one has yet studied how frequently someone with gallstones actually has undiagnosed celiac disease (or gluten sensitivity) and there is a feeling within the celiac community that this may actually be quite frequent.

What if you test negative for celiac disease and gluten intolerance?  Unless you had the DNA test done for gluten sensitivity, these tests actually are embarrassingly inaccurate in the sense that the false negative rate is very high (false negative means that you do have celiac but the test showed that you don’t).  There are a variety of ways that false negatives can occur and no one likes to put a number on just how likely they are.  But, if you remember from the beginning of this post, these tests generally only test for antibody formation (and a biopsy only looks at one very small piece of your small intestine).  The best way to be sure that gluten is not the problem is to eliminate it completely from your diet for several months (those with celiac disease can take up to 5 years to heal from the damage caused by gluten 12).  It is not enough to eliminate gluten however, as antibodies that your body may have formed against gluten may also recognize proteins in other foods.  This means that even if you aren’t eating any gluten, your body still thinks that it is (see this post for a complete explanation and list of foods to avoid).

The take home message?  There is a strong link between gallbladder health and celiac disease.  In fact, a failing gallbladder may be your first symptom of celiac disease.  Of course, I believe that a grain-free, legume-free, dairy-free, refined sugar-free, modern vegetable oil-free diet is optimal for our health in every way; however, if you are suffering from gallbladder problems, then I recommend addressing your diet as soon as possible.  The earlier you adopt an anti-inflammatory diet that prioritizes gut health, the more likely you are to save your gallbladder.

1 Lohi S et al. “Increasing prevalence of coeliac disease over time.” Aliment Pharmacol Ther. 2007 Nov 1;26(9):1217-25.

2 http://www.mayoclinic.com/health/celiac-disease/DS00319/DSECTION=symptoms

3 http://www.gastroendonews.com/ViewArticle.aspx?d=In%2Bthe%2BNews&d_id=187&i=October%2B2010&i_id=672&a_id=16015

4 http://www.glutenfreesociety.org/gluten-free-society-blog/the-many-heads-of-gluten-sensitivity/

5 Freeman HJ.” Hepatobiliary and pancreatic disorders in celiac disease.” World J Gastroenterol. 2006 Mar 14;12(10):1503-8. http://www.wjgnet.com/1007-9327/full/v12/i10/1503.htm

6 Masclee AA et al. “Gallbladder sensitivity to cholecystokinin in coeliac disease. Correlation of gallbladder contraction with plasma cholecystokinin-like immunoreactivity during infusion of cerulein.” Scand J Gastroenterol. 1991 Dec;26(12):1279-84. http://www.ncbi.nlm.nih.gov/pubmed/1763298

7 Fraquelli M et al “Gallbladder emptying and somatostatin and cholecystokinin plasma levels in celiac disease.” Am J Gastroenterol. 1999 Jul;94(7):1866-70.

8 Nousia-Arvanitakis S et al.  “Subclinical exocrine pancreatic dysfunction resulting from decreased cholecystokinin secretion in the presence of intestinal villous atrophy.” J Pediatr Gastroenterol Nutr. 2006 Sep;43(3):307-12. http://www.ncbi.nlm.nih.gov/pubmed/16954951

9 Biecker E et al “Autoimmune hepatitis, cryoglobulinaemia and untreated coeliac disease: a case report.” Eur J Gastroenterol Hepatol. 2003 Apr;15(4):423-7. http://www.ncbi.nlm.nih.gov/pubmed/12655265

10 Parfenov AI et al “Asymptomatic celiac disease in patient with chronic acalculous cholecystitis” Eksp Klin Gastroenterol. 2011;(3):122-4.

11 Galán Bertrand L et al. “Acute lithiasic cholecystitis as an exceptional presentation of celiac disease” An Pediatr (Barc). 2006 Jul;65(1):87-8. Spanish

12  Rubio-Tapia A “Mucosal recovery and mortality in adults with celiac disease after treatment with a gluten-free diet.” Am J Gastroenterol. 2010 Jun;105(6):1412-20.

 

Comments

If only I had gone Paleo years ago I might still have my gallbladder. After all of the reading I have been doing about Paelo, I am now convinced the gluten that was in my life is what caused my Fibromyalgia as well I suspect. Do you have any advice for those of us who no longer have their gallbladders to help process the fats (and get rid of the stores) beyond just staying on this path and hoping it will all get better soon?

I definitely think digestive support supplements are a good idea for anyone without a gallbladder. How much of what is not my area if expertise, but if you listen to this week’s The Paleo View we talk about it with Diane Rogers of Radiance Nutrition (and she know much more about it than I do).

Reading this makes me wonder if I lost my gallbladder due to gluten sensitivity. I had been GF for about two years when it started acting up and I had to have it removed.

When I first went Paleo and high fat, my gallbladder was already among the missing so I took digestive enzymes for about a month and added fat into my diet slowly. After about a month I was fully acclimated and no longer had to take them.

Thank you for this. Although my gallbladder was removed a couple years ago, it’s interesting to read about possible connections, especially because I didn’t have gallstones. I just assumed that it was because of the years of birth control use. And while I still don’t know what directly caused my gallbladder to fail, reading this makes me wonder if I have a gluten sensitivity. I recently did the Whole30 program and have been eating paleo with much improvement. (I just wish I had known about it sooner.) And I’ve been thinking about taking it further and removing other foods (eggs, coffee) to test for issues. Anyway, I just want to say thank you for your research. I am checking out the podcast you mentioned in a comment above, and I hope to get some more info about sticking with paleo without my gallbladder.

Hello, thank you for this article. My gallbladder was removed when I was 12 because of gallstones. 14 years later I was diagnosed with celiacs (and a dairy intolerance) and have been gluten free since the diagnoses (11 months). I have often wondered about the connection, but the information online was scarce and my doctors never put 2 and 2 together. I am wondering how not having a gallbladder affects me and my process in healing from years of undiagnosed celiacs. My docotors are not much help in this field. Can you recommend any resource for more information. Again thank you so much!

My sister has recently started having severe gallbladder problems and was told that her gallbladder is only functioning at 11%. She’s scheduled for surgery in about a week. If she began eating a paleo diet, do you think her gallbladder would begin functioning again? If so, could she do something for the pain in the meantime? She’s considered “going paleo” for about a year since I frequently talk about how great it’s been for me, but there are MANY foods (including “paleo” ones) that she can’t tolerate due to IBS. Should the gallbladder problems be even more evidence that a paleo lifestyle would be beneficial for her? Thanks!

A paleo diet should help, but gallbladders can rupture and that is life threatening, so she really needs to discuss with her doctor about delaying surgery and whether that’s appropriate for her (even if she does have her gallbladder out, a paleo diet is a great idea). I definitely recommend ox bile supplements and a very nutrient-dense paleo diet (lots of organ meat, seafood, and tons of veggies). Going low FODMAP should help dramatically with the IBS too.

Interesting correlation… the doctor who removed my gallbladder mentioned that the type of gallbladder problem I had (biliary dyskinsia) has rapidly increased in his practice. What used to represent perhaps 10% of his removals was now making up about 50%. He said he had no idea what had caused this rapid increase in about the last 10 years. However, if there has been a correlating rise in gluten intolerance (Celiac or otherwise) we might be seeing a correlation worth looking into. It’s made even more interesting when you start looking for a source… GMO wheat has a larger germ, meaning more gluten. If the introduction of GMO wheat correlates with the sudden rise in gluten problems correlates with the sudden rise in biliary dyskinesia diagnoses, isn’t that something worth exploring???

That was an awesome, compelling blog. Well done! I write about MS too, though my focus has primarily been about heat sensitivity and travel. Give it a read sometime. I’m a native San Diegan too.

Thanks for another informative post but I didn’t see anything addressing the issue of existing gallstones. Do you have any thoughts or recommendations for this? Is surgery pretty much unavoidable at this point or does it depend on how bad it is (if gallstones can have a varying degree of severity)?

I was able to save my gallbladder from a snip happy surgeon about a year ago and a paleo lifestyle has resolved all my issues, but a coworker just informed an ultrasound found gallstones and she is scheduled to see a specialist shortly. I was hoping to send her some information on alternatives to surgery but I’m not aware of any legitimate solutions.

Thanks,
Chris

There are lots of people who have successfully dissolved gallstones (whether through alternative treatments or just time on an anti-inflammatory paleo-type diet), but whether a gallbladder can be saved really depends on exactly how damaged it is, what else is going on health-wise, and how aggressively a person tackles diet and lifestyle changes (so not just paleo, but a focus on nutrient density to resolve inflammation, sleep, stress management and activity).

Wow!

I was diagnosed with chronic gall bladder disease when I was in high school. When I would have an attack, I HAD to lay down on my back for days until the pain went away. It was incruciating pain and felt like The Incredible Hulk was squeezing my organ. I narrowed it down to a few triggers, mostly unhealthy oils. This is the first time I have heard of a gluten sesitivity possibily being the culprit. It totally makes sense.

They wanted to take my gall bladder out immediately and told me it was totally normal. A voice in the back of my mind said it wasn’t normal. It wasn’t normal to have surgery on a vital organ before I was an adult. The Doctor never explained anything to me. He just wanted to remove it.

I am so glad I didn’t have the surgery especially after learning how it functions and why it is needed. After converting to Paleo, the attacks stopped. I think everyone who is told they have gallbladder disease should read this post!

Thank you!

P.S. – I do keep a bottle of Choline in the “medicine” cabinet just in case I start to feel that pain again. I pop a few, the pain goes away.

Excellent post! I would love to hear more about this connection, and especially about gallstones. I had my gallbladder removed due to MANY gallstones at the age of 27.

Robb Wolf’s book lead me to believe that if you’ve had your gallbladder removed for any reason, you are “almost certainly” undiagnosed celiac. After researching the many manifestations of celiac, I can see it has probably been a life-long condition for me – and I also have Hashimoto’s.

Thanks again, and I am so looking forward to receiving my copy of your book!

Four years ago I found myself in the emergency room due to a gall bladder attack. The doctor wanted to schedule me for surgery the very next day. I decided to do some research to see if there was anything I could do to prevent removal. Which led me to testing for allergies. I took a very aggressive approach to heal my gut and never had another attack. The only time I’ve ever had pain since then was when I accidentally had something with gluten. I am amazed at the amount of times the doctors told me there was no correlation between going gluten free and being symptom free from gallbladder disease.

VERY good timing with this. I’ve been on the SCD diet just over a year, and have pretty much chronic pain. An imaging scan last week revealed that yes, I have stones, and the gb is functioning at 34.5%, which is low normal. Many can go years like that but where I have frequent pain, I am scheduled to see a (second) surgeon shortly. Frankly, quality of life has been challenged lately. Is there any hope of still salvaging this organ at this stage? Idealistically, that is what I want, but realistically, not so much.

I have had Gallbladder attacks for years and was scheduled for surgery twice but something has always come up where I have had to put it off.. I asked if there was another option to heal it without surgery and was told it takes to long to heal with medication that I need to just remove it :( I have severe anemia and barely stay above transfusion level :( once again I have put off surgery.. but always have the fear in the back of my head that it will cause other issues if I keep putting off ( it’s been going on for about 5years).. I feel if they would’ve just gave me the meds it would be healed by now!!?! I also have Fibro, joint and muscle pain.. I can’t take inflammatories (ibuprohen,naproxin,naprosyn etc) anymore causes Gastritis.. my Dr’s are NO HELP with alternatives or any HELP at all…

Also my Daughter is 9 and having stomach issues for about 4 years they are sending her to a Rheumatoid specialist :(

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