Philip is a 43-year-old male who presents to the clinic with abdominal pain. He says the pain starts near his ribs on the right side and shoots toward his belly button. He thinks chicken fried in Kentucky (no copyright infringement there, eh?) causes the pain. Every time he eats that kind of chicken, the pain returns. The pain has haunted him for over two years. For the last six months, the pains happen more frequently.
When the pain hits, he hurts for over a half an hour. Nothing he seems to do makes it better once it starts. He thinks lying down makes it feel worse.
Philip’s pudgy stomach advertises his insulin resistance. I ask him to relax his stomach muscles while lying on the exam table. My slow yet firm push on his tummy buries my fingers into his body. When pushing between his right hip and lowest right rib, I can feel the muscle fibers hiding behind that layer of fat. With my fingers pressing firmly, his muscles relaxed after several seconds. “Take a deep breath.” His lungs filled halfway with air. He winces and stops breathing until I lift my hands.
Ultrasound of Philip’s gallbladder shows debride inside the sac-like-structure. One large stone stands out amongst several gravel-like stones. The bag filled with stones also holds Philip’s bile. Philip’s gallbladder looks 100 years old, not 40. The walls are thick and stiff. The sludge inside reeks of murky inflammation.
Should I prescribe the ketogenic diet to Philip?
In a land of low-fat diets, trouble smolders in many gallbladders. You have sent me many questions on social media wondering about a ketogenic diet and the gallbladder. Most people know that gallbladders have something to do with eating fat. Ask your friends if they all still have a gallbladder. Many have surrendered their bags of stones to a Gallbladder Graveyard. Surgeons promise you that you don’t need one. That is true. Without a gallbladder, your body will adapt. What adapts? Can our body adapt to an “all-fat” diet without a gallbladder?
The Basics about the Gallbladder
This pear-shaped organ resides under your liver. It stores gall, otherwise called bile. Bile oozes out of special cells in your liver and helps you digest fat. Eating fat tastes great! But without gall, the fats streak out the other end in the form of really smelly diarrhea. Fat-absorption depends on enzymes coming from your pancreas and bile produced by your liver. Tributaries lace throughout your liver collecting drops of bile. Bile drains out the liver flowing to one of two options: the intestines or the gallbladder. Bile in the intestines emulsifies fat. Bile in the gallbladder concentrates. If the biles sits inside the bag for a day, it only concentrates a little. If the bile swirls inside the bag for two months, it gets very concentrated.
Your liver secretes the most diluted form of bile. When bile settles into your gallbladder, tiny little pumps work to concentrate the substance. The longer that bile awaits inside your gallbladder the more concentrated it becomes.
Do an experiment on yourself. On an empty stomach, first thing in the morning, eat pure fat. Like a stick of butter.
The moment that pure fat hits your intestines you secrete a hormone called cholecystokinin, CCK. CCK causes the release of digestive enzymes and bile from the pancreas and gallbladder. Cholecystokinin sends a message to the gallbladder to squeeze. Squirt! Out slides some concentrated bile from the gallbladder oozing into the intestines. That butter gets slimed with bile. This slimy coating makes fat absorption possible.
Philip’s exam suggests an inflamed gallbladder. An ultrasound shows a big gallstone and multiple little stones.
Question: How can we be sure the gallbladder is to blame for the pain?
Answer: Cholecystokinin (CCK)
CCK helps us diagnose an inflamed gallbladder. If Philip has the same pain when we inject CCK into his body, there’s a good chance his gallbladder gets the blame. During this test, we will ask him to report if he feels any pain. Normal gallbladders do not cause pain when they squeeze. If Philip has pain, he will compare the pain to the one he feels after he eats fried chicken.
Indeed, Philip felt the exact same tummy pain. When CCK rushed out of my needle and through his veins, he wrinkled his forehead, “Doc, that’s the pain.”
Philip’s gallbladder was inflamed and out of practice.
For years Philip produced very little CCK. He ate a low-fat, Standard-American-Diet. Low-fat meant higher carbs and protein. No CCK is needed when we eat those foods. Only fat triggers cholecystokinin.
What is a GALLSTONE?
Inside Philip’s gallbladder sits one large gallstone and many tiny ones. These pebbles lurking in his gallbladder precipitated as the bile increased concentration. Under a microscope, these “stones” formed as a collection of bile and heme — the waste product from our red blood cells. The specks of goo collected more and more friends to form a sphere. Layers add to that sphere and that is a gallstone.
The larger stone is 8 to 9 times the size of the hose draining from his gallbladder. This large stone presents very little risk to Philip. However, those tiny stones put him in danger. If one of those pebbles slips into the drainage system, it may get stuck. A blocked hose stresses all the bile-tributaries lacing throughout his liver. The halted flow of bile requires surgery.
What will I recommend for Philip?
I put Philip on a ketogenic diet. What!?!
Yes. I prescribed a diet with fewer than 20 carbs per day for Philip. I warned the symptoms from his gallbladder may get worse before they get better. His gallbladder works when eating fatty foods. A ketogenic diet is 80% fat.
I want to flush his gallbladder out and get it into shape. If we can do this successfully, he will reduce the inflammation in his gallbladder along with several other areas of his inflamed body.
Philips harbors a sluggish, sticky bile-filled plumbing. To flush the pipes, we need to produce bile. The gallbladder pumps out bile when CCK triggers it. His bag of bile is stiff and old. The slightest workout of the muscles in that bag causes him pain. The wall lights up with flames. OUCH!
What’s the best way to put out those flames? An anti-inflammatory.
Should I recommend Ibuprofen?
Answer: bathe the body in ketones.
The milieu of proteins that rise and fall as a result of a ketogenic state match a system low with inflammation.
Philip faced the same struggles other patients experience with giving up carbohydrates. Swings of emotion rattled his mood for the first two days. The removal of his blood pressure medication bewildered him by the end of the first week. His grouchy deminer softened along with his cravings for sweets.
At day 10, Philip surprised himself when he reported he felt better. Thankfully, the pains in his right abdomen never surged above a 5 out of 10. We were lucky.
Over the next three months, Philip ate fat. Lots of fat. As a result, his body produced a greater amount of bile. With more bile dripping out of his liver, his storage tank for bile flushed more often. The concentrated bile became more and more diluted with each flushing.
In South Dakota, a basement hides beneath nearly every home. In each basement lurks a smelly sump pump. This pump sits in a hole below the floor of the basement and marks the lowest point of the property. Whenever water saturates the land, it drains to that lowest point. Pumping water out of this dungeon keeps the basement dry.
Look into that sump pump hole. You often find very concentrated, disgusting water. If only a small amount of water has flushed through that system, the remaining water grows thick with yuck. However, if heavy rains hit your area and saturate the ground you’ll find a steady stream of water entering your sump pump. At first, the water coming out of the sump pump is thick and brown and disgusting. However the longer the trickle continues the clearer the liquid becomes. The sediment in your sump pump hole decreases.
This same analogy fits when explaining gallbladders. Our gallbladders store bile. Years of a low-fat diet translate to an underused gallbladder. A storage bag we forgot about. The thicker and more concentrated your bile, the more sediment precipitates within the liquid. These sediments join forces into gravel or sludge. One pebble may grow into a stone as layers of sediment coat the outside.
If you want to flush your gallbladder, you must consume a diet that requires bile. Translation: a high-fat diet.
I recommend that Philip consume a high-fat diet while keeping his carbohydrates low. Low as in LESS THAN 20 grams of carbs per day.
His liver’s response to his new high-fat diet will be increased production of bile. The gallbladder will get flushed. The faucet of bile dripping out of the liver will dilute the higher concentration of bile. Slowly the sediment coating the stones will soften. Some sediments will flush away.
Can I reverse my gallstones?
Being overweight sets up a risk for gallstones. Losing weight through a low-fat diet is also a risk factor for gallstones. Which advice should I give? Lose weight or not?
ANSWER: Lose weight through a HIGH FAT diet.
We have evidence that high-fat diets protect against forming new gallstones. In 2014 the Clinical Gastroenterology Hepatology Journal reviewed several randomized controlled trials on non-surgical strategies to prevent gallstones. They studied over 13 trials totaling over 1800 patients who were going through weight loss. They found that gallstones were less likely if the weight loss happened due to a diet as opposed to surgical weight loss. They also found that a high-fat diet that flushed the gallbladder regularly made fewer gallstones.
These fat-based substances of heme and bile glob together making gallstones. The percentage of heme versus bile determine how hard or “meltable” the stones are. Flushing with bile softens the outer layer of the stones. You may peel one layer off at a time. That is not a guarantee. If your gallstones are hard as a rock and have tossed around in your gall-sack for 30 years, you may just go to your grave with that shiny, polished gallstone.
Hope and pray that none of those tiny little stones get stuck inside Philip’s hoses draining his gallbladder. The increased bile flushes some of his gallbladder debris. That large stone poses very little risk. Layer by layer it may soften due to the swirling bile through his gall-sack. The removal of those tiny stones may need a little luck on our side. As the tiny stones roll down the drainage tubes, we want to keep bile flowing. If the stream stops, a stone may settle inside the tube. This invites trouble.
Flowing bile coaxes you to spill that gravel-like debris into the intestines and flush down the toilet.
Grab a jump rope. Hop over the rope 250 times. It might take you a few attempts to jump over the rope 250 times. Tomorrow your leg muscles will crab at you in pain. What’s the best thing to do for those sore muscles?
Go for a walk. Gently use them again. Camping out on the couch for 2 days after you jump will result in less pain. It will not improve your leg muscles.
The same principle applies to the muscles squeezing bile out of your gallbladder. The inflamed muscles lining your gallbladder improve the more you exercise them.
Philip ate a low-fat diet for decades. Bile sat in his gallbladder like that murky fluid in the sump pump. He binged on fried chicken. He demanded an intense workout from his gallbladder muscles once or twice a month. This led to a gallbladder muscle that was out of shape and underused. When a commanding bolus of fat delivered a squeeze to his gallbladder … Ouch! The stiff, old-looking walls of his gallbladder flared into flames. This made him think twice before eating fat again.
Six months into a ketogenic diet and Philip’s gallbladder still twinged of pain from time to time. He grew confident in his new way of eating. At first, he struggled to eat that much fat. He found people’s questions about his food challenging.
His favorite answer to those nosey questions, “My doctor told me to eat only fat.”
Then he’d go back to eating and stop speaking. His jarring response sparked a social experiment. People didn’t know what to say.
At six months, Philip shared his satisfaction that his mind worked so much better, his sleep restored his energy each night and many of the aches and pains he had grown accustomed to were gone. GONE! He had shed twenty-five pounds. Nice.
His question to me: Is there was anything we could do for the remaining pains that happen every once in a while? I encouraged him to take his ketosis journey to the next level.
Each Sunday I begin a weekly fast. If I’m in a steady season of life, I post on Facebook to encourage my patients to join me. The voyeurism works. At first, they watch with bewilderment mixed with amusement. But slowly they awaken the idea that they too could fast. Before long, they often join me — even if I don’t know it.
We start with a small step. Twelve or sixteen hours of fasting. In Philip’s case, his inflammation rooted deep inside his body– into one of his internal organs. Ringing out that deep of inflammation requires AUTOPHAGY.
I asked Philip to start fasting once a week. “Start with a 12-hour fast. Next week extend it to 16-hour fast. Then 24.” I encouraged him to build up to 72-hours. That’s three days! It sounds extreme, but hidden in those hours of fasting hides the key to improving his old, thickened gallbladder.
Philip struggled with other chronic inflammation. Considering all his health issues we set a goal of six consecutive weeks of 72-hour fasting. I asked him to monitor his blood glucose and his blood ketones. One or 2 checks each day he fasted.
I taught him my “poor man’s formula” for estimating autophagy. I instructed him to divide his blood glucose by his blood ketones.
EXAMPLE: A blood sugar of 100 while his blood ketones were at 2.0 = 50. Phillip’s goal was to hit a calculated ratio below 50.
He jumpstarted his plan with a 48-hour fast the first 2 weeks. He used the GOOD bone broth in his fasts. Limiting ¼ cup of the broth each time he struggled with hunger.
[GOOD BONE = it will hold a gelatinous form at room temperature. See the recipe in my book ANYWAY YOU CAN]
His blood glucose ranged in the 95-105 range. His ketones ranged from 0.6-2.2. Those numbers divided out to be mostly in the 70s or 80s. Not bad.
The third week he hit the goal of 72 hours. Before breaking his fast the blood glucose was 67 and the ketones shot up to 2.3. BAM!! That’s a ratio of 29. Autophagy!!
Autophagy recycles the rusty old components of cells. These parts of the cell have lived out their usefulness. Autophagy occurs at nano-particle, sub-cellular level. We can’t see those cells recycling the old or unused proteins inside the cells. No blood test exists to measure autophagy. My best guess for whether or not someone has triggered autophagy while on a ketogenic diet is this ratio. Hit 50 and I can be rather confident you triggered the clean-up crew to get busy inside old cells.
Philip went on to complete all six of the 72-hour fasts. Each week his ratio spent more time below our target of 50. At one point his personal record was a glucose of 62 and a blood ketone measuring 6.1. That’s a ratio of 10!! Wowzers. That’s cool.
I asked how he felt with a blood sugar that low. His radiant smile filled his face as he reported, “AWESOME!”
Philip rarely has any of those pains from his gallbladder. I hold out hope that his stones will dissolve completely. Spending the money for a repeat ultrasound seems useless. His health improved greatly. His pains disappeared. That is a WIN.
In the comments below, answer this: Do you have a gallbladder and are on a ketogenic diet?