by Alakananda Devi (Alakananda Ma), M.B., B.S. (Lond.)
The gall bladder is a non-vital organ associated with the rakta vaha srotas. Often gall bladder disease manifests with an acute and possibly even life-threatening episode which will present to emergency room or urgent care. Yet the Ayurvedic practitioner may be confronted with silent or undiagnosed gall bladder disease and in addition needs to consider prevention of gall bladder disease in vulnerable populations. In this article we will review the anatomy and physiology of the gall bladder and consider options for preventing gallbladder disease and for diagnosing and managing chronic gall bladder disorders.
A hollow organ approximately 8 cm long and 4 cm in diameter, the gallbladder is seated on the liver in the gallbladder fossa. It consists of fundus, body and neck. The neck connects to the cystic duct, which joins the common hepatic duct to form the common bile duct. Microscopically, the gallbladder has three layers. Its lining of simple columnar epithelium is characterized by small pouches known as Aschoff's recesses. The lamina propria, a layer of connective tissue, overlies the epithelium. This in turn is covered by the muscularis externa, the smooth muscle wall which contains cholecystokinin receptors and contracts when the duodenum secretes this hormone. The components of bile include water, electrolytes, bile acids, cholesterol, phospholipids and bilirubin. In the exquisite economy of the body, bile serves both to emulsify fat and aid fat digestion and absorption and to eliminate waste products including bilirubin produced by the breakdown of erythocytes (RBCs).
Common diseases of the gallbladder include cholelthiasis (gallstones) and cholecystitis (inflammation of the gallbladder). Ninety percent of cases of cholecystitis result from gallstones (calculous cholecystitis) but some occur without the presence of gallstones (acalculous cholecystitis) (1). Acalculous cholecystitis is most often found in patients in Intensive Care or who are suffering from sepsis (2) and will most likely not present to the Ayurvedic Practitioner. In terms of cholelthiasis and calculous cholecystitis, in the Western world about 80-90% of gallstones are cholesterol stones. (6).
The old adage taught in medical school still holds good today. Gallstones and cholecystitis are commonly found in patients who are, "Female, fair, fat, forty plus and fecund." Parity or fecundity (having birthed one or more children) is an established risk factor (3), as is female gender, body mass index, (in men and in younger women) (4, 5) and race (white women but also many indigenous peoples) (6). Incidence increases with age (6). From an Ayurvedic perspective, look for a kapha or pitta kapha prakruti and a tendency to kapha vikruti. Elevated cholesterol and either diabetes or metabolic syndrome carries a significant risk, as does family history (6). Also consider smoking and use of oral contraceptives as risk factors (3). When a patient who has one or more risk factors presents in your practice, it is important to consider gallbladder disease within the differential diagnosis of their condition and also very important to institute preventative measures if they do not have current gallbladder- related symptoms.
Although most gallstones are asymptomatic, symptoms of gallstones or cholecystitis may include biliary colic--1-5 hours of constant pain which typically begins in the epigastic area and then localizes in the right upper quadrant. Pain may radiate to the right scapular area or the back. An attack may be precipitated by a fatty meal. In cholecystitis pain may be accompanied by nausea, vomiting or fever. If the bile duct is blocked, classic pitta symptoms of irritability, heat and yellow coloured urine and eyes may appear (7). Chronic cholecystitis in older adults may have diffuse or atypical symptoms and should be considered in diffuse abdominal pain.
Formation of gallstones involves the kapha gunas of snigdha, slakshna, picchila, guru and sthira. Later, as kapha blocks pitta, pitta gunas of ushna and tiksna manifest as inflammation develops, leading to cholecystitis. In the worst cases, which may involve abscess formation, gangrene and perforation, the pitta guna of vishram (sour fleshy smell) predominates. Understanding the gunas involved helps us see how prevention and management can arise from diet and herbs which are ruksha, khara, vishada and chala.
A kapha soothing diet high in vegetable fibre and vegetable protein has been found to be helpful in preventing gallbladder disease (8) and by the same token, a diet high in refined carbohydrates, red meat and sugar is associated with increased incidence of symptomatic gallbladder disease(5). "The results of the present study show a protective effect of vegetables and fruits on gallbladder carcinogenesis, but red meat (beef and mutton) was found to be associated with increased risk of gallbladder cancer," (9). "In a cross-sectional study, the prevalence of gallbladder disease (asymptomatic gallstones or history of cholecystectomy) was significantly lower in female vegetarians than female omnivores (12% versus 25%; p(0.01)."(10, 11) "Consumption of carbohydrate in refined form increases bile cholesterol saturation. The risk of gall stones might be reduced by avoidance of refined carbohydrate foods," (12). Flax oil, recommended in Ayurveda for kapha, is beneficial whereas animal fats and fried food worsen symptoms.
Lifestyle interventions include addressing risk factors such as smoking and overcoming the sthira quality of a sedentary lifestyle by introducing a good kapha-pacifying exercise programme.
Herbs that are lekhan and bhedan are possessed of ruksha and khara qualities and may help reduce cholesterol levels systemically and also potentially break down gallstones. Important herbs in this context included Guggulu compounds (13) and shilajit. A formula containing both guggalu and shilajit along with kapha reducing herbs like Punarnava and Trikatu will be helpful for both prevention and management; Trim Support is a good example of a formulation of this type. Since gallbladder disease is closely associated with diabetes and metabolic syndrome, use of a formula to control blood sugar, such as Sweet Ease, may be of help. Neem, an important component of Sweet Ease, is also traditionally used in Ayurveda for gallstones (14).
Although many cases of gallbladder disease will present for urgent medical care, the Ayurvedic practitioner has an important role in noticing potential, asymptomatic or mildly symptomatic gallbladder disease. The value of instituting preventative interventions in terms of diet and lifestyle is borne out by numerous studies. In addition to these holistic measures, use of herbs that balance the gunas of kapha, lowering cholesterol and breaking down gallstones provides an additional way to protect susceptible patients from acute or dangerous gallbladder episodes.
- F E Murray, R F Logan, P C Hannaford, C R Kay Cigarette smoking and parity as risk factors for the development of symptomatic gall bladder disease in women: results of the Royal College of General Practitioners' oral contraception study Gut 1994;35:107-111
- Ikuko Kato, Abraham Nomura, Grant N. Stemmermann and Po-Huang Chyou Prospective study of clinical gallbladder disease and its association with obesity, physical activity, and other factors Digestive Diseases and Sciences Volume 37, Number 5 / May, 1992
- R K Scragg, A J McMichael, P A Baghurst Diet, alcohol, and relative weight in gall stone disease: a case-control study. Br Med J (Clin Res Ed) 1984;288:1113-1119 (14 April),
- P. Portincasa, A. Moschetta, G. Palasciano Cholesterol gallstone disease The Lancet, Volume 368, Issue 9531, Pages 230-239 2006
- Vagbhat, sutrasthana, ch 11.
- KM Maclure, KC Hayes, GA Colditz, MJ Stampfer and WC Willett Dietary predictors of symptom-associated gallstones in middle-aged women American Journal of Clinical Nutrition, Vol 52, 916-922, Co
- Pandey, M; Shukla, V K Diet and gallbladder cancer: a case-control study European Journal of Cancer Prevention: August 2002 - Volume 11 - Issue 4 - pp 365-368
- AR Gaby Nutritional Approaches to Prevention and Treatment of Gallstones Alternative Medicine Review Vol 13 no 3 2009 Pixley F,
- Wilson D, McPherson K, Mann J. Effect of vegetarianism on development of gall stones in women. Br Med J (Clin Res Ed) 1985;291:11-12.
- J R Thornton, P M Emmett, K W Heaton Diet and gall stones: effects of refined and unrefined carbohydrate diets on bile cholesterol saturation and bile acid metabolism. Gut 1983;24:2-6; doi:10.1136/gut.24.1.2
- K.G. Ramawat, Marthur S. Dass, and S. Suthar, Guggulsterone: a Potent Natural Hypolipidemic Agent from Commiphora wightii - Problems, Perseverance, and Prospects Bioactive Molecules and Medicinal Plants Springer Berlin Heidelberg 2008 p 101-121
- K. Nishteshwar, Text Book of Dravyaguna, Chaukhumbha Surbharati Prakashan, Varanasi 2007 p117.
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Alakananda Devi (Alakananda Ma) is director of Alandi Ayurvedic Clinic in Boulder, Colorado, and principal teacher of Alandi School of Ayurveda, a traditional ayurvedic school and apprenticeship program. She can be reached at 303-786-7437 or by email at: firstname.lastname@example.org.