Gallstones, or cholelithiasis, are a common gastrointestinal disorder in the United States. Approximately 10-15% of adults in the U.S. have gallstones, and one million Americans are diagnosed with gallstones annually. In up to 80% of cases, gallstones are asymptomatic, and the American College of Physicians (ACP) recommends a watch-and-wait approach ("expectant management") to treatment. The surgical removal of the gallbladder (cholecystectomy) is often recommended for patients with symptomatic cholelithiasis, but it does not treat the root cause of cholelithiasis, and many patients continue to have gallstone symptoms after surgery. Therefore, functional medicine takes a more proactive approach to identifying and correcting the underlying causes of stone formation to prevent overall health and digestive function.
What Are Gallstones?
Gallstones are solid deposits that form within the gallbladder, a small organ located beneath the liver responsible for storing bile, a digestive fluid produced by the liver, and releasing it into the small intestine to aid in the digestion of fats. The condition is called choledocholithiasis if gallstones are present in the common bile duct rather than the gallbladder. Gallstones can range in size from tiny grains to larger masses and can be composed of various substances. The three types of gallstones are cholesterol stones (formed from cholesterol), pigment stones (formed from calcium bilirubinate), and mixed stones (composed of a mixture of cholesterol and pigment). (14)
What Are the Signs and Symptoms of Gallstones?
Gallstones can remain asymptomatic and go unnoticed for years. However, if they become large enough or obstruct the bile ducts, they can lead to painful episodes known as gallbladder attacks or biliary colic. A typical attack is characterized by gripping or gnawing severe pain ("colic") in the right upper abdomen, which can radiate to the upper back. The pain can be accompanied by nausea and vomiting. Changing position, taking pain relievers, and passing gas does not relieve the symptoms. Large, fatty meals can trigger pain. Biliary colic typically disappears within several hours of onset. (14)
Symptoms that persist longer than several hours may indicate acute cholecystitis, swelling and inflammation of the gallbladder that occurs when bile gets trapped in the gallbladder. In addition to gallstone symptoms, cholecystitis also can present with fever, jaundice, light-colored bowel movements, and abdominal bloating (4).
What Are the Possible Causes of Gallstones?
Gallstone formation is a complex process that starts with bile, composed mostly of water, bile salts, lecithin, and cholesterol. Although cholesterol only makes up 5% of bile, about 75% of gallstones in the U.S. are cholesterol stones. Cholesterol is not very soluble, so it must be transported within clusters of bile salts to remain suspended in fluid. When there is an increased bile ratio of cholesterol to bile salts, bile can turn into sludge, and eventually, cholesterol crystals will precipitate to form stones. (17)
Black pigment stones are composed of calcium bilirubinate, the calcium salt of bilirubin. Bilirubin is a waste product derived from the breakdown of hemoglobin in red blood cells. Bilirubin is processed by the liver and eliminated from the body in bile. Black pigment stones are more likely to develop in people with hemolytic anemia, such as sickle cell anemia or thalassemia. (17, 26)
Brown pigment stones are less common in America and are associated with bacterial and parasitic infections within the biliary tree.
Women are two to three times more likely to develop gallstones than men. This increased risk is attributed to estrogen, which increases cholesterol secretion by the liver into bile. Therefore, pregnancy, postmenopausal hormone replacement, and oral hormonal contraceptives are all associated with an increased risk of gallstones. (18)
Westernized diets, characterized by low fiber and high refined carbohydrate and saturated fat intakes, are associated with an increased risk of gallstones.
Being overweight or obese is a significant risk factor for gallstones. Researchers have found that obesity causes the liver to over-produce cholesterol, which can supersaturate bile and contribute to dysfunctional gallbladder motility - another risk factor for gallstones. However, rapid weight loss may also increase the risk of gallstones by causing the liver to release extra cholesterol into bile and prevent the gallbladder from emptying properly. (9, 10)
Patients with cholesterol stones have been observed to have dysbiotic microbiota patterns compared to healthy controls. Dysbiosis can contribute to irritable bowel syndrome (IBS), which is associated with gallbladder dysmotility. Furthermore, intestinal dysbiosis can induce intestinal permeability, which causes gallbladder inflammation and disrupts enterohepatic bile flow (26). (9)
Patients with comorbid conditions are at higher risk of gallstones and associated complications. Medical conditions related to gallstones include diabetes, metabolic syndrome, dyslipidemia (low HDL cholesterol, high triglycerides), Crohn's disease, and liver cirrhosis. (14)
Functional Medicine Labs to Test for Root Cause of Gallstones
Transabdominal ultrasonography is the imaging test of choice for patients with suspected gallstones. It is inexpensive, non-invasive, and has a 99% specificity for detecting gallstones. In the presence of symptoms and a negative ultrasound, a hepatobiliary iminodiacetic acid (HIDA) scan is indicated to screen for acute cholecystitis and biliary dyskinesia.
In addition to imaging, the following labs can help diagnose gallbladder disease and gallstone complications and identify root causes of gallstone formation to guide medical decision-making and create a personalized treatment plan.
Complete Blood Count (CBC)
A CBC measures white and red blood cells. Elevations in white blood cells can indicate the presence of infection and inflammation due to biliary obstruction. A reduced total red blood cell count, in conjunction with elevated reticulocyte count and bilirubin, can help confirm hemolysis.
Comprehensive Metabolic Panel (CMP)
A CMP includes bilirubin, alkaline phosphatase, and liver enzymes (AST, ALT). These markers will be elevated in the presence of bile duct obstructions and hepatobiliary inflammation.
Comprehensive Stool Test
A comprehensive stool analysis measures markers related to dysbiosis, fat absorption, and intestinal inflammation. All of these factors can contribute to gallbladder disease and the risk of gallstones.
Because metabolic syndrome is associated with an increased risk of gallstones, performing a cardiometabolic screening to detect dyslipidemia and dysglycemia is important for gallstone prevention and treatment. Ordering a comprehensive lipid panel, fasting glucose, fasting insulin, hemoglobin A1c, and CRP help determine an individual's cardiovascular risk.
Functional medicine doctors use blood and urine testing to assess estrogen, progesterone, and androgenic hormones. Ordering one or both of these tests for female patients can help understand estrogen metabolism and identify estrogen dominance as a cause of dysfunctional bile secretion and stone formation.
Conventional Treatment for Gallstones
Conventional treatment of gallstones can vary based on factors such as the size, type, and symptoms associated with the stones. If gallstones are small and not causing symptoms, a "wait and see" approach might be taken. Pain management is a primary concern for individuals experiencing gallstone attacks. Over-the-counter pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), might be prescribed to alleviate discomfort during these episodes. Ursodeoxycholic acid (UDCA) may be prescribed to dissolve cholesterol-based gallstones over time; this approach can take months to years and is most effective for patients with small, cholesterol-based stones who are not suitable candidates for surgery. Surgical removal of the gallbladder, known as cholecystectomy, is a standard treatment for gallstones, especially if they are causing symptoms or complications. In cases where gallstones have migrated into the bile ducts, endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), might be used to remove them. (2, 26)
Can Gallstones Dissolve Naturally?
Gallstones do not typically dissolve on their own once they have formed. However, in some cases, smaller gallstones may pass out of the gallbladder and into the bile ducts without causing significant symptoms. This passage can result in temporary relief, but the stones hold the potential to cause blockages and complications. The likelihood of gallstones passing on their own depends on their size and composition. In general, smaller stones, less than 5 centimeters in diameter, are more likely to be able to pass through the ducts. (13)
Functional Medicine Protocol for Gallstones
It's important to note that even if a gallstone passes, it doesn't eliminate the underlying issue that led to its formation. Medical evaluation and management are recommended if someone has a history of gallstones or experiences recurring symptoms. When surgical intervention is not indicated, a functional medicine approach to gallstone treatment and prevention considers the patient's medical history and lab results to construct a holistic treatment protocol incorporating lifestyle modifications and natural supplements to address root causes of stone formation and support hepatobiliary function.
Therapeutic Gallstone Diet
A healthy eating plan, along with getting regular physical activity, can reduce systemic inflammation, heal leaky gut, maintain a healthy weight, and support gallbladder health. According to research, experts recommend that individuals eat more foods high in fiber (i.e., fruits, vegetables, legumes, and whole grains) and unsaturated fats while limiting the consumption of refined carbohydrates, sugars, and unhealthy fats. Incidentally, these dietary principles align with those recommendations to prevent and treat cardiovascular disease and metabolic syndrome.
Natural Supplements for Gallstones
When safe and appropriate, the following supplements can be considered as part of a natural treatment protocol for treating cholelithiasis. Natural gallbladder dissolution may take 6-18 months and, when effective, typically only works for small stones. However, these supplements can also be used in supporting gastrointestinal, liver, and gallbladder health to prevent the formation of future stones.
Low lecithin in bile may significantly contribute to gallstone formation (12). Lecithin's major component, phosphatidylcholine, is a phospholipid that increases cholesterol solubility, reducing the lithogenicity of bile (26).
Dose: 1-2 tablespoons daily
Rowachol is a proprietary blend of essential oils, including menthol, pinene, menthone, borneol, camphene, and cineol, in an olive oil base used to dissolve or break up cholesterol gallstones. Rowachol stimulates bile production by the liver and inhibits the formation of cholesterol crystals in bile. Clinical studies have consistently demonstrated the ability of this terpene blend to dissolve gallstones effectively (12).
Dose: 1-2 capsules twice daily
This formula by Pure Encapsulations contains digestive enzymes, bile salts, taurine, and herbal extracts to promote healthy fat digestion and gallbladder function. Milk thistle, curcumin, and taurine have anti-inflammatory, hepatoprotective, and choleretic (stimulate bile secretion) properties (12). Digestive enzymes and oxbile support the gallbladder in healthy fat digestion and absorption from the small intestine.
Dose: 2 capsules with each meal
When to Retest Labs
Protocols focused on correcting dietary/lifestyle, hormonal, and dysbiotic factors predisposing an individual to gallstone formation take at least 3-6 months to have a significant effect. Monitoring the patient's clinical symptoms is essential during this timeframe; worsening symptoms indicate the protocol is not working and potentially signal disease progression/complications. If the patient's symptoms are stable or improving, repeating labs 3-6 months after initiating the protocol to track biochemical changes is indicated.
Gallstones affect millions of Americans, and while most stones are asymptomatic, their presence signals imbalances between the gastrointestinal and hepatobiliary systems. Functional medicine offers a comprehensive and personalized strategy that delves deep into the interconnected web of factors contributing to gallstone formation. The treatment protocol discussed in this article emphasizes the importance of a healthy diet and gallbladder-supportive supplements to promote bile flow and optimal gallbladder motility in preventing cholelithiasis.
Lab Tests in This Article
1. Afdhal, N. H., & Zakko, S. F. (2022, September 12). Gallstones: Epidemiology, risk factors and prevention. UpToDate. https://www.uptodate.com/contents/gallstones-epidemiology-risk-factors-and-prevention/print
2. Bellows, C. F., Berger, D. H., & Crass, R. A. (2005). Management of Gallstones. American Family Physician, 72(4), 637–642. https://www.aafp.org/pubs/afp/issues/2005/0815/p637.html
3. Blake, K. (2023, April 28). What Is a Heart Healthy Diet and Who Should Follow One? Rupa Health. https://www.rupahealth.com/post/what-is-a-heart-healthy-diet-and-who-should-follow-one
4. Cholecystitis. (2019). Johns Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/cholecystitis
5. Cloyd, J. (2023, February 8). An Integrative Medicine Approach to Thalassemia: Diagnosis, Testing, and Treatment. Rupa Health. https://www.rupahealth.com/post/an-integrative-medicine-approach-to-thalassemia-diagnosis-testing-and-treatment
6. Cloyd, J. (2023, February 14). An Integrative Medicine Approach to Sickle Cell Anemia Treatment. Rupa Health. https://www.rupahealth.com/post/an-integrative-medicine-approach-to-treating-sickle-cell-anemia
7. Conner, V. (2022, September 21). Gallbladder Disease: Causes, Risk Factors, and Treatments. Rupa Health. https://www.rupahealth.com/post/gallbladder-disease-causes-risk-factors-and-treatments
8. Di Ciaula, A., Garruti, G., Frühbeck, G., et al. (2019). The Role of Diet in the Pathogenesis of Cholesterol Gallstones. Current Medicinal Chemistry, 26(19), 3620–3638. https://doi.org/10.2174/0929867324666170530080636
9. Di Ciaula, A., Wang, D. Q.-H., & Portincasa, P. (2018). An update on the pathogenesis of cholesterol gallstone disease. Current Opinion in Gastroenterology, 34(2), 71–80. https://doi.org/10.1097/mog.0000000000000423
10. Dieting & Gallstones. (2017, November). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/digestive-diseases/gallstones/dieting
11. Doran, J., Keighley, M. R., & Bell, G. D. (1979). Rowachol--a possible treatment for cholesterol gallstones. Gut, 20(4), 312–317. https://doi.org/10.1136/gut.20.4.312
12. Gallstone Dissolution. Science Direct. Retrieved August 22, 2023, from https://www.sciencedirect.com/topics/medicine-and-dentistry/gallstone-dissolution
13. Gallstones. (2022). Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/7313-gallstones
14. Gallstones and gallbladder disease. Mount Sinai Health System. https://www.mountsinai.org/health-library/report/gallstones-and-gallbladder-disease
15. Ibrahim, M., Sarvepalli, S., Morris-Stiff, G., et al. (2018). Gallstones: Watch and wait, or intervene? Cleveland Clinic Journal of Medicine, 85(4), 323–331. https://doi.org/10.3949/ccjm.85a.17035
16. Jones, M. W., & Ferguson, T. (2019, January 16). Gallbladder Imaging. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470366/
17. Jones, M. W., & Ghassemzadeh, S. (2019, March 21). Gallstones (Cholelithiasis). Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459370/
18. Novacek, G. (2006). Gender and gallstone disease. Wiener Medizinische Wochenschrift (1946), 156(19-20), 527–533. https://doi.org/10.1007/s10354-006-0346-x
19. Phosphatidylcholine. ScienceDirect. Retrieved August 22, 2023, from https://www.sciencedirect.com/topics/agricultural-and-biological-sciences/phosphatidylcholine
20. Preston, J. (2022, September 26). Benefits and Risks of the Top 5 Most Common Prescriptive Birth Control Methods. Rupa Health. https://www.rupahealth.com/post/benefits-and-risks-of-the-top-5-most-common-prescriptive-birth-control-methods
21. Ransohoff, D. F., Gracie, W. A., & Schmittner, J. P. (1993). Guidelines for the Treatment of Gallstones. Annals of Internal Medicine, 119(7_Part_1), 620. https://doi.org/10.7326/0003-4819-119-7_part_1-199310010-00011
22. ROWACHOL CAPSULES. Drugs.com. Retrieved August 22, 2023, from https://www.drugs.com/uk/rowachol-capsules-leaflet.html
23. Sanguanlosit, S., Viriyaroj, V., Yodying, H., et al. (2020). The influence of stone size on spontaneous passage of common bile duct stones in patients with acute cholangitis: A retrospective cohort study. Annals of Medicine and Surgery, 60, 72–75. https://doi.org/10.1016/j.amsu.2020.10.040
24. Shirah, B. H., Shirah, H. A., Zafar, S. H., et al. (2018). Clinical patterns of postcholecystectomy syndrome. Annals of Hepato-Biliary-Pancreatic Surgery, 22(1), 52. https://doi.org/10.14701/ahbps.2018.22.1.52
25. Tehrani, A. N., Saadati, S., Yari, Z., et al. (2023). Dietary fiber intake and risk of gallstone: a case–control study. BMC Gastroenterology, 23(1). https://doi.org/10.1186/s12876-023-02752-0
26. Weinberg, J. L. (2022, August 9). 3 Natural Treatments for Gallstones. Rupa Health. https://www.rupahealth.com/post/natural-treatment-for-gallstones-and-gallstone-prevention