Gallbladder surgery, also known as cholecystectomy, is a common surgical procedure performed to remove the gallbladder. While this surgery is generally safe and effective, it can occasionally lead to postoperative complications, including a hyperactive gag reflex. The administration of general anesthesia during surgery and the manipulation of surrounding structures has the potential to irritate the vagus nerve, which may result in an exaggerated gag reflex. While there is limited research specifically addressing the development of a hyperactive gag reflex following anesthesia, factors such as anxiety, postnasal drip, acid reflux, and oral stimulation (e.g., dental treatments) can contribute to increased sensitivity and responsiveness of the gag reflex, which can impact a patient's digestion, nutrient absorption, and overall gastrointestinal function. Functional medicine, with its focus on the gut-brain connection, offers a comprehensive approach to address these issues and promote healing by optimizing the interaction between the digestive system and the nervous system. (1)

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CC: Nausea/Vomiting, Constipation, Weight Gain

Clinical Presentation and Complaints:

Michelle is a 44-year-old female with a history of an eating disorder. She is a mom of two boys and has experienced daily morning vomiting for a period of 10 years following gallbladder removal surgery. She experienced these daily episodes of nausea and vomiting, specifically when brushing her teeth in the morning. Frustrated with a range of distressing digestive symptoms, she also reported chronic bloating, constipation, and excessive gas. Additionally, she suffered from violent episodes of vomiting if she consumed anything after 6:30 p.m. Michelle snored, had poor sleep, frequently felt fatigued, and reported heavy menstrual periods. She did, however, work out three days a week but did not eat enough to support her workouts. Furthermore, she followed a pattern of undereating and intermittent fasting because she wasn’t sure what to eat and continued to gain weight. 

These symptoms significantly impacted her daily life and overall well-being.

Initial Lab Work

Lab Analysis

The following lab results gave us a lot of information:

Vitamin D

Poor fat absorption can contribute to low levels of Vitamin D in the body. Vitamin D is a fat-soluble vitamin, which means it requires adequate fat absorption for optimal uptake and utilization. When fat absorption is impaired, such as in post-cholecystectomy or certain gastrointestinal disorders, the body's ability to absorb dietary fat, including fat-soluble vitamins like Vitamin D, can be compromised. 

Vitamin B12 

Vitamin B12 deficiency can be caused by persistent vomiting, which disrupts the digestive process and leads to the malabsorption of nutrients, including Vitamin B12. Regular vomiting can reduce intake of Vitamin B12-rich foods and damage stomach cells responsible for producing intrinsic factor, impairing its absorption in the intestines and contributing to deficiency and digestive issues.

Elevated homocysteine levels of 10 can be associated with impaired Vitamin B12 metabolism, as Vitamin B12 plays a role in the conversion of homocysteine to other beneficial substances. Her methylmalonic acid level was within normal range, however.

Triglycerides 

Despite undereating, the patient's carbohydrate-rich diet can contribute to high triglyceride levels. Consuming excess carbohydrates, particularly refined carbohydrates and sugars can lead to increased triglyceride production and storage in fat cells. Additionally, the patient's undereating or intermittent fasting pattern may release stored triglycerides into the bloodstream, further elevating triglyceride levels.

Reverse T3

Elevated reverse T3 levels may indicate an imbalance in thyroid hormone metabolism, which can be influenced by various factors such as stress, chronic illness, inflammation, medications, and nutrient deficiencies. In particular, deficiencies in selenium, zinc, and iron can disrupt the conversion of T4 to T3, contributing to higher levels of reverse T3. Her undereating and carbohydrate-rich diet may also impact thyroid hormone levels by affecting hormone production and conversion processes.

Interventions

The following interventions were recommended:

Vagus Nerve Neurosequencing

She performed a cranial nerve sequencing exercise to reprogram the vagus nerve at the level of the pharyngeal branch along with the glossopharyngeal nerve to eliminate her hyperactive gag reflex likely attributed to anesthesia post-cholecystectomy (2). This includes a combination of diaphragmatic breathing, humming, and swallowing. 

Ox Bile

Taking ox bile after gallbladder surgery is crucial because the gallbladder plays a role in storing and releasing bile, which aids in the digestion and absorption of dietary fats. Without a gallbladder, the body may have difficulty producing sufficient amounts of bile, leading to impaired fat digestion and potential digestive issues. She supplemented with ox bile at meal times that included fats to support the digestion of fats and prevent discomfort or malabsorption related to the absence of the gallbladder.

Vitamin D

Started with a prescription dose of Vitamin D of 50,000 IU one time a week for 4 weeks to bring her levels up quickly. She transitioned to 4 drops of Vitamin D with K 2.

Vitamin B12

She started with Liposomal Methyl B-Complex (2 pumps by mouth). When serum Vitamin B12 levels are at 200, it is considered relatively low and may indicate a deficiency. 

Omega 3 

Omega-3 fatty acids, typically found in fish, are important for overall health. She does not like fish, so she was encouraged to take 3 grams of omega-3 supplements to reduce inflammation. 

Mutes (Nasal Dilators) and Xlear Nasal Spray 

Mute nasal dilators and Xlear nasal spray are recommended for nighttime use to improve sleep, decrease airway inflammation, and support vagal nerve function. Mute nasal dilators expand the nostrils, improving nasal airflow and potentially reducing snoring and enhancing oxygen intake. Xlear nasal spray, a saline solution containing xylitol, helps moisturize and clear the nasal passages, reducing inflammation and promoting a healthy nasal environment. These products indirectly influence the airway, immune system, and potentially the vagus nerve by addressing nasal congestion and inflammation. (3)

Diet Interventions

We developed a nutrient repletion diet plan for her, taking into consideration her digestive issues, fear of food and weight gain, and her desire to fuel her body for optimal performance. The plan aimed to address these concerns by prioritizing nutrient-dense foods, increasing protein intake, and reducing the consumption of refined carbohydrates.

The diet plan included a variety of whole foods that are easily digestible and rich in essential nutrients. Emphasis was placed on incorporating lean sources of protein such as poultry and lean beef, as she did not like fish, to support muscle repair and growth, as well as to promote satiety. Adequate protein intake is important for maintaining muscle mass, supporting a healthy metabolism, and providing essential amino acids for various bodily functions.

To address her fear of weight gain, the diet plan focused on portion control and mindful eating rather than strict caloric restriction. This approach aimed to establish a healthy relationship with food and promote a positive mindset around eating. The emphasis was on nourishing the body with nutrient-rich foods rather than solely focusing on weight management.

By tailoring the diet plan to include foods that supported digestion, prioritized nutrient density, and aligned with her fitness goals, the aim was to optimize overall health and performance. 

3-Month Follow-Up

After our first session and performing the vagus nerve neurosequencing exercise, she did not throw up in the morning when brushing her teeth and has not thrown up since. Additionally, she does not get ill after 6:30 p.m. at night if she does eat.  

Within three weeks of the protocol, she has no nausea or bloating, and her bowel movements are daily and normal (Type 4 on the Bristol Stool Chart).

She reports that her sleep is great. She is not snoring, and her menstrual cycle improved significantly and is now normal. 

At three months, she is consistently eating breakfast, lunch, and dinner, along with fueling pre and post-strength workouts. Her relationship with food has changed, and she lost 5 pounds safely. 

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Summary

This case study highlights the significance of targeting the vagus nerve to improve digestion and enhance her quality of life following gallbladder removal surgery. Michelle’s decade-long pattern of morning vomiting was addressed through interventions such as dietary modifications, vagus nerve neurosequencing exercises, and supplementation with Vitamin D and B12, along with the addition of ox bile with meals to aid digestion. The case aims to explore the root causes and a comprehensive approach to healing her body, with a focus on the pivotal role of the vagus nerve in improving overall digestion and well-being.