Gallbladder Removal and the Gut Microbiome

Gallbladder Long Gone: The Impact of Gallbladder Removal on the Gut Microbiome

The gallbladder is a hollow-shaped organ located in the upper right abdomen. It is positioned underneath and attached to the liver, where it plays a significant role in the biliary system. The main function of the gallbladder is to store bile that is made and secreted by the liver. Bile is a fluid necessary for the absorption of fat-soluble vitamins A, D, E, and K. Bile is also necessary for the digestion of fats within our diet and serves to balance cholesterol within the body. In short, the liver makes bile, and the gallbladder stores bile until needed for digestion. 

As with any organ within the body, the gallbladder is not exempt from dysfunction and oxidative damage. The most commonly occurring condition related to the gallbladder is gallstone disease. Other conditions include inflammation of the gallbladder known as cholecystitis, reduced contraction and ejection of bile from the gallbladder known as biliary dyskinesia, and gallbladder polyps or masses. In most cases of symptomatic gallbladder disease, a laparoscopic cholecystectomy is performed to remove the gallbladder.

Gallbladder Disease and Gut Health

There are approximately 300,000 gallbladder surgeries performed every year in the United States amongst an estimated 20 million people with gallbladder disease. Gallbladder removal is one of the most common modern surgical procedures. As with any surgical procedure, post-surgical complications do occur, with some more subtle than others. A small percentage of patients will go on to develop post-cholecystectomy syndrome. Post-cholecystectomy syndrome involves dyspepsia, abdominal pain, and sometimes diarrhea caused by the uncontrolled release of bile into the small intestines.

During my residency, I managed hundreds of post-cholecystectomy cases whereby patients presented with chronic diarrhea specifically. When these patients were prescribed bile-acid binding medications such as cholestyramine, the stools normalized in the majority of cases. This speaks to the level of bile malabsorption that may occur after removing the gallbladder, a concept that has been widely studied. While bile is a necessary component of a functional digestive system, imbalance in secretion can have detrimental effects on the human intestinal microbiome.

Effects of Gallbladder Removal on the Gut Microbiome

Intestinal bacterial imbalance and gastrointestinal changes in cholecystectomy patients has been well documented. One study showed that removal of the gallbladder is associated with an increased incidence of metabolic syndrome, gastrointestinal cancer, heart disease, inflammatory bowel disease, and non-alcoholic fatty liver disease. 

In healthy subjects, the gallbladder releases bile in a timed fashion dependent on meal consumption; however, when the gallbladder is removed, bile enters the small intestines in a continuous manner independent of meals. This creates a higher pool of bile acids interacting with the intestinal microbiome.

A vast community richness of bacteria exists in a symbiotic nature with resounding effects throughout the body. Patient populations with a history of cholecystectomy experience a documented reduction in bacterial community richness in the intestines. There is also a a documented increase in the abundance of bacterial families associated with colon cancer and those associated with intestinal dysbiosis. These effects are largely mediated by exposure of the intestines to excessive primary and secondary bile acids, which would otherwise be stored in the gallbladder.

Bacteria in the intestines produce enzymes that convert primary bile acids into secondary bile acids. Bile acids and secondary bile acids cause oxidative damage to the intestinal cells and are strongly associated with the increased risk of colorectal cancer found in cholecystectomy patients. Ironically, patients who have not undergone removal of the gallbladder, but have documented gallstone disease, display reduced diversity in the microbiome and an overgrowth of pathogenic microorganisms. 

Multiple studies reveal that the intestinal microbiome plays a role in the development of gallstones and influences the formation of the type of gallstone. We now understand that the intestinal microbiome plays a role in gallbladder disease and subsequent removal of the gallbladder plays a role in microbiome dysbiosis.

How to Navigate Microbiome Health after Gallbladder Removal

Removal of the gallbladder is associated with profound changes in the microbiome that may negatively influence health. Currently, the best-studied interventions for improving intestinal microbiome health include diet, lifestyle, and environmental modifications. 

If your gallbladder has been removed, focusing on increasing butyrate levels within the colon is a worthwhile strategy in improving long-term colon health. Butyrate is one byproduct of the bacteria in our gut breaking down and metabolizing the fiber in our food. Plant sources are naturally full of fiber, and ensuring a plant-rich diet is one way to improve the overall health of your gut. Selecting the appropriate digestive support, which may include probiotics and dietary supplementation, can also be useful, as many patients report changes in digestion after gallbladder removal.

Dr. Asia Muhammad, ND

Naturopathic Doctor

Dr. Muhammad, ND has committed her practice to honoring the power of lifestyle modification to achieve optimal health. She has a special interest in GI health, evidenced in her practice’s focus on gastroenterology, as well as mind-body medicine, and stress management. Dr. Muhammad provides her patients individualized attention and evidence-based naturopathic solutions, including food, movement, botanicals, supplementation, and hypnosis. When she’s not working, she likes to play the piano, dance, and explore new foods.

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