It started on a Sunday afternoon. I was sitting on the couch working on my laptop when I suddenly got an upset stomach. I hid cramps the nausea, but it quickly escalated. But in a few minutes, I was crouched in my bathroom floor with a sharp pain just below my rib cage. It felt like I was being repeatedly stabbed on my right side. The pain was so intense that my diaphragm wasn't contracting. It felt like it was
stuck in place. I crawled into the next room, where my husband was napping, and I tried to gently call to him so as not to alarm him, but I was having trouble breathing, so I just managed to stammer, I don't feel well. He startled awake and was instantly worried. He said my lips were white. He was calling nine one one no, I croaked, I just need water, Bring me a glass of water. He hesitated, but acquiesced and went to the kitchen while I lay on the floor
trying to reason through what was happening. My symptoms didn't match appendicitis or a heart attack, and since I was out of ideas, I figured it must not be anything serious. Silence from the kitchen.
Now.
My husband is not a whimp, but he has been to faint while having his blood drawn, and once when an acquaintance went into diabetic shock, he stepped outside to call nine one one, and then promptly passed out on the phone with a dispatcher, such that when the EMTs arrived they attended to my husband crumpled on the sidewalk, and not the man inside having a seizure. So the silence worried me. I called to him, Yes, he said, quietly. Are you passing out right now? I asked, trying not to,
he said meekly. I made a mental note not to allow him in the delivery room if I ever went into labor, and tried to remind him of the task at hand. I could really use that water. I heard the faucet turn on, and then a few moments later he shuffled over and set a glass down next to me, then plopped down on the floor with his head in his hands to fight the light headlessness. I was flattered on my back. I can't drink this, I told him,
I need a straw. He looked at me as if I'd asked him to climb everest, but he stood up and shuffled back into the kitchen. It was at this point that I realized I need to snap out of it, because I would need my wits about me when he inevitably fainted and hit his head on the countertop and I had to call nine on one for him. I brought myself up to sitting against the wall, and he shuffled back with a travel mug of water. I took a sip, and in a few minutes I started to
feel better. I returned my place on the couch. That was weird, I said. Now, let it be known that my husband wanted me to go to the hospital anyway, but I told him I didn't have time to sit in the r all night. And sure, that was pretty strange, but I felt fine now. My husband flew the South Dakota the next day and the rest of the week when as usual until Saturday afternoon, when I took her dog for a walk. I made it one block to her forest trailhead and the stabbing pain returned. I couldn't
stay upright. I had to lay down on the forest floor. It was tick season and I live in a place with a very high incidence of lime disease, so this didn't seem prudent. You're gonna feel like an idiot if you get lime disease because of a stomach ache, I thought, and forced myself up. The walk was excruciating, but I managed to stumble home without vomiting in my neighbor's yards. When I got in my door, I laid down on
the entryway bench. There I ride and literally moaned in agony for over an hour until I eventually made it to the couch, where I continued to writhe and moan some more. There was no position that was comfortable. After several bouts of dry heaving, I started to cough of blood. Maybe it's an ulcer, I thought, so I texted my close friend who had an ulcer and told her my symptoms. No, she said, I've never experienced any of that. You should go to the hospital. I can't drive right now, I
told her, I can't even sit up. Then call a friend. She texted back, you know I don't have any of those, I replied, I had moved to a new state recently and making friends is hard. Well, then call an ambulance. She said, that seems like overkill, I told her. Plus, the dog would lose his mind and I am in no state to control him right now, and so I lay there alone, hoping the pain would subside as it
had before, but it did not. My husband arrived home around eleven PM, having had to rent a car from the airport since I had texted to say I would not be there to pick him up as planned. He also wanted to take me to the hospital, but since I still couldn't sit up, I dreaded the thirty minute car ride and a long wait in the r waiting room. I promised him i'd go in the morning, when I planned to be feeling better. I spent the night on the couch without sleep, though the pain did start to
lessen in the morning. He reminded me of my promise, but I still wasn't feeling up to the trip. I renegotiated the terms such that I would go to urgent care when I was capable of sitting upright, which happened around noon. At this point, I was actually feeling almost normal, so I insisted on taking myself and I told the check and staff my symptoms. I was told they could not see me at urgent care, I'd have to go
to the er. I called my husband from the parking lot and bated whether to wait until Monday morning to see a doctor rather than going to the er, where I truly waste time. But he was sufficiently worried that I relented and drove over to the ar. To my surprise, if you tell the check and nurse that you are experiencing sharp stabbing pain just under your ribs, there is basically no weight. I was called back to a little curtained room almost immediately and blood and urintests were taken,
as well as an X ray. The doctor came to tell me my results a couple hours later. My liver function tests were off the charts. He suspected my gall buttter had to come out. They kept me in the hospital overnight. I had an MRI to confirm Coli societis the next morning, and then laparoscopic surgery the next and I went home that same day. After three days of recovery. I felt great, and I promised everyone in my life that the next time my gall butter goes, I'll go straight to the hospital.
Oh my gosh, Maria, Maria, Maria, I mean disclosure. I have heard this story a couple times now, and every time I'm just like I am enthralled and horror spired at the right parts and believed at the right parts and laugh at the right parts. It's just yeah, it's a great story. It's a great story. And I'm glad you're okay.
Set of circumstances.
Yeah, yeah, thank you, Maria, Yeah.
Thank you for thank you reliving that yet again for us and everyone who's listening.
Yeah. Hi, I'm Aaron Welsh and I'm erin on an Updike and this this podcast will kill you.
Today we're talking about the gallbladder.
Just the gallbladder, the gallbladder, the golfbladder.
I almost texted you multiple times to be like, it's just gallbladder, right, We're not doing like a specific part. It just it's gallbladder, a specific part of the gallbladder. Like we're not just doing like golf gullstos or like.
Or like gallbladder cancer or like.
This didus Holy, Yeah, we're doing gallbladder.
Yeah.
I can't wait.
I mean, And and the reason that if you had texted me that my answer would have been like, I don't know, I don't know what these things are so whatever, we could do anything you want to do our podcast.
We've promised this for a while now we have. I'm really excited to finally be doing it.
I mean, of all of the organs to start with.
Is this the first like organ episode?
Yeah?
Isn't it? Yeah? Yeah? Is that right? I feel like we've talked about doing like the heart, We've talked about doing other organs.
I can can you think of other organs?
I mean, the uterus is the first one I think of it. We've done a lot of like uterus right, the discussions, but we've not just like done a whole episode on the uterus.
Nope, not yet. Well, gallbladder here we are here. We are celebrate the gallbladder and also chastise it for the things that it does poorly.
I can't wait. I'm really really excited. I have no idea what you have in store for me, Aaron, but I it's gonna be fun.
I know that we'll see before we get into all of that thought quarantine any time, quarantin any time. What are we drinking this week?
We're drinking on the stones, like on the rocks.
We're going to do gall of stone.
Oh I thought we said Oh no, you're right.
We did do on the Stones.
Okay, we have a lot of ideas.
We did well, we had two at least so and in on the Stones we're actually doing a classic cocktail which I've always heard of but never knew what was in. It's a Harvey.
Wallbanger, not to be confused with Wait wait wait, Harvey Wahlberg isn't a person, is it.
There's Mark Wahlberg, right, and then there's Donnie Wahlberg and I assume other Wahlberg's.
I don't know why that was the first thing I thought of when you said Harvey Wallbanger, you did?
You were like, what's in the what's in the the Harvey Wahlberg, I'm like, excuse me?
What?
Yeah, okay, in the Harvey Wallbanger or on the Stones is orange juice vodka a like a yellow kind of vanilla e liqueur called galliano or guyano Guyiano I'm not sure how you pronounce it, and a marishino cherry delish. Yeah, it's delish. The reason we chose this too is because I when I was like thinking of the quarantine, I was like, Okay, well it's got to be yellow, because that's what bile is, and then I told you and
you were like, yeah, but bile's not yellow. I mean what we're going with it anyway.
It's yellow. It can be yellow. It ranges from like yellow to green or black is not a good color for bile, but sometimes so it's a spectrum. I think we think of it in our minds as more bright yet like more on the light yellow spectrum than it. It's closer usually to the darker side of the spectrum.
But you know what, already learning things, already learning things. We will post the full recipe for on the Stones on our website this podcast will Kill You dot com, as well as on all of our social media channels, so check it out.
Check it out. Also check out on our website, our merch our bookshop, dot org affiliate account, and our good Reads list our music by Bloodmobile, who's also on Instagram, Treon page, transcripts, sources from all of our episodes, and so much.
More, so much more. We're on YouTube.
We're on YouTube, follow you exactly right network, subscribe to it all. We're on what do you call It? iHeart podcasts, Now and Apple Podcasts and all of the other ones. Thanks for listening.
At the end and now over to the beginning.
I'm going to talk us through what the heck is the gall bladder right after this break Aaron. You know those like old timey water skins, like I think they're probably made out of like animal organs, but you see them in like old movies, like old westerns, like you put it on a saddle bag and then you drink water out of this. Yeah, okay, So your gallbladder.
Oh oh af to an unusual start.
Is kind of like a little water skin kind of okay, okay, it's like it shaped a little bit like that, like what I what I think of it as those little water skins. It's like this seven to ten centimeter so it's quite a bit smaller than those water skins. So two and a half to four inches long.
I'm a little so little pouch.
Yeah, And it sits just on the underside of your liver, and your liver hangs out in the right upper quadrant of your abdomen. It just like a butts against your diaphragm, which is what separates your abdomen from your thorax or your chest.
The liver is always so much higher than I think of like for some reason, I just think of the chest cavity as empty, and all my organs are somehow crowded.
At the very bottom, your chest cavity is empty, not like your well, my heart.
That's okay, loves you heart, and then well there's anything else until like my until the bottom.
Yeah, the liveries weigh the heck up there, way up there. And this little pouch sits just there's like a little a little groove, a little divot that it basically sits in. And it is part of what's called our biliary system, which is basically a series of tubes like a I think of it as like the branching plumbing system that
the super Mario brothers travel through. Some of these tubes come from the liver they're called the hipatic ducts, and then they join together with the tube from the gall bladder, which is called the cystic duct, and those all joined together into what's called the common bile duct. And then another branch comes over from the pancreas. I don't know why I went this way, because it's coming from your left side, and these all together empty out into our duadnum,
which is the first part of our small intestine. So you have this series of duct work that connects our liver, our pancreas, and then there's this one branch that ends in a blind pouch, and that blind pouch is the gall bladder. To better illustrate this.
Oh, do we have props?
We have props today. I made a billiary tree, Oh my gosh, out of some pipe cleaners and a balloon. So if you're just listening, imagine thank you. I tried to get my kids to help, and they were like, nah, I'm good.
But minecraft to watch exactly.
So I made this. Imagine if you're just listening, I'm going to talk you through it. Basically, we've got two pipe cleaners that come together in like a y shape. These are our two hepadict like left and right hepadic ducts. These are what are bringing the bile which is made in the liver down into the common hepatic duct. This pouch, which is a balloon, a squeezy balloon, is the gall bladder. It's connected to this whole system by the cystic duct here. Okay,
then we have the common bial duct. This branch coming out towards the left, which is really quite skinny, connects really close to the bottom of the common bial duct, and that is what connects the pancreas. That's the pancreatic duct.
Okay, the blues the pancreas, got it.
And then it lets out in a sphincter. So there's a muscular sphincter here called the sphincter of odie, and it is what allows flow out into the duadnum or testin.
Hold on, where's the liver again?
The liver here is up there, okay, Okay, So the liver is what's covering the top part of this, and then your gall bladder sits just underneath the liver just kind of poking out. Got a day, okay, And so the gall bladder it's essentially a storage unit or really like a storage and handling unit. Okay. Our liver is producing bile, and it produces something like a leader a day, which is more than I realized. But it produces this
bile I know, right. It produces this bio at different rates depending on whether we are eating or whether we're fasting, right, in response to hormone signals that it gets when we're eating. And then this bile is traveling ultimately to the duadnum. Right, It has to get into our intestine because it's going to help us digest our foods. But because there is this muscular sphincter at the bottom, it's regulating the flow of bile, So the bio is not just free flowing,
gushing all the time into our duadnum. So depending on the timing pre meal, after a meal, if you're snacking and the pressure of this sphincter, bio will either flow outwards into the small intestine or it gets diverted into the gallbladder.
Okay, so if you're like, we don't need to digest right now, just hold on to this until for a little.
Bit, then boop the pressure Like that sphincter's closed, so the pressure builds up here and then bloop, that fluid gets diverted into our gallbladder. Something like ninety percent of the bile that's produced during times that we're not actively eating or digesting our food ends up going into the gallbladder for storage. But while it's there, it's not just sitting there. Our gallbladder is doing a job, and that
job is concentrating this bile. You can think of it kind of like a barrel that's aging your fine wine, right yeah, some of I'm really going hard on the analogies here today.
I like it.
So, if you have wine in a barrel, like some of that wine soaks into the barrel, right, so the wine that comes out after a certain amount of time is a little bit different than what went in. It's the same thing here. So the bile that exists in the gall bladder is more concentrated because there's all these crypts. It's not like a smooth wall on the inside of the gall bladder. It's got like folds and layers and
these cryps. So you actually even end up having like layers within the gallbladder of this fluid, this bile where the most concentrated stuff is deep down in the crypts, this inner lining, and then there's less concentrated stuff on top.
So after a meal, and depending on how big that meal was, how much fat was in that meal, like a lot of different components, how much hormones are being secreted out, how well your gallbladder squeeze is to begin with, our gallbladder will get to work squeezing and pushing that concentrated bile out the cystic duct, which will mix with
stuff coming from the liver. That's free flowing still, and then we'll eventually travel while mixing also with enzymes from the pancreatic duct out through that sphincter into our duodenum so that we can digest our fat burger.
Two questions give it to me? How is it concentrating?
Like?
And number two, what is bile?
I knew you were gonna ask that question, So my literal next part is what the heck is bile? So God, when we work together, Well, the way that it's concentrating is basically there's like, you know, a bunch of transporters, like ion transporters and different things in the wall of the gall bladder itself, like in that intestinal lumin or
not intestinal, but in that bile lumine. And so it's going to be like soaking up like basically taking back some of that water and maybe other parts of what's in the bile and leaving a more concentrated bile behind. If that makes it. Yeah, So bile, great question. So glad you asked. Is this yellowish greenish liquid that's made in our liver and it's made up of a bunch
of different things. It's a combination of bile acids, which is the most kind of active part and probably one of the more important parts of bile and bile acids are We've talked about them in one of our pregn the episodes when we talked about cholestasis of pregnancy. But these are made from cholesterol. So our liver is making cholesterol and then through a process of a whole bunch
of enzymes converting that cholesterol into bile acids. And then what it also does on top of that, there's another thing called biol salts, and that's just a fancy name for the liver will take these bio acids, combine them with other amino acids to make them more hydrophilic so that they're more soluble in water, because cholesterol is fat
and fats don't mix well with water. So our liver makes these cholesterol products called bio acids, then makes them into something that's more hydrophilic that we call a bio salt, and that's a big, huge component of our biole It also contains bilirubin, which is a byproduct of like red cell breakdown. It also has other phospholipids. There's probably just some like plain processed cholesterol in there. There's water, and
then there's other salts and minerals. What bile does, especially these bile acids or bile salts, our help in the digestion of lipids or fats in our gi tract. They are helping to emulsify and facilitate the absorption of our fats and things like fat soluble vitamins. Okay, they also are going to grab onto and help eliminate cholesterol from our body by grabbing onto it and then essentially like we'll poop it out, so they'll like block some absorption
of cholesterol. And because these are made in the liver and then traveling via this biliary system maybe pit stopping in the gallbladder, and then being re secreted after they're in our digestive tract and they're doing their jobs, they actually get reabsorbed through our intestinal wall later on in our small intestine, then re enter what's called our entero hepatic circulation, go back into our liver where they can be reprocessed, re secreted and used again.
Okay, so we recirculate bile.
H Yeah, most of our bile is recirculated. Our liver is always making more, but we need way more bile than it's making in a day, if that makes sense, so we recirculate it.
That's really fascinating. And this is, like you said, a leader a day at least. Yeah, that's such a huge amount of Okay, yeah, when you're we talked about this a little bit, but just again to go over it. When you're barfing and you get to the point where you're just barfing up like a little kind of gummy, sticky, snotty liquid that's bright yellow, Yeah, is that ever bile or is it just stomach acid?
It could or it could not be bile. Okay, really billious vomiting is like considered pretty bad. So like that would mean like something is pretty wrongs.
Have to be like from your small intestine backups through exact stomach, so like that should not that's a one way path.
It should be a one way path. And so that tells us that there's something going on that's causing that much of a backup, So we think of that with maybe something like a small bowel obstruction or something like that. That doesn't mean that it's impossible to barf up bile.
We definitely like people barf up bile, you know for sure, But most of the time when you're doing that, like dry heaving, and then you get out just a little bit, it's probably mostly just your stomach contents and like the stomach acid that's left in there, that's what leaves that really terrible taste in your mouth and things.
Okay, yeah, I feel like I have a lot more questions, but they're all related to the things that can go wrong, and I agree with feelings. That's what you're going to talk.
About, that is how can things go wrong? Oh so I mentioned already that a big part of what your gallbladder is doing is concentrating this bile. Anytime that you have a liquid that's not just like say pure H two O water, but you have a solution that gets more concentrated, the solutes in that solution are at risk of precipitating out. And that is essentially what happens when you get gallstones there where.
Now the stuff precipitates out.
Yeah, it's not like perfectly as simple as that, but that's the simplest way to think about it. Because gallstones, there's a few different types of gallstones, but something like eighty to ninety percent of gallstones are cholesterol stones, so they're basically a solid mass of cholesterol from these bile acids that essentially crystallizes as well as calcium other proteins. And then these things called musins, which are produced by our gall bladder and can kind of act as if
you've ever made like rock candy. Have you ever made rock candy?
I've eaten rock candy.
If you're gonna make rock candy, you make us supersaturated solution of sugar water, and then you have to take your stick or your string or whatever and roll it in sugar crystals and dunk it in there, and those.
Sugar crystals kind of exactly domino crystallization exact.
Actually, yeah, And so these musins are something produced in the gall botty that can act as one of those crystal formations. They kind of are like that, not a catalyst, but they are that first thing where your cholesterol crystals can start to precipitate out and then eventually form a gallstone.
There are other types of gallstones, So pigment stones are mostly made up of bilirubin, and so those can happen if you have an over abundance of bilirubin in the bile, which we might see in something like a hemolytic disease or some other kinds of medical disorders, but those are much less common. Most gallstones are cholesterol gallstones. You can also have mixed gallstones, and.
That's just where the cholesterol is falling out of solution and kind of like.
Making little chunkies. Okay, so we're big chunkies.
How common are gallstones and then how common are gallstones that cause a major problem?
Great question. Gallstones are quite common. It's estimated that like ten to fifteen percent of adults in the US and in Europe where we have the best data, but I also saw some studies out of China that were like around twelve percent, So like ten to fifteen percent of
adults have gallstones. Eighty percent of people with gallstones totally asymptomatic, never even know that they have them unless they happen to get a right up or quadran ultrasound and we see them huh, okay, not so bad until they go really wrong. And there are a lot of risk factors for gallstone formation, and we really, in all honesty, you
just don't really understand them. Like maybe poor gallbladder motility might have a role to play, because we see that in conditions like pregnancy, which we talked about, where everything slows down, things aren't contracting as much, and so then you can get stasis. And if you have stasis, you have increased concentration of this solution, and then you have more precipitation. We can also see that in diabetes, because diabetes can cause a slow down of the GI tract.
Side note, GLP one medications are friends like ozeen pic slow down the GI tract and have been associated with an increased risk of gallstone formation.
Very interesting.
There's also probably genetic predisposition to things like excess musin production or just slow gut transport in general, or differences in the way that bile salts are metabolized and reabsorbed because you can end up with more or less hydrophobic versions. So some that might just be more likely to precipitate to begin with, if that makes sense, they're just not as good at dissolving in water. There's probably microbiome considerations. Estrogen my play role. There's a lot and we don't
fully understand it. But most of the time gallstones just hang out there in your gallbladder and don't really cause any problems. But if they're going to cause problems. Most of the time. The first presentation if someone is symptomatic is what's called billiary colic, and that is this kind of I mean good example that Maria gave us an
herb perstent account. Unfortunately, it's this post pran deal. So after eating, about an hour or so after eating, this episode of really severe usually right upper quadrant, because that's where your liver and gallbwater are. Pain that can be very severe, very intense, lasts for maybe an hour, maybe a few hours, and then eventually resolves on its own.
That is the classic description of biliary colic. We think that usually this biliary colic is caused by a stone or what's sometimes called sludge, because sometimes you don't get like a full on stone formation, but you just get sludginess where it's like really thick, concentrated stuff that gets lodged some where in this biliary system, right, whether it's in the cystic duct or somewhere else in this biliary system, and then it causes irritation and inflammation and pain because
it's activating our like visceral sensory nerves. More than ninety percent of people who have one attack will have a recurrent attack of biliary colic within ten years. A lot of them will have a repeat episode within two years. Okay, but these type of attacks, this kind of biliary colic is usually considered self limiting, right, it's not necessarily causing
an emergency, it doesn't need intervention necessarily. But these gallstone blockages can also cause a number of more severe complications, which all have various idis names because they're associated with a lot of inflammation. We can get acute colycystitis, we can get bacterial cholanngitis, we can get pancreatitis. Gallstone are also a very well known risk factor for gallbladder cancer down the line. So I want to kind of talk through how each of these processes happen, because they're kind
of all actually the exact same process. It all just depends on where in this biliary system a stone is getting lodged. Basically anytime that you have a tube in your body, but especially when you have a blind tube right like this pocket where there's no exit on it. When that tube gets blocked, you're going to increase pressure
behind that blockage. So in your gallbladder especially, this increase in pressure is going to cause swelling, which especially along with this supersaturated bile that's already present in your gall bladder, will cause further inflammation. And inflammation in our body comes with edema or swelling, which will further increase this pressure.
So acute coly sostitis is when you have a gallstone that has blocked the cystic duct and then causes this increase in pressure and inflammation and swelling in the gall bladder itself. Eventually, this can lead to the wall of the gall bladder not being able to get enough blood supply.
So then parts of the tissue because of just there's so much like edema and swelling, so then the blood can't flow there well, and so then the tissue will start to die, so we can see necrosis, and with necrosis you can see hemorrhage right because you're going to have bleeding from where this tissue is dying. That can eventually lead to perforation of the wall and the gall bladder, which would cause it to spill out its contents into
the peritoneal cavity. And that's super concentrated bile acids that they're supposed to digest stuff, So that can be really severe. Okay, but even if it doesn't perforate, as you continue to have all of this edema and sell death and necrosis, you eventually can get a purulent phase where you get a lot of white blood cells. Inflammation, bacteria can get into this system, whether they're coming from the GI tract, whether they're kind of they're already but not causing problems
until they proliferate. They make their way in there one way or another and then cause a bacterial infection on top of this. So that can happen in any part. If it happens near the pancreatic duct and blocks here, you can get inflammation in the pancreas, and that's called a cube pancreatitis. Fifty percent of cases of that are
caused by gallstones. Okay, you can get a stone that lodges somewhere in the common bile duct itself right so below the gallbladder, but before the pancreatic duct, and that can cause what's called coolanditis. It's usually bacterial colanditis, and that's really severe because this is a relatively small tube, so a small increase in pressure you could potentially have a perforation that could be a lot more severe. So we see people really really sick when that happens.
And so, but like, no matter where the stone or the obstruction is happening, the gallbladder will continue to be backed up and swell. Or is it only when that stone is at the opening of the gall bladder.
Yeah, it kind of just depends. So you can definitely get pancreatitis without having any gallbladder swelling, like without having colicicitis on top of it. Colicystitis. Acute colicstitis is specifically when it's blocked at the neck of the gall bladder somewhere, so it's the gall bladder that is most affected.
Like the hotel California of gallbladder issues, you can check, you can go in, but you can never come out. It's like the worst It's all I can think of is like you can you can Yeah, you can't leave.
Yeah, you can't leave exactly, nothing can leave. Yeah. The same is true though, like if you get if you get a stone blocking somewhere else, it just depends on how long it's there, how severe it gets, whether it's ever able to pass. You could certainly get inflammation, like you can end up with an infection in the gall bladder or inflammation in the gall bladder when you also have colandritis in other places, in other places, and at the heart of it, the problem ultimately is the gallbladder
itself in any case, right yep. And so for a lot of these cases, though I will say not all of them, Like especially not when we're talking about pancreatitis. The treatment for that is potentially different. But especially when we're talking about acute colis istitis, when it's this inflammation of the gallbladder itself, treatment is usually take out that gall bladder, cut it the heck out, cola systectomy.
So what are the consequences of this? What is the deciding factor? So obviously if like if it's severe enough, yeah, what do we ever just remove the gall stone?
You absolutely can. Yeah, there's a number of procedures that you can do to just remove the gall stone. There's also medication that you can use. We use it definitely, like in pregnancy when it's the colistasis of pregnancy, which is different, that's like it's a different process. See our pregnancy episode we talked about it. But so there is a medicine that we can use that helps to kind
of break up these gallstones. Themselves, but it's not necessarily like all that effective long term and prevention of complications. But that is one option. We used to do a lot more of like what we do for kidney stones, which is like go in and like ultra sound wave them somehow and break them up. That's not really done anymore.
So another option if someone is really really sick with acute coalisistitis, so this infection inflammation in the gall bladder and they cannot have a surgery, because ultimately surgery to remove that gall bladder is the treatment, especially for acute
cola sisiitis. Okay, if someone cannot have that surgery because they are too sick or they cannot have that surgery, then sometimes we'll put a drain in it, so that would come from the outside, and that's called a percutaneous collisystostomy tube, and so that's just going to drain all of the infected fluid, all of the pus, everything, all of the bial But it's sort of just a temporizing measure. Eventually you're going to have to do something more permanent.
So yeah, I mean, it really does depend though on what the presentation is. So if somebody just has that biliary colic that we talked about. They may or may not decide to get their gallbladder removed. If they do, a surgeon is probably going to want it to be at a time when there's not any issues going on, because then everything is calm and cool, and it's easier to remove because you don't have irritation and inflammation.
I have a question about diagnosis though, So, like you said, this is a These attacks are fairly characteristic. It's like right upper quadrant debilitating pain. Like I've heard some people that I know I've had it describe it as like they're like, yes, I've had children, and this is worse than unmedicated child birth. Yeah, which is wild to think about. And and but it like you said, it's it's self limiting. It's it does go away eventually unless there's doesn't more
severe unless it doesn't. And so if that goes away, and then you go to your doctor a week or two later and let's say there's no gallstone, yeah they can find, so then what what do you do.
Yeah, it's a great question. It kind of depends, Okay, it depends on if it comes back most of the time, Like most of the time you see something whether that's sludge, right, so you might not see a stone. If you had a small stone and it passed, you know, during that episode, then we might only see sludge. But even just sledge itself can cause billiary colic, right if that sludge get pressed up against and then ends up causing irritation. But yeah, I mean, it all just is going to depen and
on that specific presentation on how often it's happening. There are other things, of course that can mimic this, so I don't have an easy answer for that.
All right, So but what if you get your gallbladder out? Obviously this happens a lot. Yeah, yeah, what happens.
It depends some people they don't even miss it and they have no issues whatsoever, and then they live their life without gallstones, and isn't that great news. But a lot of people can have post colo systectomy complications and that can really really range estimates. I saw most of them were around forty percent on the high end. Some were a lot lower, and I'm not sure that I believe that just based on all of the other papers
that said anywhere from like five to forty percent. So I think there's a pretty huge range of looking at different studies, but the symptoms can also range, and I'm not talking about like acutely. There are of course complications from surgery that can happen, right have injury to the bile duct, you could have leakage things like that. But outside of that, like just postop period, some people can have acid reflux that they can get after a procedure
like this. We don't fully understand. Some people get persistent right upper quadrant pain, so like they still end up having pain in that area where they were having pain from their gallbladder. Some people very commonly end up with diarrhea, and that has a lot to do probably though we
don't fully understand it. With the changes in how you now are getting bile acids into your GI tract, right you're no longer having these concentrated bile acids, but you are having more of a constant free flow of less concentrated bile acids into your GI tract. And it's thought that this likely changes the gut microbiome, which will then shift how these bile acids are like conjugated or unconjugated, or what they're conjugated with when they go through processing
and all of that kind of stuff. So there's a lot of potential changes that happen after a close etectomy, and yet you can function and your GI tract can function just fine without your gallbladder.
You just kind of snip it, snip snip.
Yeah that's the end. Oh okay, Aaron, Oh wow, tell me about this, would you.
Maybe we'll see, we'll see what what I come up with. Okay, have you ever heard someone described as like having the goll to do something? Yeah? Like what goal he has to suggest that?
Don't tell me that that has to do with GOLs.
Tones, of course it does.
I don't know why I thought it was the gallbladder. I know, but I this is so embarrassing, I'm not going to say it out loud. I thought it was like the glants are like, no, like the birds. Oh goal, Yeah, I thought I had something. I mean, I knew it was gall but I don't know why I just assumed that it had something to do with birds.
I mean, I would say, goals do have a lot of goll.
I would agree, because it's like usually it's like you know someone who's bold hands exactly the goal, the gall on that goal, the audacity based on what it is.
Yeah, I love it. It's it's such a great word. It's like a little pearl clutching word. I don't think we use it enough. I let's use it for the goal and it comes Yeah, it comes from the gallbladder.
Okay, Like why what does the.
Gallbladder have to do with personality or temperament or daring? So today we may not think that often of our gallbladder, except for the subset of us who have been at the mercy of our organ because of gallstones or coally systectomy or some other reason. Like how many of you out there listening knew what the gallbladder did or could locate it on a diagram before this episode? I could not at all. Yeah, I mean you could do it.
Yeah. We don't think about it very often. We don't.
We don't. But this sort of backseat, overlooked role that the gallbladder now plays is actually a relatively recent one. For centuries, the gallbladder, or maybe more precisely, the substance that it stores, was a star. It was famous among the organs, or among the substances produced by organs, crucial for how it affected not only your health and well being, but also your outlook on life? What and that is
the story that I want to tell today. Okay, I've touched on it in other episodes of the podcast, but it's not one that I've ever really told or thought about in full. And so what better time to discuss the humoral theory of disease? Yes? Eight years into this? Yeah, so you might be thinking, Okay, well, what do we care about an outdated and disproven model for understanding human health and disease? Fair enough, I care, I mean yeah, but I asked myself, why is this really the right
thing to do? It doesn't give us a ton of accurate info about our bodies inner workings, but it does give us insight into how the world was perceived in past centuries and how that perception actually lingers today in a surprising way, long after the humoral theory of disease was supposedly discarded in favor of germ theory and other concepts of modern medicine. Okay, but before we get too deep into the humors, I figured I should at least share some fun gallbladder facts that get collected.
Give it.
The largest gallstone removed laparoscopically was twelve point eight centimeters long and seven centimeters wide, So that's five point one inches two point eight five point one by two point eight inches.
Yeah, that's hefty.
It's hefty. It's like a smallish avocado, is what I would say, like a quite small avocado.
Just stitting in your gut.
That was a laparoscopic removal for Yeah, the largest removed in a traditional surgery, at least like documented in recent times, was sixteen point eight centimeters long and seven point eight centimeters wide, so it's like six point six and a half by three inches. It's like it's large avocado, good sized avocado. Avocado. And also they kind of art were avocado.
Shaped because the gall bladder is a little alike.
It's avocado.
Yeah, pair shaped, avocado shaped.
That one weighed to one and seventy eight grams or zero point six pounds. Wow, it's a large avocado lot. I've got citations for those, But this next one comes from a more questionable source. So I googled like largest gallstone and then found the ones that are like in
you know, medical journals. But then the Guinness Book of World Records of course has an entry stop it quote the largest gallstone reported in medical literature was one of six point two nine kilograms or thirteen pounds fourteen ounces removed from an eighty year old woman by doctor Humphrey Arthur at charing Cross Hospital, London. Okay, yeah, okay, no citation provided for this, so I hunted it down. I read the original paper titled a Large Abdominal Calculus by
Humphrey Arthur. Couldn't find anything in that paper that was like, this is a gallstone. I made you read.
It, huh?
And I was like, do you see anywhere that they tie this to a gallstone they identify as a gallstone.
And it doesn't sound like a gallstone either, doesn't sound like a bladderstone.
Yep. In the paper it's not a gallstone. So someone has got to notify Guinness to say, you know, sorry, that ain't a gallstone.
Listen, Guinness, wrong, are you hearing this? Can someone at them right now, right now, right this minute? You have your largest gallstone? Wrong?
Yeah? Wrong? I mean the largest one I could find in the literature was point six pounds. That's not thirteen.
Pounds fast difference, fast pounds. Yeah.
So anyway, I.
Will say, don't you remember at the Sturgical Science museum in Chicago. They had some hefty gallstones.
There had so many gallstones. Yeah, it's highly recommended, such a great museum. Yeah, let's go back. Okay, Okay, gallstones have been found in ancient Egyptian mummies.
Of course.
There is a bronze model of a sheep liver and gallbladder from the second century BCE that was found in a field in Italy, and the first gallstone removals began in the late nineteenth century, led by German surgeon Carl Langenbuk who reasoned that some mammals don't have a gallbladder, so that probably means that humans can survive with that one that but like they were like, eh, that's probably fine.
That's probably fine.
Previously, surgeons would treat gallstones or like any gallbladder complaint primarily by like creating kind of an opening like you described, like a fish Jula's what they described, to excess and remove.
Stones, remove stones.
Yeah, okay, what else we can add acute coalesistitis to the list of things that allegedly killed Alexander the Great. Oh, I think we've covered like poisons on this before, or some infection, whether it was typhus or typhoid. Who knows.
I mean, you can have poisons, so you can get colosistitis from not gallstones, like ten percent of cases are called a calculus. So maybe in fact it was both a poison and a cute could be?
Could be. The famous American surgeon William Stewart Halsted performed surgery on his mom to remove gallstones in eighteen eighty one, prolonged her life by a couple of years, And in September nineteen sixty five, President Lyndon B. Johnson had his gallbladder removed. Okay, you know, laparoscopy helped cut down complications and speed up healing time, and the first laparoscopic coali systectomy was performed in nineteen eighty five. And now we've
got robotic assisted coally systectomies. Yeah, pretty pretty cool. Revolutionary healing time is yeah, it's it's neat. It's neat stuff. That's the end of my gallbladder facts.
Love it.
Let me know if you out there have more for me. That's really all that I could find for this. Go onto humoral theory.
Okay.
In the fifth century BCE, our old friend friend of the pod Hyppocrates, along with his buds put together the revolutionary medical texts that would come to rule Western medicine over the next two thousand years. In it, they described a person's health, their psychology, character, behavior, preferences, and appearance, and how all of this could be traced back to the balance or imbalance of four substances in the body.
The humors. Quoting from Galen, who was a few centuries later, quote to begin at the beginning, The elements from which the world is made are air, fire, water, and earth. The seasons from which the year is composed are spring, summer, winter, and autumn. The humors from which animals and humans are composed are yellow bile, blood, phlem, and black bile. End quote.
I love it, He's like listen, it's four four four, okay.
Four four four. There's a symmetry that is beautiful, undeniable, undeniable. The humors were related to the elements of the world, like air and blood, water and phlegm, fire and yellow bile, earth and black bile interesting, and also to temperature and moisture. So blood was hot and moist, phlegm was cold and moist. Yellow bial was hot and dry and melancholy or black bile.
Was cold and dry, okay, interesting, too.
Much of one humor could be deadly. Your death could be caused by excess phlegm, like that would be on your death certificate. Let's say you maybe ate too much of something or drank too much of something that gave you that excess phlem. That was what led to it, and treatments were advised based on the precise imbalance. If it was an excess of blood, bleeding was your best
course of action. If it was yellow or black bile that you had too much of, you should probably take some laxatives or emetics, something to make you throw up. And if it was phlegm that was bothering you, like it clearly is bothering me. Nothing better, Nothing is better than something that caused you to sweat or expectorate.
Quick question. Sure is phlem back then the same thing as phlem today?
I think so, But it's kind of this is where it gets a little bit weird, because what the heck is black bile?
Yeah, that's what that was gonna be my next question.
Yeah, it's we'll get a little bit more. No, we'll get a little bit more into it. But like I think that we have to suspend our our perception of we have to see what these substances are and where they're coming from, because a lot of it was not in how they're coming out of your body, but just.
This like idea of how they exist in your body. Yeah, okay, I feel like I always thought of flem as like lymph, and I know that they didn't really know that that was the thing, but like in my brain act like that's what it is.
Yeah, right, and maybe it is. You know, sometimes these did come out like you could see maybe flem is you know, snot or whatever. Blood obviously is more visible, but like there's blood. Wasn't necessarily blood if that makes sense.
Oh my god, it doesn't, but I'm going to go with it.
You know, like, well there was like the blood that you bleed, and then there was the blood that was like a part of your core that beat was different, Yeah, which really I mean we got to just try to
think in their in their minds. Yeah. And so what you what you wanted to do with treatment was basically treat with opposites, so like allopathy as opposed to homeopathy, which is like like with like and so guided by these general principles, people suffering from whatever ailment didn't necessarily have to seek the help of a physician only in extreme cases, but they could concoct their own remedy or
buy a home remedy. Poultices, aenem syrups, potions, powders, pills, ointments, antidotes, fomentations, inhalations, infusions.
Lots of options, less possibilities yep.
And the quality of the treatment was determined not by its efficacy necessarily, but generally how rare or expensive the ingredients were or how complicated it was to put together. But even for the healthy person, there were general guidelines for how to live your life under the humoral theory of disease. Eat less in the summer and more in the winter. Beer nourishes provokes urine has a laxative effect, causes gas truth vinegar induces melancholy. I'm not sure about that one.
For me.
Ye, blood letting is best in springtime and only for those older than seventeen. Baths are not recommended during the summer months, which is also a time to eat cold food and avoid lovemaking, Oh dear, which might be related to the baths. Okay, sideline, I'm not sure, but alongside temporary imbalances. Rocking the boat people tended to have a
certain humoral imbalance, which determine their personality. Those with more yellow bile or collar colar were choleric, achievement oriented, driven, bold, decisive, independent, argumentative. These this yellow bile was associated with or people of this temperament was associated with summer and adolescence or youth.
If you had an excess of black bile, you were of the melancholic personality, sensitive, indirect, detail oriented, loyal, associated with maturity and audit, and a tendency to delirium or depression. A phlegmatic person or phlegmatic person had more. You guessed at phlem and they tended to be calm, steady, introverted, agreeable, indirect, slow to action, associated with winter and old age.
Okay.
And then finally, more blood led to a sanguine personality, optimistic, social, serene, fun loving, extroverted, active, associated with springtime and childhood. And there's like diagrams that you can see that have like these different colors. So like red is sanguine, obviously, black biles black. I'm pretty sure yellow bile is yellow, and then phlegm, I think is orange or not orange blue. Interesting, Yeah, and it has like it's like an idiogram. Yeah, I
don't know if there are like wings and whatever. And I was like thinking in my head, like, oh yeah that you know, yellow bile, the choleric personality really sounds kind of like an eight or a three, And then like yeah, but then I was like, I can't these are not one to one.
Yeah, obviously obviously, but yeah.
So the humoral theory of disease provided a framework to understand not only a person's health or disease, but also their emotions and personality, linking the two. And it drew connections between the environment, diet, and just inborn temperament to not only explain a disease, but also to provide a prognosis how the disease was expected to play out, guided by adjustments to humoral balance. And more than this, the humoral theory of disease represents a revolution in how people
understood the world to work. Rather than divine intervention or superstition, there was a physical basis for every phenomenon of the human body and a corresponding explanation. All you had to do was closely observe your patient, maybe take a case history, which led you to a diagnosis than prognosis than treatment. This approach to medicine was really the first to resemble the scientific one that we use today to some extent.
Interesting because instead of there being one answer to every question of why, which would be because God decrete it, there could be a multitude of answers. This framework of humoral theory had its own logic, even if that logic is not based on our current understanding of anatomy and physiology, and it allowed physicians to, you know, do all of
these things in order to care for their patient. And the humoral theory of disease persisted for centuries despite the you know, the lack in our eyes were like you kidding me, what even is black bios like, what is that? What is it? Based? Not based on fact or on what we know? It's still persisted because it gave meaning to the world. It answered these unanswerable questions, and I think it provided some form of certainty, and we know
how much people hate uncertainty. Yeah, and so in this way, the humoral theory of disease was deterministic, like everything including behavior and mood, could be explained as it related to humors. Oh, well, of course you have this, you know, like and I imagine that would be both satisfying and also like very irritating, right, Like, no, I'm not upset because I ate hot soup and my bile is up. I'm upset because you borrowed my toga and you stained it. But you have a sanguine temperament,
so of course you wouldn't understand. But at the same time, people couldn't use their humoral imbalance as an excuse for bad behavior, like if an imbalance represented a diseased, unnatural state of being, they should try to act against it, to use their rational mind to make decisions and take action, like.
You're supposed to overcome this kind.
Of yeah, yeah yeah, and to not overcome it, to be beholden to your inborn temperament was kind of like viewed as a weakness like you know better, Yeah, fascinating, okay. And so the order and explanatory power that the humoral system provided is really what helped it survive for so many centuries because it could be folded into any religion like this is how whatever deity you believed in created humanity. It could explain any illness or any state of mind,
and it was adaptable. Like if you needed to add a little bit more color to your diagnosis, you could just say, well, you know, it wasn't just an excess of blood, but it was the type of blood, how viscous it was, where it came from, which organ or like part of the body was it concentrated in.
Could get really really neat gritty with you could your various humors yep.
So like smallpox, for instance, was believed by one ancient physician to be the result of retained menstrual blood by the fetus. So like you got smallpox as a fifteen year old because as a fetus there was retained menstrual blood in your mom's womb.
Oh like not okay, yeah, oh okay, like okay exactly.
So like there's there's no limit to the mental gymnastics that you can do.
Yeah wow, okay, just come up with an idea and then you could say you could you could humor it.
There you go.
Uh.
Infectious inheritable diseases also fit nicely into this, since miasma explained how could it could be transmitted from person to person, like humors and humoral temperament could be transferred from parent to offspring.
MM naturally.
Were also less about curing someone than they were about guiding someone through their natural course of disease and doing their best to get the best outcome, and with things like diet and then later on herbal remedies. So this left more wiggle room for physicians who weren't expected to cure their patients. So it wasn't like you don't know what you're talking about because this person's not getting better.
It was just like, this is the destiny, and I'm trying to do my best to fix things, but I'm you know, I can only do so much.
I'm limited.
I'm limited. Yeah, And the basic principles of humoral theory were also fairly easy to grasp, Like if you could remember each of the humors and what season or moisture they were associated with, and then various foods and their you know, moisture or heat levels, yeah, you could make a good guess as to what your disease was and how to manage it, even if you had no formal training or education.
Okay.
The other thing that let humoral theory rain was that autopsies were not permitted for a good chunk of this time. That excess of black bile was based on external observations of just like someone's symptoms, and as we'll later see, fact checking would undermine the credibility of humoralism.
Once they tried to find out what the heck is black bile, then they were like, there is no such thing. Okay.
And this isn't to say that humoral theory remained unchanged until the seventeenth and eighteenth centuries. You know, there were scholars like the famous Persian physician Avicenna who added his flare to it, and overall interpretations became more complex, as did the mental gymnastics that were required to come up
with these explanations. So, for instance, a combination of heat and the liver weakness of the spleen, external cold and a long disease history could lead to a heightened amount of black bile in the organism.
Okay, how do they know what is a liver and what is a spleen if they're not yeah, and animals okay, animals okay, And then they they really do okay.
Yeah, they would do autopsy or not autopsies, dissections on animals and then like make assumptions like that must be what the human coralate is.
Yeah, so do we even know if yellow bile is what we call bile today?
I think it was because I believe that Hippocrates thought it was produced by the liver or not not the liver, but a he thought it was produced actually by the gallbladder by we're going to attach to the liver, got it. So I do think that it was related to the bile.
That we we have at least those coralates, and phlem might be really phlem and then black bio is the real question mark here.
Yeah, I had a little bit about black bile, but now I have forgotten what it was. It was just sort of like, we don't really know it a certain type of blood, is it? I don't know.
Interesting so interesting arin.
Yeah, And humoral theory, it's not like it remained super popular during this entire time, so it fell out of favor occasionally, like in the Middle Ages when Christianity was on the rise and treatment was thought to like corrupt the soul and go against like God's wishes, or when an epidemic exhausted the explanatory power of humoral theory, like when the Black Death struck Western Eurasia in the mid
fourteenth century. You can't explain away a third to a half of the population dying because they all took a bath in the summer.
Like that's that's just can't do that.
Yeah, yeah, So that was a crack in the certainty that humoralism had provided, and that crack just widened over the next centuries as people tried out alternative frameworks to understand the world, you know, magic, religion, alchemy, homeopathy, anatomy. By the seventeenth century, humoralism was under threat, with the taboo against dissections slowly breaking down. You had anatomous like Visalius publishing intricate drawings of the human body, and artists
like Michelangelo celebrating the naked form. People were gaining a clearer insight into structure and function. And then you have microscopes allowing a view of the world as it had never before been seen. What these new perspectives revealed was that humoral theory simply did not hold up under scrutiny. The vena cava was not connected to the liver as Galen had claimed, nor were the lungs simply there to cool the heart. Oh, I mean, there were entire humoral structures missing.
Wow.
I mean, yeah, we've talked about breath before and how it was not understood why.
Breath was what breath was.
Yeah, yeah, because we didn't know about oxygen. And yeah. Anatomical dissections ironically were permitted because they were supposed to support humoral theory and provide more detail, not dethrone it, and so Visalius's findings were quite an unwelcome shock to the medical establishment of the mid sixteenth century, which had, you know, still was adhering to Galen's teachings. But you couldn't uncrack that egg, and this marked the beginning of
the end for humoralism. Observable evidence obtained through experimentation became the gold standard for establishing new laws of nature and guidelines for practicing medicine, just empiricism basically, but there was no concept of health and disease that could immediately replace
humoral theory, and so it was a slow decline. It didn't help that humoralism was literally embedded in language, not just for physicians or scientists, but for everyone, Like it was how you understood yourself, it was how you understood the way you moved about the world. Blood wasn't just blood it could be invigorating or excessive, pure or corrupt.
But that connection grew thin as scientists discovered that blood, well was just blood, and the human body actually bore a closer resemblance to the machines that engineers were inventing, rather than the mystical being imagined by the ancients. The feeling was that everything would eventually be figured out in
short order, and for many things that was true. The nineteenth century saw germ theory oust miasma, The circulatory system was fully mapped, the beginnings of hormones and vitamins were starting to be understood, and there were effective treatments developed for a myriad of illnesses. Bit by bit, body part by body part, medicine was laying claim to distinct areas of human health. The one realm that seemed stubbornly opaque
was the brain and nervous system. Still true, neurology as it was born in the late eighteen hundreds wasn't explicitly modeled after humoralism, but it certainly paralleled it. Hysteria was associated with excess fluidity okay, and was thought to be impacted by diet exercise. Too much of this, too little of that some of which might have a trace of truth to it, right.
I think that's what's so interesting about I mean, like, you know, not to the extreme of like don't do this in summer, don't do this in winter, but like so much of it is like still, like we should move our bodies makes sense?
Is common sense? A lot of it is just common sense advice. Yeah, but then there were Yeah, things like neurasthenia also had associations that were very like humoral in nature. Melancholy remained pretty much unchanged in its conception. It was like, oh, black bile cooled the brain, it makes you depressed.
Interesting.
The psychiatrist of decades past, just like those today, have sought to bridge the gap between the brain and the mind, and part of that bridge has really been constructed with the concept of temperaments, Like why do we respond the
way we do to certain events? Do certain individuals tend to be affected by this disease or that disorder, whether these are mental health illnesses, or whether these are like physical illnesses, people who are high strung, they are thought to have higher blood pressure and all these things.
Why.
The reason is because humors have not left the building. The traces of humoral theory can be found in the language that we use, like sanguine, like melancholy, good, humored, bilious gall In Greek, the word coli means bile. Melon means black, So melancholy black bile, Like that is directly what it comes from. Isn't that fascinating?
Wow? I didn't know that.
Yeah huh. But the humoral theory has also lingered beyond linguistics, like we still seek balance in our lives, whether it's our work life balance, getting the right the balance, diet, enough exercise and relaxation. We feel like we should eat certain foods in certain times of year, right, like warm and hearty soups in the winter. We take ginger for nausea and humoralism ginger is warming, and so that was
supposed to help to combat whatever it is, phlem or something. Yeah, yeah, eucalyptus for stuff sinuses like, also straight from humoral theory. We're only now recognizing the role that diet might play in a myriad of things that we just kind of had discarded previously, like mental health, maybe via our microbiome. This would not have surprised humorists at all, which I find really fun and interesting.
It's all a circle.
It's all a circle.
Yeah.
Today, scientists and medical practitioners operate under a framework that's been refined by decades of observation and experimentation, and we rely on these general rules to make sense of the world. But when we discarded humoralism in favor of empirical science, we also left behind perhaps what I think is like the most important lesson of humoral theory, and that is that each patient is a unique person, and you have to first understand that individual and where they come from
and who they are in order to help them. So like that's I don't know, that was something that I was thinking about in terms of like just how the temperaments. Yes, it is putting people in boxes, but it is also acknowledging them as individual people right at the same time. So I just thought that was an interesting little foray. That's the lesson that I could draw from humoralism. I mean, to be honest, just full disclosure. I wrote most of this when I was sick, and so I like reading
it over. I was like, wow, this feels like a fever dream. You can hear it in my voice to me.
Maybe the humoral theory all is it is a fever dreamer, so maybe it.
Was a fever dream. Yeah. I had no idea what I was going to do for gallbladders. I did not expect to come down this path of funeral theory of disease, but I thought it was fun Then I was like thinking, like, what what humoral temperament? Temperament? Am I?
Yeah?
What are you?
I don't know. I asked my sister actually, and she said I was choleric, which is like the argumentative one I.
Would I would agree with that, but I would say I was going to guess myself is the same, So I.
Think we might be. Yeah, we might be a mix of of choleric and sanguine as well.
I think on the border line there yellow and red, perfect can optimistic also, right, yeah, sometimes, But that's all.
I've got for gallbladder, which is really the humoral theory of disease.
I did not expect that journey, and I really quite enjoyed it.
I'm glad. I'm glad. What's what's going on with gallbladder stuff today? Let's let's wrap this up by getting back to where we started.
Sure, let me tell you about it. I kind of already told you about it, Aaron, Honestly, Okay, ten to fifteen of adults in the US and in Europe, and we don't have data on like across the whole globe, but it's estimated on average ten to fifteen percent of adults end up with gallstones. But luckily most people eighty percent or so of people with gallstones are asymptomatic. The other twenty percent may end up with complications at some point.
Ten to fifteen percent of those complications will be acute colisciitis, so that is by and large the most common complication of gallstones. There are pretty big differences in like prevalence of gallstones, especially if you're looking at different like racial
or ethnic groups, like within the US, for example. But it is not necessarily thought that this is genetic, Like we haven't found genetic markers that clearly explain this, and so the thought is maybe it's more related to say, dietary factors in different like populations or different areas, which my underscore that it's just a social construct after all.
Of course, Okay, I did think though that like there tended to be gallbladder like family history of gallbladder might or gallbladder removal makes you more likely to have gallbladder there.
Yeah, so there are some like familial clustering, but we still haven't found any like genetic markers. So is it microbiome where you know, you have similar microbiomes when you live in the same households and things. I don't know. We don't know, Okay, does it could also be genetic and we just don't know it yet. Sure, people assigned female at birth are more likely to have complications from gallstones, although that's also less true in older populations, Like it
kind of evens out the older that you get. So that's why it's maybe thought. Is it the estrogen that we have higher levels of, especially you know in our younger years prior to menopause. We don't. We don't know, but those are some of the risk factors. There's also other things. Sometimes higher BMI is associated with the higher risk of gallstones, but also so is weight loss associated with gallstones and complications. I mentioned diabetes and some of
our diabetes medications. And we know too that it's not just a cute coli cystitis. The incidence of acute pancreatitis is about forty per one hundred thousand each year in the US. Okay, I should have aired mathat but I didn't. But about fifty percent of those are from gallstones, and gallstones are kind of the major risk factor for gallbladder cancer, of which there are an estimated one hundred and fifteen thousand or socases each year across the whole globe. So
that's my stats. Okay. According to most sources in the US, there are about half a million Coli systectomies performed every single year, So that means half a million gallbladders. Get the bucket kicked? WHOA, I know it's a lot, right. Oh.
I have a question, okay, if you have a liver transplant, uh huh, is the gallbladder ever come with?
I don't think so.
No, Okay, I don't know why. I was just curious.
That's an interesting question, I think so. No, okay, great question. Do they take the gallbladder out? I don't. I feel like I ought to know more about this, but they're like, yeah, they're butts their pals. There's a little pouch for it. Yeah. No, I don't know. Great question.
I love that you abbreviated question. Great question.
Listen, what are we doing in terms of research with the gallbladder. Great question. I don't know, okay, okay, but I did find a really interesting paper. It was like real long and like deep in detail. So if someone wants to get deep into this, I got some sources for you. I underestimate just how important bio acids are and how much of a role they serve outside of just digesting are fats. They're important in like intestinal homeostasis.
They're important in like absorption. But if there's too much of them that makes it to the colon, they can end up causing diarrhea. If there's not enough, you can end up with chronic constipation. So there's been like bio acid dysfunction implicated in ibs. They're affecting our microbiome. That might even affect the increases in risk in colon cancer. And we've seen a lot about colon cancer lately and increased risk especially in young folks. That might have something
to do with bio acids. We don't know, still up for debate, And there's just increasing evidence of bio acid's role in a myriad of other disease processes, and so there's research ongoing into using drugs that target bio acid receptors. Either black looking them or activating them as potential treatments for a number of different diseases. We also do use bile acid sequestrians, so that's like things that grab onto bile acids and help us to just poop them out
rather than reabsorbing them, mostly to treat elevated cholesterol. But we don't use them really often because they have quite a lot of side effects, especially diarrhea and like bloating and things like that. So yeah, none of that is very gall bladder specific, but it's just I mean, but bile, bile and bile acids so so interesting. So if you want to read more, let us tell you about all of our sources.
Yes, if you want to read more about definitely something that is not gallblader specific in any way, shape or form. There is a book called Passions and Tempers and it's about the humoral theory of disease by Noga Arika. And then there's a paper which just has a few funt tedbits. It's a book chapter actually called History of Medical and Surgical Management of Acute Coalesistitis by Barry and Frank from
twenty fifteen. And I've got a few more sources, especially on those big gallstones and you know, so Guinness Booker World Records, get on this.
Yeah. I also had a number of sources I used, primarily also a textbook chapter. It was from the textbook Comprehensive Physiology, and the chapter was called Functions of the gallbladder. Surprise, surprise. I also used a bunch of other specific papers to look at. For example, there was one from the Lancet
in two thousand and six called Cholesterol gallstone Disease. There was a Gamma review from twenty twenty two called acute coalsistitis, a review I've got one on gall bladder cancer, one on pancreatitis, a few others on bile acids, both the synthesis and their use in these other like the other functions that they serve. You can find all of that on our website, this podcast we Kill You dot Com under the episodes tab.
Certainly, Ken Maria, thank you so much again for sharing your story.
Yes, seriously, thank you so much, so much for telling us that story and sharing it with all of our listeners. We really appreciate it.
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