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I have to apologize for last week’s post. I’m not apologizing for the subject matter (the obsession that reigns supreme among some alt-med aficionados over “cleansing” their colons to “purge toxins” and achieve the super-regularity of several bowel movements a day). Rather, I’m sorry I probably didn’t emphasize quite strongly enough just how disgusting one of the links that I included was. Among all the glowing testimonials found there touting how lovers of that “clean feeling” inside felt after having supposedly rid themselves of all that nasty fecal matter caked on the walls of their colons and achieved the Nirvana of many bowel movements a day (or, as one happy customer put it, “awesome adventures in the bathroom” and another put it, “I have not noticed anything really weird come out of me yet, but I am sure that there will be”), there were also links to various pictures people took of their own poop, complete with graphic descriptions. A couple of years ago when I showed an acquaintance of mine the Dr. Natura website shortly after I had discovered it, he declared it the “grossest thing on the web.” Sadly, I had to assure him that it was not–not by a longshot. However, I will try spare you any links to anything significantly grosser, preferring instead to leave finding them as an exercise for interested readers.

After having apologized for perhaps grossing out some of our readers, who come to this site for science- and evidence-based discussions of various so-called “complementary and alternative medicine” therapies, not pictures of the various excretions of the human body proudly lined up by the humans who produced them, I thought about what might be a suitable followup this week to such a topic. There really is only one followup that’s appropriate to this stuff, believe it or not. The problem with which I wrestled is that it really is pretty much as disgusting as last week’s topic, if not more so. (You’ll soon see why.) So there I was, trapped on the horns of a dilemma. Hesitating only momentarily, though, as any good general surgeon would do (remember, before I specialized in breast cancer surgery I was a general surgeon, as prone to dive into big brown on the loose as any other general surgeon), I decided just to dive in to the topic as I would have in the old days dived into a particularly foul belly full of purulence, particularly since this week’s “ CAM ” modality of choice claims to be able to take away a big chunk of the “bread and butter” practice of general surgery by curing a common surgical disease without all that nasty cutting, even if these days it’s almost always done laparoscopically.

So, are you ready for liver flushes? Of course you are. Don’t you want a way to “remove gallstones without surgery“?

Of course you do.



First off, so that I don’t repeat the same mistake as last week, be advised that some of the links mentioned here will lead to some disgusting pictures, particularly things that people have fished out of their own feces, although not as disgusting as last week. (Don’t ask me why they spend so much time examining and picking through their own waste; if I understood it, I probably wouldn’t be writing about it. The fact that believers in this particular therapy are prone to straining through their stool looking for nuggets that prove the therapy “works” is, in fact, why some may consider this topic to be even more disgusting than last week’s. Click at your own peril.) So, warning completed, what sorts of benefits can you expect from liver flushes? To answer that question, let’s go to a woman who is the very embodiment of all that is bad about CAM in that she blames all cancer on a liver fluke (hence her interest in “flushing them out of the liver) and claims to be able to cure virtually any disease, Hulda Clark, for some input, from her book, The Cure for All Diseases (you didn’t believe me when I told you she claims to be able to cure virtually any disease, did you?):

“Cleansing the liver of gallstones dramatically improves digestion, which is the basis of your whole health. You can expect your allergies to disappear, too, more with each cleanse you do! Incredibly, it also eliminates shoulder, upper arm, and upper back pain. You have more energy and increased sense of well being.

Pretty amazing, eh? I can’t figure out why such flushing would eliminate allergies or shoulder, arm, and back pain, but then I’m not Hulda Clark. I suppose her latter example might have been meant that it will get rid of the referred pain of gallbladder and other biliary disease, which is often perceived radiating to the right shoulder and upper back, but I suspect that might be attributing too much medical sophistication to someone who blames a liver fluke for all disease. In any case, let’s continue with her rationale for this particular form of “therapy”:

It is the job of the liver to make bile, 1 to 1.5 quarts in a day! The liver is full of tubes (biliary tubing) that deliver the bile to one large tube (the common bile duct). The gallbladder is attached to the common bile duct and acts as a storage reservoir. Eating fat or protein triggers the gallbladder to squeeze itself empty after about twenty minutes, and the stored bile finishes its trip down the common bile duct to the intestine. For many persons, including children, the biliary tubing is choked with gallstones. Some develop allergies or hives but some have no symptoms. When the gallbladder is scanned or X-rayed nothing is seen. Typically, they are not in the gallbladder. Not only that, most are too small and not calcified, a prerequisite for visibility on an X-ray. There are over half a dozen varieties of gallstones, most of which have cholesterol crystals in them. They can be black, red, white, green or tan colored. The green ones get their color from being coated with bile. Notice in the picture (pg. 545) how many have imbedded unidentified objects. Are they fluke remains? [Note: Your friendly neighborhood surgeon-blogger almost spit up his drink upon reading this question; suffice it to say that, no, they are not fluke remains.] Notice how many are shaped like corks with longitudinal grooves below the tops. We can visualize the blocked bile ducts from such shapes. Other stones are composites- made of many smaller ones- showing that they regrouped in the bile ducts some time after the last cleanse.

Hulda’s apparently never heard of ultrasound, which is very good at visualizing both gallbladder and liver stones. If there were gallstones or liver stones there, ultrasound would almost certainly be able to detecit them in the vast majority of cases. Certainly, ultrasound is also very good at detecting bile duct obstruction as well. Best of all, it’s a noninvasive, relatively inexpensive, and radiation-free test–just the sort of test that any CAM practitioner or patient should love! And, in the uncommon cases where ultrasound fails, CT scans can often see biliary obstruction and stones. Also, I don’t know where Hulda got the idea that gallstones are common in children, but they aren’t. I could quote epidemiology, but a less boring way is to have you just ask yourself: How many children do you know or have you seen who have needed gallbladder surgery? Not very many. How many adults, now? I will give Hulda credit for one thing, though. She’s correct that some cases of gallstones are completely asymptomatic or only mildly symptomatic (usually bloating or other vague GI symptoms). And guess what? These days, we evil allopathic surgeons who are constantly castigated for “medicalizing” and “overtreating” everything generally don’t recommend cholecystectomy just for the presence of stones. If the stones are truly asymptomatic and only incidentally found on a study done for other reasons, we usually leave them alone, except sometimes in cases where a case of cholecystitis would be very dangerous, as in elderly diabetics or patients with other comorbidities. We usually wait for symptoms to occur, and in an impressive percentage of cases they never do. The stones remain asymptomatic, and the patient takes them to the grave. In the case of vague symptoms that might or might not be attributable to gallstones (a not uncommon clinical situation), before taking out his gallblader, we will tell the patient that, although his symptoms are probably due to gallstones, we can’t be absolutely certain that something else isn’t going on and we can’t guarantee that the surgery will relieve all his symptoms.

But I digress somewhat. Let’s get back to Hulda Clark’s claims:

At the very center of each stone is found a clump of bacteria, according to scientists, suggesting a dead bit of parasite might have started the stone forming.

Wrong.

Most gallstones do not contain any such thing. Gallstones and liver stones form when cholesterol and/or bile salts in the bile form tiny crystals, which then enlarge. Most gallstones are cholesteral gallstones, and liver stones are much less common. Not that that stops Hulda:

As the stones grow and become more numerous the back pressure on the liver causes it to make less bile. Imagine the situation if your garden hose had marbles in it. Much less water would flow, which in turn would decrease the ability of the hose to squirt out the marbles. With gallstones, much less cholesterol leaves the body, and cholesterol levels rise.

Not quite. In any case, if true obstruction were present and increasing the “back pressure” on the liver, it would be fairly straightforward to demonstrate by observing dilated biliary ducts in the liver on ultrasound. As is the case with most tubular structures in the body (small bowel, colon, bile ducts, ureters, etc.), when bile ducts are blocked, pressure behind the blockage causes them to dilate proximal to the cause of the obstruction, in the case of chronic obstruction quite impressively. Distal to the obstruction they tend to be normal in caliber or even collapsed (otherwise known as “distal collapse”). That’s how we figure out initially whether the obstruction is somewhere within the liver or if it’s in the bile duct outside of the liver. This part of surgery is not particularly complicated. It’s simple fluid dynamics, and that’s how we can usually tell where an obstruction is. It ain’t rocket science, as they say. So why don’t we see dilated bile ducts in all of these patients complaining about “liver stones? Hulda has an answer, of course:

Gallstones, being porous, can pick up all the bacteria, cysts, viruses and parasites that are passing through the liver. In this way “nests” of infection are formed, forever supplying the body with fresh bacteria. No stomach infection such as ulcers or intestinal bloating can be cured permanently without removing these gallstones from the liver.

The vast majority of stomach and duodenal ulcers are caused by H. pylori. Is Hulda claiming that gallstones form a “nest” in which H. pylori dwell? On what evidence? None, of course. Hulda’s a bit different than most liver flushers, though, in that she emphasizes her all-powerful and all-explaining liver fluke as the cause of cancer and “all disease.” She thus recommends the use of her “zapper” to “kill parasites” before doing a “liver flush” to flush them out. Most practitioners selling liver “cleanses” emphasize their flushy goodness as a means of eliminating “liver toxins” (whatever that means) and “stones”:

The liver is the gateway to the body and in this chemical age its detoxification systems are easily overloaded. Thousands of chemicals are added to food and over 700 have been identified in drinking water. Plants are sprayed with toxic chemicals, animals are injected with potent hormones and antibiotics and a significant amount of our food is genetically engineered, processed, refined, frozen and cooked. All this can lead to destruction of delicate vitamins and minerals, which are needed for the detoxification pathways in the liver. The liver must try to cope with every toxic chemical in our environment, as well as damaged fats that are present in processed and fried foods.

So what, exactly, does a liver flush entail? Most liver flushes involve drinking large quantities of fruit juices of some kind, usually along with epsom salts and oils such as olive oil. For example, here’s one protocol found (where else?) on CureZone that resembles many that I have seen:

Materials: 1 gallon apple juice (freshly pressed) 2 ounces orthophosphoric acid (Phosfood from Standard Process or Ortho phos from Nutra-Dyn) Enema bag and colon tube Coffee Epsom Salts Whipping cream and berries Olive oil Protocol: Add one bottle (2 ounces) of orthophosphoric acid to the gallon of apple juice. Shake and refrigerate. Over the next three to five days, drink the gallon of juice (3 to 4 8-ounce glasses a day) between meals. Be sure to rinse your mouth out with baking soda and/or brush your teeth after drinking the juice to prevent the acid from damaging the teeth. Eat normally during the liver flush. On the day following whatever day you finish the gallon of juice, eat your normal breakfast and lunch. Two hours after lunch, drink 1-2 tablespoons of Epsom Salts dissolved in warm water. Four hours after lunch, do a one pint coffee enema. Five hours after lunch, drink 1 tablespoon of Epsom Salts dissolved in warm water. Six or seven hours after lunch, eat a dinner of heavy whipping cream and frozen or fresh berries – as much as desired. At bedtime, drink 1/2 cup of olive oil. A small amount of orange, grapefruit, or lemon juice may be added if desired. Immediately after drinking the oil, go to bed and lie on your right side with knees drawn up for 30 minutes. You may feel nauseated during the night. This is due to the release of stored toxins from the gallbladder and liver. This is normal and a sign that the protocol is working. Upon arising in the morning, do a coffee enema.

Ah, yes, the coffee enema, arguably the most ridiculous “ CAM ” therapy there is, other than homeopathy. I still haven’t figured out how the coffee enema “flushes” the liver. I also still haven’t figured out why anyone would want to partake of the glorious caffeine-laden coffee bean in any way other than the usual way. Certainly, enemas are a rather difficult way to get a morning caffeine fix!

There are, of course, many variations to the basic “liver flush” protocol. Here are but a few:

The list goes on and on and on and on. (And so will you if you try these cleanses.)

So what will happen if you do this (besides your producing a lot of unusually stinky and liquid poop)? Well, you will find things in your stool. If you read the many testimonials and look at the disgusting pictures on all the websites touting liver flushes, you will see photos proudly displayed of greenish balls or various other things that sort of look like–well, sort of “stone”-like. Naturally, the liver flushers claim that these are gallstones–without actually proving that’s what they are. Indeed, although it is certainly possible to pass gallstones into the stool and occasionally even find one, it’s highly unlikely to pass such huge numbers of stones (as claimed by testimonials) without previous clinical symptoms of gallbladder disease or without easily detectable stones on ultrasound examination. In some cases, the number of “stones” observed in the stool would have required a gallbladder the size of a football to hold them all! And, given that more always seem to “come out” when additional flushes are done, it would seem to imply that there is an endless supply there to be “dumped” out, a concept that defies plausibility, given that gallstones do not form rapidly enough to replace all the ones supposedly “flushed” out. In any case, check out this testimonial to see what I mean:

I just completed my 3rd liver cleanse. Whew! 1st cleanse 250 small stones pea size or less brown and green. 2nd cleanse 460 stones, small stones pea size or less brown and green. 3rd cleanse 260 stones light and dark green. Many marble size and 2 almost as big as golf balls (I saved these!) I highly recommend Andreas Moritz’s book, “The Amazing Liver Cleanse”. I followed to the letter and did colosan and colonics before and after. I read your testimonials and thought I would add my information.

As a surgeon, I feel obligated to point out that I have never seen a common bile duct (the tube that runs from the liver to the duodenum, through which bile passes) the diameter of a golf ball. The claim that anything so large could “pass” thanks to these flushes strains credibility to the breaking point. This testimonial gets a bit closer to what may be the truth behind liver cleansing:

I did a ‘liver cleanse’ or gallbladder flush about 6 nights ago! I’m a 50 year old female in good health. I’m not overweight and have no health problems. I’m active and have been a schoolteacher for 25 years. I did not have any symptoms of gallstones nor did I have an ultrasound. I just had always been curious to try a gallbladder flush and see if anything came out- as they say most everyone has these gallstones and it’s good to get them OUT. I did the flush at about 9:30 p.m. And I vomited about 12:30!!! I thought oh hell what an un-pleasant waste of time. BUT the next morning I DID pass some (25?) gelatinous looking things that were greenish – none larger than a small pea. I felt lousey – bloated and not hungry the next day. But since then I’ve felt great!! I think I vomited because I ate some plain white rice and drank some carrot juice about 5pm. I have been researching various liver/gallbladder cleanses and most say NOT to eat all day and to drink organic apple juice and only that for at least 2 days prior. I took only 4oz of fresh squeezed lemon juice followed by 4 oz of olive oil at about 10 pm. I nearly gagged **YUK** as I was taking it! I will do it again but will follow your directions. I wish I had come across this website BEFORE I did my flush!

Note that this is an asymptomatic woman with absolutely no evidence of gallbladder or liver disease by clinical history, lacking the classic symptoms of right upper quandrant abdominal pain after a fatty meal (more succinctly known as biliary colic)–or any GI symptoms at all! (Although she certainly did produce some symptoms, didn’t she?) Because of curiosity, she made herself miserable for a couple of days with this “liver flush” and then noticed something “coming out.” These “gelatinous things” were almost certainly not gallstones. There are several varieties of gallstones. Of these, cholesterol stones can be rather soft and easily broken, but I don’t think they could be correctly described as “gelatinous.”

In any case, if these “flushes” actually flushed gallstones in to the GI tract, to be removed via the feces, it would be fairly straightforward to test scientifically, as I’ve pointed out time and time again in other venues. All that’s needed is an ultrasound machine and a willing radiologist, and possibly a biliary surgeon to evaluate symptoms and response. (Whether any IRB that is truly dedicated to human subject protection go for the protocol, however, I can’t guarantee.) Certainly, the ultrasound machine is not an onerous requirement, either. Ultrasound machines have become quite ubiquitous, as the price has fallen dramatically (and the quality has increased dramatically) in recent years. Virtually every OB/GYN practice that does prenatal care has at least one in their office, if not one in each exam room. Many general surgeons have them now, too; as do most emergency rooms. Pretty much any self-respecting breast cancer surgeon has at least one. There are even good portable ultrasound machines that fit into briefcases, and you can even find ultrasound machines in very poor parts of China and India, where, unfortunately, they are used to determine the sex of fetuses, so that parents can abort the females they don’t want. All that’s left is to draft a scientifically valid protocol with the proper controls and then to follow through and document symptoms, physical examination, diagnosis, pre-flush stone load in the gallbladder, and post-flush stone load in the gallbladder rigorously with high quality ultrasound examinations. Not surprisingly, it’s still never been done, as far as I can tell. I search in vain for actual physical evidence to support the claims of liver flushers.

What has been done, however, is a lovely little study that suggests just how much self-delusion is involved in liver flushes. Like the case of colon cleanses, when seasoned con men learn how liver flushes actually “work,” they will be likely to tip their hats in appreciation for such simplicity and perfection, a scam, where the remedy induces the “evidence” of its efficacy. But on to the case report to which I refer that a group in New Zealand contributed to the Lancet:

A 40-year-old woman was referred to the outpatient clinic with a 3-month history of recurrent severe right hypochondrial pain after fatty food. [Note: Here “hypochondrial” means “below the ribcage,’ not “hypochondriac.”] Abdominal ultrasound showed multiple 1-2 mm gallstones in the gallbladder. She had recently followed a “liver cleansing” regime on the advice of a herbalist. This regime consisted of free intake of apple and vegetable juice until 1800 h, but no food, followed by the consumption of 600 mL of olive oil and 300 mL of lemon juice over several hours. This activity resulted in the painless passage of multiple semisolid green “stones” per rectum in the early hours of the next morning. She collected them, stored them in the freezer, and presented them in the clinic. Microscopic examination of our patient’s stones revealed that they lacked any crystalline structure, melted to an oily green liquid after 10 min at 40°C, and contained no cholesterol, bilirubin, or calcium by established wet chemical methods. Traditional faecal fat extraction techniques indicated that the stones contained fatty acids that required acid hydrolysis to give free fatty acids before extraction into ether. These fatty acids accounted for 75% of the original material. Experimentation revealed that mixing equal volumes of oleic acid (the major component of olive oil) and lemon juice produced several semi solid white balls after the addition of a small volume of a potassium hydroxide solution. On air drying at room temperature, these balls became quite solid and hard. We conclude, therefore, that these green “stones” resulted from the action of gastric lipases on the simple and mixed triacylglycerols that make up olive oil, yielding long chain carboxylic acids (mainly oleic acid). This process was followed by saponification into large insoluble micelles of potassium carboxylates (lemon juice contains a high concentration of potassium) or “soap stones”.

In other words, the “stones” that liver cleansers are so proud of and go to such effort to strain their poo for after doing their flushes are not gallstones and were almost certainly the product of the actual flush itself! (Cue the con men tipping their hats in appreciation.) It makes perfect sense, if you think about it. These protocols usually involve fasting and then consuming up to a half liter or more of olive oil at one time. That could easily provide the conditions for this sort of reaction to take place. Neat, isn’t it? The very sign of “success” of the liver flush is something that has nothing to do with gallstones and everything to do with the results of the flush itself. Indeed, it’s quite clear that, even if you don’t have gallstones, if you do a liver flush and then look closely enough, you’ll find things in your stool that very much look like gallstones that are really due to saponified oil. Now I know (and you do too) why virtually every liver flush protocol includes large amounts of olive oil or similar oils plus epsom salts or orthophophoric acid and fruit juices. Unfortunately, I have not seen any more recent studies, and I’m not sure if any are really needed after the investigators discussed above conclusively showed that they could mimic these “stones” chemically.

In any case, it’s a beautiful scam. People do these flushes, they see things that look to them like gallstones being “flushed” out, and they believe it works. Consequently, they keep doing it. Because these flushes involve materials that don’t have to be purchased from a “healer” (although certainly many “healers” sell various “supplements” to “aid” liver flushes), they can be viewed more as a means of healers to demonstrate their skill and keep the patient coming. (And going, too!) It also serves as a way of “demonstrating” the efficacy of “detoxification.” After all, if this “flush” appears to cause “gallstones” to be eliminatd as promised, then perhaps the other detoxification modalities beloved of alt-med believers are also “flushing out toxins” as claimed and might be worth a try. (Never mind what the “toxins” are.) In this light, liver cleanses might indeed be viewed a “gateway” CAM therapy that leads users to the even more scientifically implausible ones, like homeopathy (which at least has the advantage over liver flushes of not making one spend long periods of time on the porcelain throne). To me the ironic thing about liver flushes is that they are so strongly advocated by CAM believers, who frequently castigate “conventional” medicine for “iatrogenic diseases or complications” (iatrogenic=caused by doctors). What, then, can we call these “stones” coming out of people using liver flushes, given that they are caused by the very CAM therapy that claims to be getting rid of them?

I’m open to suggestions.