Better late than never: Ask EneMan!

I was away at a training conference in Chicago over the weekend and then flew back Saturday night--only to be on call yesterday! The good news is that I got to see my sisters and visit one of my favorite restaurants in Chicago. The bad news is that, unfortunately, there was no time for blogging. (Yeah, yeah, I know. I could have planned ahead so that his appearance was ready to post on the first of the month; that, however, would have required too much foresight.) Now, fortunately (or perhaps unfortunately, depending upon your point of view), I had an idea that is a natural extension of our Flushing Hero's last appearance. Introducing, for the first time, an occasional feature (which just means that I don't plan on necessarily doing it every month--unless, of course, I feel like it):

Ask EneMan!

Dear EneMan:

I've been having some crampy right upper quadrant abdominal pain over the last few months. It's not consistent, but seems to be most often provoked by eating, especially when I hit McDonald's for a nice, tasty Big Mac and fries. Sometimes it's pretty bad; sometimes it's just discomfort. A friend of mine told me it sounds like gallstones and recommended that I start doing "liver flushes." He was really enthusiastic about them, but I have my doubts. These "flushes" seem to involve drinking a lot of juices, olive oil, Epsom salts, and grapefruit in a strategy to make me poop a lot and flush out the stones from the liver and gallbladder, along with toxins. Supposedly, the stones will come right out in my poop and I won't need surgery!

I figured, given your purpose in life, you'd know whether there was anything to this treatment. So tell me, EneMan, does it do any good? Does it work to get rid of gallstones? Help! I'm really afraid of needing surgery!

Stoned and Crampy

Dear Stoned and Crampy:

My goodness. Sorry to hear about your pain. It really sucks to have cramps like that. Fortunately, I'm a bit of an expert in things that cleanse the colon.

First, you really need to see a real doctor. Does your friend have "M.D." after his name? Is he a general surgeon or a gastroenterologist? Or is he just some guy who thinks he knows what he's talking about? No doubt he gave you a lot of testimonials as "evidence" his favored remedy works, rather than actual scientific studies or well-designed clinical trials. You may indeed have gallstones, but there are lots of things that can cause upper abdominal pain. You shouldn't just assume that it's gallstones, even if the symptomatology seems to point to gallstones as the most likely culprit. Go see your doctor forthwith! You might need surgery for symptomatic cholelithiasis, but these days its usually done through a laparoscope and is much less painful than in years past. Or you may not even need surgery. However, you're not going to find out either by writing to a walking, talking, giant Fleets enema or by listening to some friend of yours with no medical training. You need to see a real doctor, get a real history and physical done, some lab work, and an ultrasound of your abdomen.

One thing I can tell you, though, is that these "liver flushes" or "cleanses" are, if you'll excuse the term, a load of bullshit (or, in your case Stoned and Crampy shit). The idea seems to be that, by provoking a lot of colon activity, you can somehow "flush out" the supposed "toxins" or "stones" in the liver and gallbladder. And, indeed, these "liver flushing" regimens will provoke a lot of colon activity, as they often use large quantities of olive oil, flaxseed oil, frequently mixed with epsom salts and various fruit juices. (Heck, they probably provoke more colon activity than I myself can.) Sometimes the protocols will even tell you to take coffee enemas, much like the ones Orac warned about months ago.

As "evidence," liver flush proponents seem strangely proud to display rather disgusting pictures of things that they picked out of their poop. Don't ask me why these people are so obsessed with their own waste! Their fascination with feces puts even me to shame, and I have an attachment on my head designed to--well, best not to speak of it. They will claim that these things are "liver stones" or "gallstones" (or even "parasites").

What you will never find is an actual well-designed clinical trial that shows that any of this actually works to remove gallstones. Here's what my bud Orac once recommended as an easy and relatively inexpensive pilot trial that could be done to test the claims of these "liver cleansers" empirically:
All you would need to do such a pilot study is a interested and/or sympathetic radiologist to team up with a "healer" who has an ultrasound machine--and, of course, the will to document symptoms, physical examination, diagnosis, pre-flush stone load in the gallbladder, and post-flush stone load in the gallbladder rigorously.
Neat, clean (well, given the nature of a "liver flush," not really so clean, but you get what I mean), and not that difficult to do. To make it even more rigorous, you could even limit it to only people with ultrasound-documented symptomatic gallstones; randomize them into two groups, one group getting the flushes, one group not; and see whether you find more such "stones" in the stools of the treated group compared to the controls. You could then of course analyze these "stones" to see if they are real gallstones. It should come as no surprise to any skeptic, though, that you will never find such a trial supporting the contention that these flushes remove liver or gallstones, at least not in the peer-reviewed medical literature. If such a trial existed and supported the effectiveness of flushes at removing gallstones and liver stones, you just know the alties would be trumpeting it! They don't. Instead they trumpet testimonials and disgusting pictures. And they make all sorts of claims for these "flushes," as well, such as the ability to make allergies disappear and purge "toxins," even mercury. (I wonder if there will be a turf war between the liver flushers and the chelationists.)

One complaint was that "healers" don't have access to CT scans. Orac answered thusly:
"Healers" don't need a CT machine. They just need an ultrasound machine, which is less expensive by a factor of at least 25-50. 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. Many general surgeons have them now, too; as do most big emergency rooms. They now make portable ultrasound machines that fit into briefcases....Heck, you can 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 females they don't want. So don't tell me alt-med "healers" can't get access to basic ultrasound machines. I don't buy it for one minute, particularly since I've seen ads from such "healers" claiming to use ultrasound as part of their approach.
Quite true. Some of those alties are raking in the bucks from the rubes, but they always plead poverty when it comes to spending a little of that green to do a real clinical trial.

But, you ask, what are those truly disgusting "stones" that colon flush advocates strain out of their own poop and display proudly as "evidence" that these "liver flushes" work? A group in New Zealand recently contributed to the Lancet a case report that gives an idea of what they probably are:
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. [EneMan's 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”.
So it would appear that it is in reality the flush that probably produces the "stones" these alties are fishing out! It makes perfect sense, if you think about it. These protocols usually involve fasting and then drinking a as much as 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.

What's the harm, you ask, if some alties regularly purge themselves and think that it somehow improves their liver health? You should know from things I've said before why! I abhor anything that can screw up your colon, as you should know, and purging like this can most certainly do that! Even colon cleanse advocates acknowledge it implicitly, even as they tout its supposed health benefits. Look at some of these warnings from altie liver flush protocols themselves. Remember, this isn't me, Orac, or some other skeptic; this is the colon flush advocates themselves:
Warning: if you take everything at once, you will almost surely barf and be very mad at me for telling you about this protocol.
Or this:
Webmaster WARNING:

This recipe is included here for information purposes only!

This recipe is rather extreme, because the amount of oil is EXTREME (2 cups), and the amount of juice to be taken in a short period of time is also extreme! If you are new to liver cleansing, I urge you to first try Hulda Clark's recipe, which is very potent, but all you need is 1/2 cup of olive oil. If you are liver cleansing veteran, and you like to explore your limits, then this cleansing recipe may just be the right for you to try! You may get very sick after consuming 2 cups of olive oil. 1/2 cup or up to a 1 cup of oil happened to be more then enough for most people! You have been warned!
And, finally, look at this variation:
The most dangerous part of a traditional liver flush is a deep abdominal massage used to push the blood and lymph through the system. Only an expert can perform this procedure. With more than the usual amount of pressure and force, the therapist reaches two or three inches under the rib cage, and massages the liver, gently pushing the blood and lymph toward the intestines. This technique cannot be applied to the obese, and can be especially painful to those with a muscular physique. Even for people with loose skin, the technique is inevitably painful and leaves colorful bruises.
Why on earth would anyone want to "explore their limits" with respect to liver cleansing or to subject themselves to such a procedure, I have no idea. What I do to a person's colon is really very mild in comparison to this. I tell you, these people are so oddly convinced that their body is so full of toxins that must be purged, that I think they must be taking a cue from General Jack D. Ripper and his fanatical desire to protect his "purity of essence." To them, the external environment and the human body must seem vile things, full of nastiness, toxins, and all manner of unnameable evils that must be expunged. It sounds more religious than scientific to me!

But I've dwelt on this rather disgusting topic long enough. It's October and Halloween is coming up. Time for me to strut my stuff. Sorry I'm late, but Orac seemed to think that learning about partial breast irradiation, visiting his sisters in Chicago while he happened to be there, and taking care of patients on call yesterday were all more important things to do than helping me get my monthly appearance ready to post on time! Geez.

EneMan 2002-10
October 2002

EneMan 2004-10
October 2004

EneMan 2005-10
October 2005

And, as always, here is a list of every appearance of EneMan since the very beginning:


  1. "Why are you waiting for the Great Pumpkin, Eneman?"....

    Thanks, as always.


    I think Ene Man should make contact with a close neighbour!



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