I finished the previous post with the sad story of my patient, illustrating diagnostic difficulties at the fringes of biliary disease. And I began the series by stating that the vast majority of gallbladder problems are straightforward, with surgery leaving patients happy and symptom-free. In the time it's taken me to write these things, I haven't changed my mind: surgery on the gallbladder is typically gratifying all the way around. But a few patients defy understanding and can end up miserable.
Doctors have a few diagnostic categories that, in my opinion, are over-called, and under-stood. Fibromyalgia. Chronic fatigue syndrome. And, in the current context, biliary dyskinesia and sphincter of Oddi dysfunction. I'm not a primary care doc, so I include the first two on the list in this sense: I know it's nice to have a fancy name to toss out when you have no idea what's going on. Having a disease or two up your sleeve the diagnosis of which is fuzzy, the description of which is plastic, the treatment of which isn't fully worked-out, isn't always a bad thing. Gets you off the hook for a certain grace period. (In the case of "biliary dyskinesia," for example, there seems to be confusion even over the meaning of the term: to some ((me, included)) it means a problem with how the gallbladder works. To others, it encompasses the whole pantheon of pre- and post-op bile-related difficulties.)
These diseases all fit that category, to some extent. I'm pretty sure there are plenty of people out there who have them; yet I have no doubt each handle is too frequently grasped. But here we'll stick to the gallbladder (the colon often does, after all, and we know of what it's full.) The treatment for these conditions is surgical, so the stakes are high.
"Biliary dyskinesia" is the term for uncoordinated muscular contraction of the gallbladder (it also sort of slops over, as I said, into the concept of sphincter of Oddi dysfunction ((SOD)), but let's keep them separate for the purposes of this series); it's sort of like irritable bowel syndrome (should have included that on the above list. Too late now.) For the gallbladder properly to empty when it squeezes, the muscles at its opening need to relax while those in the body of the bag contract. If not, it's like having a stone in the way: the muscles squeeze against a blockage (in this case, an un-relaxed muscle) and cause pain.
If a person has pain very suggestive of gallbladder origin but has no stones, biliary dyskinesia is properly suspected. To what extent there's a reliable test for it is a matter of opinion. It always has been, and remains, first and foremost a "diagnosis of exclusion," meaning once you step into that arena, you need to go through the long list of other possibilities and rule them out. Then you do a HIDA scan with CCK (Hepatic IminoDiacetic Acid; CholeCystoKinin); ie, injecting a material that's taken up in bile, illuminating the gallbladder, then giving a hormone that makes the gallbladder contract.)
To be on solid ground, two things must happen: first, the gallbladder should not empty properly (less than 30% of its content) and, second, the injection of the contracting juice should reproduce the pain pattern in question. But it's not crystal clear: how much less than 30%? How exact is the pain reproduction (CCK causes cramps and nausea in lots of people.) It's always made me a bit nervous to operate on people with the diagnosis, but the fact is that when the emptying (ejection fraction) is very low (say 10%) and when the pain syndrome is clearly evoked, cure of symptoms is very high (90%, thereabouts.) Would that it were 100% -- but in life, what is? (Funny story: prior to my discovery of blogging, I used to spend some time answering questions on a couple of online medical fora -- in fact, it's where I first "met" Kevin, MD, who was official on one to which I just interloped. In googling aspects of biliary dyskinesia for helpful links, I came upon -- quite high on the list -- several of my answers on the subject. So I might have referenced myself to support my post. Should have gone into politics...)
Sphincter of Oddi dysfunction is iffier, in my experience/opinion. That's what my patient in the previous post was presumed to have. The concept is that the valve at the southern end of the bile duct doesn't open properly, allowing bile pressure to build up in the system, causing biliary-type pain, maybe some nausea, cramps. It makes sense. But the problem is the test: pass a scope down the throat into the gut (which usually requires sedation which can affect the muscles of gut function), then pass a pressure-measuring tube into the bile duct, across the very structure whose function you're trying to measure. "Uncertainty principle" anyone?
Some people get better when SOD is diagnosed and treated. My patient didn't. She's not alone. The sad truth is that absent proven gallstones, or clear signs of inflammation of the gallbladder, our ability to be certain what's going on is imperfect at best.
In the olden days, you heard a lot (if you were a surgeon) about "cystic duct syndrome." It referred to people who continued to have their pre-op symptoms after gallbladder removal, and in whom the tube (cystic duct) between the gallbladder and the main bile duct (common duct) was left intact. We were taught to remove that whole duct along with the gallbladder, right down to the common duct. I never stopped doing it that way. With the advent of laparoscopic gallbladder removal, however, and the attendant increase in surgical injury to the common duct, lots of surgeons decided it's ok to leave the cystic duct long -- which reduces risk of other ductal damage. What you don't hear about is an increase in the syndrome (ever have a professor pronounce it "SIN droh me"? I have. Like "SAHN tih meeter for centimeter.")
I admit to having operated on a couple of patients whose evaluation showed a long cystic duct after operation by another surgeon and who persisted with pain. One got better. Objectively, I'd say there's no real science behind it; just a few papers with small numbers of patients and somewhat mixed results.
It's clear that some people have gallbladder trouble without having stones ("acalculous cholecystitis", which means inflammation without stones): it's not at all rare to see a patient with an inflamed, tender -- even infected -- gallbladder that's completely free of stones. That's not a diagnostic or therapeutic problem: at some point in the course of the illness -- acutely if not improving, or after resolution -- the gallbladder gets removed. It's not so clear what the mechanism of the problem is: presumably in at least some cases it follows from a "dyskinetic" episode.
There's another category of therapeutic vagary: the person who has symptoms and stones but who doesn't get better with surgery. The group has its own name: "post-cholecystectomy syndrome." Included are a wide variety of unfortunate folks: those whose preoperative symptoms evidently weren't in fact due to their stones (stones are often asymptomatic. Not every belly-ache in a person with gallstones is due to the rocks); those who develop side-effects from losing their gallbladder (most don't. Those that do generally get cramps or diarrhea, especially after eating fatty foods); those who have that mysterious SOD. All I can say is I hate it when it happens; I know from experience that a significant number of those people will never get complete satisfaction.
The good news: when I've been absolutely certain that symptoms are due to stones, I've had only a very tiny number fail to improve with surgery. I've had a few with diarrhea problems, almost all easily controlled with diet. And I've had some failures of therapy -- like the patient in the last post -- who fell through the cracks of understanding. If you read those medical fora to which I referred above, you'd think everyone who ever had his/her gallbladder out is miserable. The happy ones, obviously, don't complain. And -- take my word if you can -- they outnumber the problems by a huge margin.
Next I'll write about operative considerations, just for the heck of it. Taking out a gallbladder can be a lark, a walk in the park, pure fun. Or it can be the hardest thing you've ever done, scary as hell, suborning self-soilage...
Sphincter of Oddi dysfunction is iffier, in my experience/opinion. That's what my patient in the previous post was presumed to have. The concept is that the valve at the southern end of the bile duct doesn't open properly, allowing bile pressure to build up in the system, causing biliary-type pain, maybe some nausea, cramps. It makes sense. But the problem is the test: pass a scope down the throat into the gut (which usually requires sedation which can affect the muscles of gut function), then pass a pressure-measuring tube into the bile duct, across the very structure whose function you're trying to measure. "Uncertainty principle" anyone?
Some people get better when SOD is diagnosed and treated. My patient didn't. She's not alone. The sad truth is that absent proven gallstones, or clear signs of inflammation of the gallbladder, our ability to be certain what's going on is imperfect at best.
In the olden days, you heard a lot (if you were a surgeon) about "cystic duct syndrome." It referred to people who continued to have their pre-op symptoms after gallbladder removal, and in whom the tube (cystic duct) between the gallbladder and the main bile duct (common duct) was left intact. We were taught to remove that whole duct along with the gallbladder, right down to the common duct. I never stopped doing it that way. With the advent of laparoscopic gallbladder removal, however, and the attendant increase in surgical injury to the common duct, lots of surgeons decided it's ok to leave the cystic duct long -- which reduces risk of other ductal damage. What you don't hear about is an increase in the syndrome (ever have a professor pronounce it "SIN droh me"? I have. Like "SAHN tih meeter for centimeter.")
I admit to having operated on a couple of patients whose evaluation showed a long cystic duct after operation by another surgeon and who persisted with pain. One got better. Objectively, I'd say there's no real science behind it; just a few papers with small numbers of patients and somewhat mixed results.
It's clear that some people have gallbladder trouble without having stones ("acalculous cholecystitis", which means inflammation without stones): it's not at all rare to see a patient with an inflamed, tender -- even infected -- gallbladder that's completely free of stones. That's not a diagnostic or therapeutic problem: at some point in the course of the illness -- acutely if not improving, or after resolution -- the gallbladder gets removed. It's not so clear what the mechanism of the problem is: presumably in at least some cases it follows from a "dyskinetic" episode.
There's another category of therapeutic vagary: the person who has symptoms and stones but who doesn't get better with surgery. The group has its own name: "post-cholecystectomy syndrome." Included are a wide variety of unfortunate folks: those whose preoperative symptoms evidently weren't in fact due to their stones (stones are often asymptomatic. Not every belly-ache in a person with gallstones is due to the rocks); those who develop side-effects from losing their gallbladder (most don't. Those that do generally get cramps or diarrhea, especially after eating fatty foods); those who have that mysterious SOD. All I can say is I hate it when it happens; I know from experience that a significant number of those people will never get complete satisfaction.
The good news: when I've been absolutely certain that symptoms are due to stones, I've had only a very tiny number fail to improve with surgery. I've had a few with diarrhea problems, almost all easily controlled with diet. And I've had some failures of therapy -- like the patient in the last post -- who fell through the cracks of understanding. If you read those medical fora to which I referred above, you'd think everyone who ever had his/her gallbladder out is miserable. The happy ones, obviously, don't complain. And -- take my word if you can -- they outnumber the problems by a huge margin.
Next I'll write about operative considerations, just for the heck of it. Taking out a gallbladder can be a lark, a walk in the park, pure fun. Or it can be the hardest thing you've ever done, scary as hell, suborning self-soilage...
315 comments:
«Oldest ‹Older 201 – 315 of 315Awwwwwww shucks.
Hi Dr. Schwab,
Happy Thanksgiving! I need an independent professional opinion, please! I had a complete abd.USG 6 months ago which showed a small polyp and a slightly dilated pancreatic duct, but no gallstones. The only symptom I was having at the time was occasional intense pressure over my left chest area which lasted only about a couple of mins(2+yrs ago I had a random excruciating pain over my GB area at two different times which lasted about 30 min.,didn't see the doctor and hasn't returned)
I also had a Calcium CT scan after the first USG. to check arteries for the left chest pain. That was normal. Pressure rarely happens now. On my first USG 6 mo. ago the radiologist didn't note the size of the polyp. My internist, GI doc, and surgeon all agreed that I should get re-scanned in 6 months to see if the polyp has grown or crushed by the gallbladder. All three doctors recommended I should have my GB taken out if the polyp grows to 1 cm. The GI doc had me get a specialized CT scan to rule out the slightly dilated pancreatic duct. The results of that test was normal.
I had the second complete abd USG done yesterday, and it showed the polyp was 3 mm and the pancreatic duct was still slightly dilated, but now I have GALLSTONES!!! :( I'm scheduled to see my surgeon soon about my gallstones and to possibly have my GB removed. I have had some pain over my GB a few days ago, but it started after seeing my internist last week. He pressed on my GB area and rt.side very hard which I wonder if that stirred things up a bit, but the pain has since gone after a few days of slightly hurting. It was a dull, throbbing, and intermittent pain.
BTW, I chose not to have a Hydascan that my internist suggested 3 months ago, if I wanted to do it. I chose not to do it because my GB area wasn't hurting. Also, my GI's nurse practitioner told me I shouldn't have my GB removed solely based on the Hydascan. She said you can live with a non-functioning GB. But, if I'm having pain or other problems then I should consider having it removed.
Sorry so much back story to get to my question, but can gallstones not show on one scan then grow that fast in 6 months, or do you think the first USG wasn't done properly? The first scan was done at a different facility than the second one. The gallstone amount or size wasn't told to me by the phone nurse when when she called me yesterday. The radiologist had called my internist after my scan and had given a verbal report.
I really don't want to have my GB taken out now just because I have gallstones. I'm not having any serious pain or problems as far as I know, and the polyp is only 3mm. I don't feel like either one warrants surgery. Need some advice before seeing my surgeon please!
Well, the turkey is on the grill, so what else is there to do at the moment? Yours is not an uncommon situation: gallbladder pathology of some sort without classic and convincing symptoms. I really can't give specific advice in specific situations without being directly involved. So I tend to make general comments
Gallbladder polyps are a grey zone thing and when they are really small (3mm, for example) it's very unlikely they're causing symptoms. The recommendation for surgery when they're as big as a cm is pretty typical; one begins to worry about gb cancer, which is pretty rare and which is far less than a one to one correlation with large polyps.
People who have stones didn't always have them, so they develop at some point. It's not necessarily an indication of erroneous previous studies that they'd show up 6 mos after a study that didn't show them. They don't always show when they are very small.
If you read through the many comments here, you'd probably see me saying the same thing: there are few circumstances where I tried to talk someone into surgery when they didn't want it; especially when it wasn't crystal clear that they were symptomatic. When there are stones, there's the possibility of problems. Most people don't go from no symptoms to really serious issues (jaundice, infection in the bloodstream, pancreatitis) without developing some symptoms first. And when such serious things happen, it's rare that they can't be dealt with.
In my view the primary reason to have the operation is to relieve symptoms that the person has had enough of. A secondary reason is to prevent more serious complications. In deciding not to have surgery, the owner of the stones is, I think, saying that the symptoms aren't enough that they want surgery, and that their concern about developing complications isn't all that great.
The people I was more concerned about were diabetics (because if they get infection it can be more serious) or people who'd had pancreatitis or other evidence of stones in the bile duct, or people who'd had severe inflammation that subsided without the need for urgent surgery.
Thanks for responding so quickly and alleviating some of the urgency to have surgery! Grilled turkey? Sounds good, hope it turned out well!
Peace and blessings.
Dr. Schwab...thanks for your blog. BEST information I've read.
I am one of those who is in the high stress position of trying to make a decision from a borderline case. A quick background...I am male, 55, overweight. I did a good low calorie diet last year and lost 50 pounds, but then I started to suffer from stomach bloat or distention (max pain 4/10). I had a CT scan, sonogram, blood tests and finally a HIDA test. My result is that I do not have any stones but my function test result was only 5%. The pain felt in the test did not replicate bloat, but was a semi-sharp pain 4" above my belly button (pain 6/10). This pain passed in just a few minutes.
My bloat feelings have been reduced by a low fat/low calorie diet, but is not completely gone. Anxiety and stress will quickly and give me a heartburn feel on the left gut...(all my pain has been on the left side). I talked to my surgeon who basically left the decision to me, but I am left with several unanswered questions.
1. How often are there bad side effects to removing the gall bladder? (Surgeon said 1%, internet says 20% of the time)
2. Are there long term risks to NOT having my gall bladder removed and just managing symptoms with diet?
3. Is there a risk to the liver if the duct gets damaged in surgery? (i.e., need a transplant?)
4. Does the pain from my function test not mimicking the bloat meet your criteria?
5. My daily pain is managed to 2/10 on a pretty restricted diet, is the surgery risk worth the reward?
6. Is there any risk from the titanium clamps used to clamp off the cystic duct, damaging other organs or the bile duct?
7. Even if I delay, will I eventually need the surgery anyway?
Thanks for any thoughts.
1. How often are there bad side effects to removing the gall bladder? (Surgeon said 1%, internet says 20% of the time)
I'm going with a surgeon over "the internet." Cholecystectomy is one of the most common operations; on the internet you hear from people who have problems. The ones that don't (which I'd say is much closer to 99% than 80%) have no reason to go to the internet to say so.
2. Are there long term risks to NOT having my gall bladder removed and just managing symptoms with diet?
Assuming there are indeed no stones, the answer is mostly "No." I say that as a general response, since I can't really say if your gallbladder is a problem or not. The main risk for problems from the gallbladder is having stones plug either the gallbladder or the bile duct, or cause pancreatitis. Absent stones, there's not much that can happen; although there are instances of gallbladder inflammation without stones. In that case, however, it's typically easy to see on ultrasound.
3. Is there a risk to the liver if the duct gets damaged in surgery? (i.e., need a transplant?)
Damage to the bile duct can damage the liver. I suppose it might have happened that the damage required transplant, but it'd be so rare as to be nearly zero.
4. Does the pain from my function test not mimicking the bloat meet your criteria?
"My" criteria don't seem to be met by your description. However "my" criteria aren't carved in stone; and I don't have a way of addressing your specific situation from this far away.
5. My daily pain is managed to 2/10 on a pretty restricted diet, is the surgery risk worth the reward?
Risk/reward for any operation is hard to put a number on. In your case I suppose the calculation would include the chances that your symptoms are due to your gallbladder (I can't say, and probably no one can, accurately), the degree to which you find your symptoms bad enough to undergo surgery knowing it might not help, and the chance of significant side effects or injury. None of those things are really predictable. When someone has symptoms that are clearly consistent with gallbladder origin, and has stones, and especially if there've been more severe issues than pain alone, such as infection, jaundice, etc, the math is pretty easy.
6. Is there any risk from the titanium clamps used to clamp off the cystic duct, damaging other organs or the bile duct?
Clips, per se, don't cause problems. (You'll find lots of claims to the contrary on the internet.) If they're placed inaccurately they can cause damage.
7. Even if I delay, will I eventually need the surgery anyway?
I can't say because 1) I don't know if there's anything wrong with your gallbladder and 2) they say surgeons have brass balls, but we don't have crystal ones.
Thanks, doc...I'm still on the fence, but your answers were definitely helpful and much appreciated. BTW - I forgot to mention the Colonoscopy my doctor gave me for Christmas...and I didn't get him anything. Everything was fine. As a test, I am going to try and use anti-gas pills to see if that helps my bloat after eating, since that is my main symptom.
I have two questions: 1) I had my gb removed May 2010. Since then, I have been diagnosed with SOD and had an ERCP with sphincterotomy and balloon sweep (found "debris") in February 2014. Prior to that and once about a month later, my liver enzymes used to spike up to 1,400-1,500. Since then, I still have "attacks" of pain, but my liver enzymes do not rise. My doctor sent me for a HIDA scan which reproduced my symptoms. It also came back showing SO dyskinesia, but my doctor still says he's not sure it's my SOD. He said that > or = 6 is considered abnormal, and my score was 6. My question is, if the injection of CCK caused the same exact pain and nausea that I get with attacks, and my HIDA scan came back abnormal, isn't it likely it's still the SOD?
2: As I said, my liver enzymes on several occasions would spike up to 1,400-1,500. I also have a history of NASH stage 1. Should I be concerned about further damage to my liver, with my enzymes having been so high on at least 3 or 4 occasions? I'm wondering if I should talk to my GI doctor about a repeat liver biopsy?
KimD: SOD, in my opinion, is a pretty vague diagnosis, and one for which there's not, far as I know, a highly reliable definitive test.
In my experience the value of HIDA scans with CCK injection is in unclear situations with patient who still have their gallbladder. CCK makes the gallbladder contract; I'm unaware of it making the bile ducts contract, so I'd have to think that the fact that CCK reproduced your pain in the absence of a gallbladder suggests the pain originates elsewhere than the biliary system. CCK also causes intestinal tract contractions.
Your thoughts about contacting your gastroenterologist sound right. I wouldn't take my word for it at all, since I'm so far away. And the fact that I'm unaware that CCK would cause diagnostic contractions of your bile ducts doesn't mean it doesn't. Just that I'm not aware. I'm retired, and don't read as much as I used to.
Hi, Dr. Schwab.
A couple weeks ago, I had horrible all-over abdominal pain that lasted for about 2 hours. Could not get comfortable, no matter what I dd. Eventually the pain subsided, and I was able to fall asleep. Next day, I was working out and trainer noticed I was pale, cold and clammy and made me stop based on previous night's problems. She wanted me to go to ER, so I did. Arrived, tachy....EKG fine; all blood work and ab x-rays and chest x-rays was unremarkable. Next day, had appt with Gastro (had already been scheduled because have had swallowing difficulty). Told Gastro doc about Sunday night's events, which puzzled him. Showed him where on my back I get radiating pain from side. Set me up for colonoscopy and EGD, which I had two days later. Said after that was done and results were in, would try to determine what was causing back pain. Determined I have celiac disease, but everything else on tests were okay. Sent me for abdominal ultrasound...unremarkable. Two days later, with real bad back pain, called his service and doctor on call said it sounded like gallbladder problems and he would suggest to my doc that he order a HIDA scan. So had that last Monday. EF was 14%. Appt with surgeon is for next Friday. Would celiac disease cause any kind of problems with gallbladder? Would being gluten free for a while help with that side/back pain? I am aware of soreness most of the time, but can't say that I have horrible pain all the time. Will the surgeon recommend surgery if he doesn't really think it is necessary and just take a wait-and-see approach, you think? I don't want to have a surgery that is not truly necessary. Just very nervous about the whole thing because all I keep reading is about all the problems people have afterwards....diarrhea, continued pain, can't eat certain foods, etc. etc. I know, as you have said, that only people with the problems come online and post things like that. If you are not having a problem, you're not going online to say as much because you've put it behind you! Guess I am just rambling. Need reassurance. Don't want to make a mistake!! Also, have CT scan scheduled for Monday. So I'll have that done before appt with surgeon too.....Thanks much! Pam
Oh, also....when I had the HIDA scan and they injected the CCK, I had only very mild pain for a couple minutes. No nausea, cramping, any real pain....just slight discomfort. Have been on Prilosec since Feb 10...would that make test unreliable? Thanks. Pam
Pam, it sounds as if you've read my stuff here pretty carefully, and that you're aware of the difficulties of diagnosing "biliary dyskinesia," and of interpreting HIDA scans. Seems that you're right in the middle of that gray zone.
Or not. As I've written, the situation in which I've had some confidence in the diagnosis is when 1) the patient has symptoms that are typical of biliary pain, AND 2) there are no gallstones AND 3) the HIDA shows significant delayed emptying AND 4) injecting CCK reproduces symptoms exactly.
Far as I can tell, you're one out of four. I can't make diagnoses or specific recommendations from this side of your computer screen. All I can say is that what you have described doesn't fall within the parameters by which I'd recommend surgery to a patient. Obviously, however, it's indispensable to be there in person to understand the situation.
As to a surgeon recommending surgery she or he doesn't think necessary? I'm guessing you know how I"d answer that!!
Good luck. And you might have to be patient before it's all worked out.
Dr. Schwab,
I have not yet met with the surgeon. I don't know how he will feel about doing a surgery based on my symptoms and test results. When I went into see my gastro doc for followup visit regarding celiac disease, I had had my HIDAscan and he was the one who brought up surgery for gallbladder removal and his office set up appt with the surgeon. I don't think I am committing to surgery by meeting with him and going over all tests I have had done and their results and letting him evaulate the situation (at least I hope not!) If I continue to have episodes in the middle of the night like I did a couple weeks ago, I may change my tune. I am putting my faith in the surgeon and if he feels I should take a wait and see attitude and maybe another HIDAscan in a month or two, then I would gladly accept that. He comes highly recommended so I don't think he would do an surgery he felt was not necessary. Hopefully he won't feel I have wasted his time if I leave his office without a surgery scheduled. Thank you. Pam
Dr Schwab, my girlfriend situation is a nightmare and I am hoping you might have some suggestions that my help me. 10 years ago I came down with chronic pancreatitus. They did an ercp and found that both the common bile duct and the pancreatic duct were dilated. Plus I had stones in the gall bladder and gunk in the pancrease. For several years we did ercp,so every 3 months, with placement of stints in the pancreas. After doing this every 3 months for about 3 years I was sent to surgery. The first surgery was to remove my gall bladder, which did nothing.Four months later I had 95% ofor the pancreas removed and with islet cell transplant. My cells were transplanted into the portal vein. Still had pain so they removed the rest of the pancreas. Since then, I have had two more surgeries for blockages.I still have severe chronic pain and am now insulin dependent.I am now preparing to get on the pancreas transplant list, because I am a brittle diabetic and I can'take tell when my sugars are droppong, one minute they will be 200 five minutes later I am about to pass out because my sugars are now 27.Also, I have delayed emptying and problems at the as as to moss site, so things are getting pushed backwards, into the common bile duct. I can't eat anything but white bread because I get sick, I have episodes of fatty stool, and I still have severe,unremitting pain,anywhere from a 7 and up. After every surgery I will get better for a few months and then everything comes back again. I am searching everything that I can think of that might be a factor.For example, several years before the onset of the pancreatitus, I had a compression fracture, that burst, of L2. This required five surgeries,the last one was an anterior fusion, between L1-L2,L2-L3, with the discs removed and bone frome my hip put in. So there is a ton of scar tissue.My concern is that none of the surgeries have removed the pain, not permanently anyway.The new pancreas will hopefully help with the diabetes and the digestive issues, but I am concerned that I will be left with the pain. Have you heard of phantom pain after organ removal? I know this is a lot to digest. I know that you can only give me general advice because you haven'the seen me or my records, but I would be incredibly grateful if you have any ideas that I can look into. The pain is where the pancreas used to be and also above the liver. Some tests have showed some liver issues but nothing that would explain everything. I know that there miget be several different things going on but, again, I would appreciate any insight you might have and any suggestions of things that I might look into to help make the diagnostic issues clearer. Thanks for any help you might be able to give. Hurting in Va
Hurting: I've not heard of phantom pain after organ removal, which is not to say it doesn't exist.
As you said, you situation is complicated by the spine issues which could also be playing a role in your pain. If it were possible to be pretty sure your pain is not related to your back, one thing to consider would be a celiac plexus block, which is an injection of anesthetic or other materials into the nerve plexus related to the pancreas, among other things. Here's a link which has good info, but, weirdly, misspells plexus in a couple of places.
http://my.clevelandclinic.org/services/anesthesiology/pain-management/treatments-procedures/celiac-plexis-block
It can be done first with a long-acting anesthetic and if it seems to be effective, it can be done with alcohol to destroy the nerves for permanent relief.
I can't say, of course, if it's a consideration in your case. But it wouldn't hurt to bring it up with your doctors.
I'm one of those people! I had celiac disease for years before it was diagnosed (at 27 in 2010), and in the year prior to diagnosis started to experience severe RUQ pain. After going GF I had nearly continuous excruciating pain, and after a week long stay they finally removed my gallbladder. Pathology came back as chronic acalculus cholecystitis, and the doctor said they did find bile turning black inside it.
I was pain free for almost 3 years, when at 6 months pregnant I started experiencing severe RUQ pain again, especially if I get "glutened". The attacks have been getting more severe, closer together, and lasting longer. I've been let out of the ER a few times now with pain scrips, but I'd really rather sort this out and get off the medications!
Seems like everyone up here (I'm in Canada) is reluctant to do much for it, since my liver function is fine even during periods of pain, and I have no visible stones. I've got a requistion for a HIDA but I'm reluctant to do it if it's not a helpful test, and opinions on PubMed seem to be mixed at best. Any suggestions? I'm on the waiting list to see a GI (I haven't seen once since celiac diagnosis in Dec 2010) but I like to go in informed - I was pushed off for over 10 years with the celiac as being either a hypochondriac or IBS before the tests came back with complete villous atrophy (and my 1 year old son was just diagnosed celiac as well by biopsy incidentally).
PS - love your Confusion Corner sign pic at the top of this post. I used to live in Winnipeg and drove or rode the bus through there almost every day!
Sounds like you're in for some frustration before getting to the bottom of it, Karlie. I don't think HIDA will be all that useful, as its "speciality" is to look at gallbladder function, and you don't have one. I think I'd be thinking more of ERCP, which needs to be done by a GI doc in most cases. So trying to get in to see one seems like the right move. That person may or may not think ERCP is the right move, of course; and I'd give more credence to those able to see you directly than some online guy like me.
Oh for sure - I might just hold off on the HIDA then until I get my referral to the GI. I just can't imagine that the best solution is for me to keep showing up in ERs every 3-6 months needing IV medication for 12 hours. There must be some organic reason for such specific pain in such a specific spot.
One more question, sorry! I'd like to learn more about digestive and biliary disorders so I can be more informed, can you point me in a good direction? I have two degrees in science so I have some experience in reading scientific literature (albeit largely in geography and geology). I've read quite a few journal articles on PubMed about celiac and a few about biliary problems, but I'm wondering if there are other texts that may be helpful as well.
I've found the websites of Mayo Clinic and NIH to be informative for laypeople. Also webmd
http://www.mayoclinic.org/
http://www.nlm.nih.gov/medlineplus/
http://health.nih.gov/
http://www.webmd.com/
Dr. Schwab,
A little over a year ago I went to the ER with what felt like a gallbladder attack. Twice before over a 15 yr period I had done the same. On those occasions, an ultrasound showed no stones, so I had a follow up cck a few weeks later, which were normal. On this most recent occasion, I saw a general surgeon. I told him of my history, and that I had been diagnosed two years prior with celiac disease, which the GI felt had been a lifelong condition due to my history of abdominal distress and severe villous atrophy. The general surgeon ordered an ultrasound. Again, no stones were visible, however, when I had a CCK test within a few days this time, my gallbladder function was less than 10%...however, I experienced no pain during the test. The general surgeon recommended removal, which I had done the following week. It should be noted that I experienced no more pain after the ER visit. The surgeon visited with me briefly after surgery and stated that he had been surprises that my gallbladder appeared pink and healthy, with only mild inflammation. In my fuzzy state I dis not think to ask him why he had gone ahead with the removal. My recovery was very painful, I was still experiencing pain at my 6 wk check, which he dismissed. Three mos after surgery I was exposed to gluten accidentally at a restaurant and a had a violent attack which mimicked my previous "gallbladder" episodes, and I went to the ER. As my liver enzymes were over 300, I was kept for three days until they normalized and the pain was gone. At that time, the same surgeon who had done the gallbladder removal referred me back to the GI who had diagnosed celiac, and recommended an ERP. The GI advises me against the procedure due to the risk involved. He explained that Celiac patients often experience a spasm of the bile duct during episodes, which mimic a gallbladder attack, and that most likely I had sphinchter of Oddi dysfunction. It took many months after this episode for me to feel normal again, and on two occasions since when I was accidentally "glutened" I again experience the same type of attack, which confirmed his suspicion.
My question is this, when the surgeon visually inspected my gallbladder and noted its apparent good health, save for minor inflammation, should he have gone on with the procedure, or sewn me back up and referred me to a GI?
Since the gross appearance of the gallbladder doesn't really say much, if anything, about past or future behavior, I doubt any surgeon would abandon the procedure based on that alone.
BTW, as I've written, a perfectly normal gallbladder looks blue inside the body; if it really was pink, that suggests a degree of inflammation, which isn't normal.
I wrote to you some time ago on this thread and you very kindly answered and suggested I keep you posted. I am the pharmacist from Canada who had a lap chole in 1992, ERCP and sphincterotomy in 1998 for suspected stones (that never materialized). Things were great for almost 10 years, then new onset of RUQ pain in 2012. Gen Surg noted no indication of anything pot-surgical, went to second gastro who started Urso based on the premise that my bile is somehow "abnormal". Then I started noticing some vague weakness. Figured it was post-polio syndrome as I had vaccine-associated poliomytlitis from the OPV back in the '60s. Saw an amazing physiatrist who did EMGs and low and behold.....signs of a myopathy! I am now being genetically tested for myotonic muscular dystrophy. In 25% of those with MMD type 1 gastrointestinal symptoms are the key problem, RUQ and liver enzyme elevations including "Sphincter of Oddi dysfunction" part of the picture. So, after 25 years of pain and a multitude of diagnostic procedures....we might finally have an answer! Of course no cure, but at least an explanation. It is a little sad that after seeing so many doctors all for issues like trouble swallowing, delayed gastric emptying, constipation, SOD symptoms, (all muscular issues) that someone couldn't put 2 and 2 together! The medical system is so siloed with every doctor that you see only concentrating on the issues that pertain to their specialty or reason for the consult. Anyways...maybe undergrads in GS and Gastroenterology could use a little education about the GI impacts of some primary myopathies! Will let you know when I get any definitive tests back!
Wow. Thanks for taking the time to follow up, Lori. It's a lesson for us all. I guess we docs are often like that story of the blind people and the elephant. How lucky you are that you found someone able to step back and look at the bigger picture.
Hi Dr. Schwab, I am about to undergo gallbladder surgery but am very nervous about it after reading about the side effects of some people,ie worse symptoms. I had a HIDA scan with a score of 4 percent. Pain was recreated with administration of the enzyme but much milder than when experiencing the "real" thing. Since the scan I have not had an attack.. symptoms seem to have no consistent triggers. I can go weeks or months with no symptoms regardless of diet. Then I will have nights of pain so severe I have gone to the emergency room. Nothing stops the pain- not antacids, GI slider, anti-spasmodic the, etc. In fact, high doses of Dexilant etc only seem to make pain worse. Anyway, I don't suppose there is any way to say for certain if surgery will make things better or worse?
J. Davila
No way to say for certain. Although you didn't provide some details (such as whether you have stones, thickened gallbladder wall, etc), it sounds as if you're in the category where there's a good chance of improvement. Your surgeon, having more details, should be able to give you a more useful answer.
I'll say this, though, as a general proposition: internet searches for patient comments on any sort of treatment tend to find those that aren't happy, and it really skews the perception of the treatment. Gallbladder removal is among the most common operations, and, assuming it's done for the right reasons, the outcome is extremely likely to be excellent.
hello and thank you for reading this post. hopefully i am not duping it because i keep getting bumped out!
To make it short- i question one of my symptoms...
i have severe upper abdominal tightness after eating that lasts for quite some time. it actually makes me feel short of breath.
my Hida is 21%, my US shows normal as does my endoscopy. i have URQ discomfort and pain in ky right shoulder blade after eating fatty foods. my CCK did provoke the tightness. my surgeon says it's a go. but my GI for the past year says the tightness isnt my gallbladder and says i'm fine. the surgeon is the one who irdered the Hida. do you have any thoughts? thank you and happy labor day!
Christine, I understand the frustrations of being in that gray zone, and of getting such different opinions from your surgeon and your GI doc. I can't really offer much from so far away and I prefer to provide general information rather than specific recommendations for people who aren't my patients. All I can suggest is that if you're unable to have a sense of which doc you find more persuasive, you seek another opinion from someone who can see you and review all the records, which I have no way of doing. Good luck!
I'm getting my gallbladder out on Tuesday 17th November and I can't wait!
I have been in so much pain and paracetamol helped until about a month ago when I ended up in a hospital with an out of hours doctor at 3am, who gave me Dihydrocodeine but that took about an hour and a half to work. Then just after a week later I went to A&E with more severe pain as I didn't take any codeine as I didn't want to become addicted to it and I'd heard you shouldn't take it for more than 3 days, but the doctor said that it was okay. That happened early Sunday morning and I had a blood test which was normal and the next day I phoned the hospital to chase up on when I was getting the surgery, which they managed to book for 3 weeks away at the time.
I'm in the U.K. so I get it free on the NHS. I'm so lucky as I've been reading about people in the U.S. that can't get it done because they have no insurance. I couldn't imagine having to pay for surgery or going to see the doctor- we only have to pay if we go private.
I'm actually having a very painful attack as I write this and am waiting for the codeine to kick in. I just want to say I have enjoyed reading this thread and it has made me feel good about getting the procedure done. If you want I can let you know how it all goes.
Thanks again.
Hi, me again!
Do you know why females are more prone to gallstones?
Thanks.
Thanks for taking the time to comment, Sarah. I'd guess you'll be very pleased with the outcome. As to females and gallstones, it's all about the estrogen, and its effect on bile composition.
Me again!
While browsing the internet I came across this site I thought you might find interesting, about Chinese surgeons only removing the gallstones. What do you think?
http://skepticalscalpel.blogspot.co.uk/2014/02/gallbladder-surgery-goes-back-to-future.html
I think what I've always thought, based on fact: any modality that removes gallstones without removing the gallbladder is highly likely to result in reformation of stones at some point. The study only went to less than two years. And they used ursadiol post operatively.
Hi. Had the chole today and I feel great. Dosed up on painkillers. Had 8 stones that looked like round chocolate cereals! Very brown, round and pitted. Can't believe I just had an organ removed! I recommend this surgery if you have painful gallstones. I luckily haven't had any pain from the gas used to inflate the abdomen. Been moving around easily with a walking stick and I even got a wheelchair ride to the car!
Thanks for taking the time to post, Sarah. Glad to hear the good news.
General Surgery Post
Dr. Schwab,
I've really enjoyed your blog. But I am in a diagnostic challenge at this time. I'm a 59 y/o man and started having RUQ pain wrapping around to the back about 8 months ago. No relation to meals and no nausea or vomiting. Had a negative ultrasound and labs. Since pain continued I then had a negative CT scan. Then a normal colonoscopy. Then went for a UGD which was normal except for very mild gastritis and was H. pylori negative. Started on PPI. Over the summer sxs subsided somewhat but returned about 6 weeks ago. RUQ pain under rib cage wrapping around to right middle and right upper back. Still no relation to meals or nausea or vomiting. I know I'm getting more anxious too. In last few weeks have felt occasionally like being on verge of a viral illness, slightly chilly feelings sometimes but never any fever (I've checked) and no other focal areas of sxs. Had a couple of ER trips with negative labs. HIDA a week ago with normal GB filling normal ducts and 98% EF. Saw a general surgeon 3 days ago, negative abdominal exam, he doubts GB right now but will talk with my GI about possible endoscopic ultrasound. He says continue PPI's. I'm really feeling beaten down by this. Not sure what to think.
Yours is a very frustrating situation for all involved, especially you. But I've been there, too, with patients I've wanted to help but didn't know what to offer. It's conceivable, if not very likely that this could be a nerve irritation problem, even shingles, although by now one would expect some sort of typical rash. But nerve root irritation emanating from some process in the spine isn't entirely out of the question.
Were you my patient I'd likely share your surgeon's reluctance to operate. It's good that you're hanging in there with your docs; hopefully with more time (as if it hasn't already been too much!) they'll figure it out. Good luck.
Thanks very much for your quick reply Dr. Schwab. I appreciate it. I'll post back as this problem hopefully gets worked out.
Hi, it's Sarah again. Doing really well almost 2 weeks after surgery. External is healed but internally still get a bit of pain.
What is used to tie off where the gallbladder was removed?
Is it stitches or clips or does it differ with surgeons?
I found this about a woman having 12,000 gallstones!!! I thought having 8 was bad enough.
http://metro.co.uk/2015/11/28/unfortunate-woman-has-record-breaking-12000-gallstones-removed-5531954/
How big must her gallbladder have been?!
Especially when it's done laparoscopically, the gallbladder duct (cystic duct) and the artery that feeds the gallbladder (cystic artery) are "tied off" using clips. The gallbladder is attached to the undersurface of the liver by thin tissues and a few tiny blood vessels that are generally cut away using electro cautery.
I've seen gallbladders with several hundred stones; the ones in the article are tiny enough that the gallbladder might not have been enormous. Being that small means a much higher likelihood of passing out of the gallbladder and causing complications like jaundice or pancreatitis. But, really, she's no more at risk than anyone else with small stones. If you got 'em, you got 'em.
Hi Dr. Schwab!
I have a unique situation. I am a 52 year old female. I don't drink or smoke. About a year ago I noticed weight loss and loss of appetite. I had a colonoscopy and endoscopy March 2015, both found nothing. I got better, I got worse, off and on... I thought it could be gluten and went on a gluten free diet, but I continue to have these very painful episodes. A year ago it started as more general abdominal pain but now is URQ and upper right back pain, severe headaches, weight loss, loss of activity, etc.
During this past year I moved to a small town south of Reno, NV. I countinue to lose weight. I ended up in the ER in January 2016. The blood work, urinalysis and US all normal. During this year my bowel movements changed. They are softer - not diarrhea - and lighter brown. ER sent me to a GI doc who sent me for a CT - normal - and HIDA which was 78%. BUT when I had the HIDA done the tech explained the procedure and told me what I should see. My gallbladder filled normally but it never contracted. Stuff dumped out through what appeared as a LARGE opening - something as large as my gallbladder and not a smaller duct. Also, my gallbladder never got smaller. When the tech came back I said "I don't think that was supposed to happen." She said "No, it's not." When my Dr. told me my results were normal I asked him to look at the actual scans. He told me they don't do that. What!
My questions are: Am I out of line asking my diagnostician to look at the actual scans? And is there a limit to how much bile a gallbladder should eject in an hour? i.e. Can your system handle a lot of bile dumped at ounce? Could this cause extreme pain?
I believe it's related to gallbladder inflammation. I was on anti-inflamatories as a result of neck surgery (I'm an equestrian - enough said). But when I went off them the pain got much more severe, much more localized and the episodes last longer.
Please help me with ANY info you might have to help my unique situation! Thank you!
Gail Seat, you seem to be in that frustrating zone where diagnosis may take a while. At this point from what you said, there's little if anything pointing to your gallbladder. Were there inflammation, it should have shown on the CT scan and/or the US (no test is perfect, of course.) I don't know what to make of what you describe in the HIDA. As I've written, though, for me to pin it on the GB in the absence of stones, there would have to be typical GB symptoms, a HIDA scan that shows significantly decreased emptying, and reproduction of the pain syndrome when the CCK (the drug that causes the GB to empty) is injected. You have, at best, one of the three: meaning you have pain in the right area, although it's not typical of the sort of colicky pain associated with a gallbladder attack.
It can happen that the gallbladder becomes attached to the duodenum or, rarely, the colon, and inflammation causes a connection between them to occur. I suppose in that circumstance the GB might behave as you describe on the HIDA scan. However such a connection would likely have been suspected on the CT scan; or, at least, some sort of inflammatory process in the area would have shown up along with, most probably, air in the GB. In short, I don't know what to make of it. You're certainly within your rights to ask your docs about it. However, if the radiologist thought it was normal, I'd take that more seriously than what the tech said.
Assuming otherwise normal anatomy, I don't think the amount of bile a gallbladder is capable of holding and ejecting is enough to cause intestinal symptoms. It happens several times a day in most people.
P.S. Gail: your comment about history of breast cancer, which you left in another thread, doesn't raise red flags in my mind, because of the stage at which it was caught. OTOH it's important that your docs are aware of it and take it into account as they sort through the possibilities.
Good evening, Dr. Schwab,
I am the Mayor of Frustration Town. In 2008 I was diagnosed with having gallstones and it was recommended I have my gallbladder removed. I lost my insurance shortly after and never had the surgery. At the same time I was diagnosed with the gallstones, I began having issues with food "getting stuck." Sometimes these episodes resulted in vomiting attacks that would last in upwards of an hour. The strange thing was I could eat and be fine for months, then all of a sudden I couldn't go several meals without these episodes happening. Over the past several years I have noticed from time to time I would have pain under my right rib cage but it would subside after an hour to two hours it would subside.
This past December I began to see a gastro doc who thought I had a stricture which was causing the swallowing issues and he did an endoscopy with balloon dilation. After the procedure he commented on the stricture being minimal and that is should not have been giving me the problems I described.
I continued to see him as other symptoms began appearing; after eating rather fatty foods I would begin to have excessive belching, feel nauseated, have a bad taste in my mouth and the center of my stomach (just below the center of my ribs) would ache and radiate towards the right for hours. It is always worse at night. I have had several tests (CT with contrast, ultrasounds, colonoscopy, endoscopy, bloodwork), I do not have gallstones currently but do have a few polyps which are 6-8mm in size.
I have lost 32 pounds since November (I do not loose weight easily. I once did Weight Watchers for 3 months and only lost 12 pounds) and am still having all the above symptoms except for the food getting stuck (my diet is restricted so I am not sure if that is completely resolved.) The gastro doc suspected a "lazy gallbladder" because of the absence of stones in the latest ultrasounds and ordered a Pipida Scan with CCK. The results from the PiPida Scan show a 29.9% ejection fraction and he said it's within normal range so it's not my gallbladder. He has basically thrown up his hands and recommended I take Dexilant for acid reflux. Been there, done that, doesn't work...neither does Zantac or Omeprazole.
My frustration is that none of this makes sense. I have had "silent reflux" since 2008, maybe longer it was just diagnosed in 08 (basically my body revolted in 2008, as other things happened not mentioned but unrelated)and I have never had the symptoms I have been experiencing for the past 3+ months. It is also frustrating because I do not have the classic symptoms of gallbladder. I don't run fevers (in fact my normal body temp is 96.2), I do not have the sharp, doubling over pain (only a chronic ache that is tender to touch during an attack), I am not jaundice, my bilirubin levels are not elevated, I do not have pain radiating to the back or shoulder. During some "attacks" I feel pain under the right rib cage when I inhale, and pain when trying to lie on my right side.
I understand you cannot diagnose but my question is, could this possibly be gallbladder related? I know polyps do not typically cause symptoms, but could the polyps be causing the pain? Is it possible for a gallbladder to be "bad" inspite of negative test results? I am seriously losing my mind.
Thanks in advance for your time.
Short answer, Kimberly: yes, it's possible.
Longer answer: if you've read my posts on gallbladder issues, and the reams of comments in response, you'll know that there's the easy stuff with gallbladders, and then there's everything else. Among the many difficult issues are gallbladder polyps. In and of themselves, they don't seem to cause problems, usually. However they can sometimes be confused with stones; and when they are as large as 6-8 mm, they could conceivably be causing problems themselves. In addition, some people think that when they are growing, there's reason to consider removing the g.b. for that reason alone.
As to symptoms: biliary colic alone isn't associated with fever or jaundice: those things happen with complicated gallstone disease. So what you describe is within a broad category of "maybe."
As I've written, I considered it significant if, on the HIDA scan, the injection of CCK reproduced the symptoms in question. You didn't mention that. OTOH, since CCK can cause nausea, etc, it's hardly a perfectly diagnostic finding.
You're right that I can't and don't try to diagnose here, or to make specific suggestions. You're in a general category, however, where I'd say it couldn't hurt to have an opinion from a surgeon who'd be able to evaluate the big picture with you.
Dr Schwab,
Not sure if my response went through so please forgive if it came through twice. I had a Pipida Scan with cck. I know it differs from the Hida Scan in the tracer used but other than that, what is the difference?
What is the "normal" ejection fraction used for Pipida? I did experience some mild cramping beginning towards the end of the cck injections (the tech administered 3 injections over about 15 minutes and I went home about 5 minutes after the last injection.)About 30-45 minutes after I left I had more cramping, began burping and had nausea.
I fasted for 8-9 hours prior to the test, not sure if that matters.
Thank you in advance :)
Far as I know, the "normal" parameters are the same.
My concept of the CCK reproducing the symptoms is during the injection, ie, as the gallbladder is contracting.
First of, thank you so much one more time for the wide range of informations you are sharing with us since years it seems.
I'm writing from France, I'm French and I'm 24 years old. I contracted Lyme disease and coinfections 2 years ago and it's late stage, multi systemic and imitate multiple sclerosis. Anyways, eventhough it's all controversial in the general medical field because of lack of researches, there are doctors that treat chronic Lyme since decades like dr Joseph Jemsek, who also used to treat aids patients before Lyme patients. This brilliant Doctor realized that 80% of his patients ended up loosing their GB because the Lyme bacteria supposedly likes to hide in the GB, making colonies and creating biofilm, which often led to abnormal ejection fraction on the long run and GB that are full of inflammation and scarring tissue. As far as I'm concerned, everything started a year ago or so, when I would make green juices or do more heavy detox routines than usual, I would feel discomfort in my epigastric area. Then I was put on ceftriaxone (antibiotic) which is well known to cause GB attacks. I kept my GB anyways despite super high bilirubine levels. Here I am one year later, it's been 3 months that I have constant pain in my epigastric area and on my left side under ribs, pain that I aquired after couple bad attacks triggered by food (fatty food). All my tests are normal, MRI, ultrasound, bloodtests (except slightly elevated bilirubine). I managed to get a hida scan prescribed despite the fact that it's not a routine exam in France and it's really hard to get, so I did the test but they didn't have the hormone that makes the Gb contract, so to replace this I ate a high lipidic meal to stimulate my GB during the hida scan and we continued to take images of it. Anyways, in 3 hours it turned that my GB ejection fraction was 15% (usually the test is made in 1.5 hour) so it seems if I would have done the regular test it would have been below 10% . Anyways. This is the only abnormal thing we can find. Despite the terrible constant pain that I'm having especially on my epigastric area and under left ribs.
I also am terribly bloated and I don't digest fat at all, I always find my stools floating.
I am still waiting to see a gi doctor and I'm scared he will have a hard time interprete the hida scan especially since it's not a routine test here.
I also thought of sphincter of oddi dysfunction but it seems it's more a post surgery thing, and I still have my GB.
Could it be possible to have sludge that wouldn't show up on regular images that would block bile flow?
Thanks so much in advance,
Merci
Sonya
Sorry to hear of your troubles, Sonya. As to the specific question about sludge: if there's something actually obstruction bile flow one would expect to see evidence of that on imaging studies, meaning evidence either of dilated bile ducts or distended gallbladder.
As I've written here, slow emptying on HIDA scan, alone, is hard to interpret.
Hopefully, your GI doctor will be able to put the puzzle pieces together. It might take patience on your part and on his or hers. Good luck.
Hi Doc! This is Gail Seat again. I'm still going through the same problems... they continue with still no answers. Since I last wrote to you I have had an MRCP that was also "normal". I'm beginning to hate that word "normal", although I would like my doctors to find something, I would like it to be something that's fixable and not something deadly.
I was reading a post from sgmorr on 11/27/15. I was wondering if you have ever received an update from him? His story is almost identical to mine! I was wondering if he ever received a successful diagnosis and treatment?
I am also VERY interested in your thoughts on the nerve irritation problem that you mentioned to him. About 6 months before all my abdominal problems started I had cervical fusion surgery C5-C7 Anterior (although I still have quite a lot of pain...) Could this be a cause of all my problems? How do I go about looking into this as a cause of my problems? (Since everything else is turning up "normal"!)
Thank you for your guidance ~ Gail Seat
Gail, I haven't heard anything in follow-up from the commenter sgmorr. As to your cervical fusion: nerve irritation in that part of the spine shouldn't cause pain in the abdominal area; but having had problems in one portion of the spine could mean there are problems lower down, too.
Mid-thoracic spine is the area from which those nerves emanate. Imaging of some kind, MRI or even plain spine X-rays, would likely show something although they'd probably not confirm the association. That might require a visit to a spine surgeon or a rehab-type doc.
Dr. Schwab,
I noticed a posting from Gail and a response from you recently. Gail mentioned my post from 11-27-15 and that her symptoms were very similar. I thought I would follow up.
I continue to have feelings of mild fatigue, general malaise and occasional feelings of chilliness. But a couple of weeks after my November post I developed a new onset headache, generalized but frequently right temporal. And by this time (mid December) my RUQ pain and right flank and mid back pain was mostly gone. The headaches persisted and I've seen rheumatology and neurology. I've experienced sensitive areas on scalp and face also. Dx of temporal arteritis has been entertained but sed rate and other inflammatory markers remain negative. I've had normal brain CT and MRI also.
So I'm still faced faced with a diagnostic dilema. I doubt this will help Gail but I wanted to update my situation.
Thanks,
sgmorr
Thanks! Thoughtful of you to do so. Cases like yours, and Gail's, and so many others, remind me (not that I've ever needed reminding) how little we doctors know about so much. Not that it helps, but it's nearly as frustrating to us as it is to those we cannot help.
Thank you sgmorr and Dr. Schwab for your response. I actually have excruciating headaches and have ended up in urgent care because of them. I have had different thoughts about them - either they are caused by my neck problems, or because I'm not able to absorb nutrition from what little food I can stomach. My abdominal problems sort of came and go. I had several months where I felt pretty good. Now, it's been at least 4 months in which I have felt awful.
I am planning to redo the HIDA scan. The hospital where I had it done the first time told me they could not get CCK so they gave me Ensure instead. My sugeon would like it redone with CCK to see if my symptoms are replicated. Since I am going through a particularly painful time right now I am thinking I should schedule this as soon as possible. Hopefully, this will tell my surgeon something!
Also, my GI Dr. mentioned sending me to Stanford. Would this be worth it? What other tests would they be able to run?
Thank you for your valuable info! ~ Gail Seat
In these frustrating and challenging situations I've always welcomed (and sought) input from uber-experts. I can't comment specifically on Stanford, not knowing about their programs (even though I'm about the only one in my extended family who didn't go there for undergrad); but if your docs think it could help it's worth considering.
Thank you for this blog.
I had my gallbladder removed after being in pain and having a HIDA scan with a result of 14 ejection rate. I hadn't been scoped first, nor had I had a colonoscopy.
I had seen a GI specialty nurse, but no GI doctor. I have been second-guessing my decision because of the fact that I still have right-side fullness and upper shoulder pain (although, not at the same levels yet). And I can feel the food traveling through my gut -- not to mention the stool issues that I'm having.
I have been kicking myself. But reading your words today gave me much comfort about the loss of my gallbladder:
"One thing I can say: your liver produces the same amount of bile with or without a gallbladder, and it all ends up in the gut. The gallbladder stores a small amount, but continually empties itself (normally)."
While only time will tell if I get better, thank you again for this blog.
And thank you for taking the time to comment.
Hi Doc, Gail Seat again...�� I have been diagnosed hyperthyroid - actually with a hyperactive thyroid adenoma, my TSH level is too low but T3 & T4 are normal. What my endocrinologist said is the nodule is overactive and the rest of my thyroid is not really doing much. I have had this nodule for about 40 years with no problems but right after I had the anterior cervical fusion that's when my problems started. I have started on low dose of Methimazole to begin with. But I ended up in the ER again with severe abdominal pain and more weight loss. Could this severe abdominal pain be associated with IBS caused by hyperthyroid? (I tried to contact my Endo but he hasn't returned my call). Could all my abdominal pain/problems be caused by a hyperthyroid nodule?
I'd say it's possible, Gail. IBS could be worsened by hyperthyroidism; but from the numbers you provided it sounds like the nodule isn't overfunctioning very much. Kinda out of my area of expertise, though, so hopefully you'll connect with your endo soon.
I am the post a few above about not being scoped first or having a colonoscopy before gallbladder surgery.
I just want to encourage those of you who don't have stones but have low-functioning HIDA scans with likely biliary issues to consult with a GI doctor first and to make sure you have all your tests done first.
Reread the doctor's original post on this thread for advice. I wish I had found it before my surgery.
My pain is still very much there -- although definitely not as intense.
"Stomach" through the pain and follow all protocols before you make a hasty decision on gallbladder removal if you have a low-functioning gallbladder (no stones). Stones are obviously a very different issue.
Dr. Schwab - Thank you so much for the time and effort you spend on this blog. It really does provide excellent information (which is absolutely comforting to those of us in distress). I am in the hard-to-be-sure camp. Normal ultrasound (no stones, wall thickening, fluid, or swelling). But HIDA scan was 27% AND I had extreme bloating during second half of scan. And I have slightly elevated ALT/AST enzymes, which I've never had before. Chronic diarrhea and intense bloating/distention (especially after fatty meal) are my main symptoms with intermittent URQ pain. Scheduled for surgery Friday on diagnoses of binary dyskinesia/acalculous cholecystitis. Nervous about it based on some of these comments, but as you have so rightfully said, gotta know the true numbers (so many of these surgeries are performed but only those who do not realize complete relief tend to complain). Here's my question for you - in your experience, have you ever had gallbladder patients complain about heart palpitations? In your opinion, do you think heart palpitations (PAC's) could somehow be connected to gallbladder trouble?
humming71: I'm not aware of a direct relation between gallbladder issues and PACs, but I'd think that in a person with tendency toward such arrhythmia, the endocrinological response to pain or nausea could be a trigger.
Hope the surgery helps. Your descriptions suggest you are, indeed, in a grey zone.
Hey doc, I'm a 19 year old male, a couple months ago I had a gallstone attack the morning after from eating a double cheese burgers or dinner. I was had this belching pain and came and go for like 4 days(I forgot). Since then I changed all my diet, from no fat, no red meat, jsut a lot of fruits and veggies. I do exercise and workout everyday. And 2 months ago I think, I went to get an ultrasound with no gallstones. Now I think I'm just suffering from gallbladder disease. My symptoms right now are: soft tan stool most of the time, little bit of heart burn in the stomach(burping the acid in my throat), mild vague ache like poking in my right rib area sometimes traveling to the back and gurgling. And I do not want to remove my gb for it can cause more problems and I do not want to risk that. And I never got a hida scan, will hida scan do anything and give me pain/affects? I'm currently taking herbal medications like, turmeric pills which I don't know if I should be taking, some gallbladder herb capsule and fish oil pills. Do you think that will help if I take it twice or thrice a day because I'm only taking them one pills a day. so you think I should keep it up? Is there any other ways I can reduce these symptoms? Especially the soft stool.
Daniel, I'm sorry but there's really no way for me to know enough about what's going on to make either a diagnosis or a recommendation. I'll say this much, as a general statement: it's very uncommon for a 19-year-old to have gallbladder troubles, especially if there are no stones. So if your symptoms and concerns are continuing I'd suggest sticking with your doctors until they can figure it out.
If you've read much of my stuff here, you know I don't think much of herbal and other "alternative" therapies, although I doubt in your case they'd do any harm.
Good luck working it out, and sorry I can't be of specific help. Online is just too far away to diagnose or treat.
Hi Dr Schwab, I don't know if you received my last message but I did finally have my gallbladder removed. I found a surgeon that sent me for a proper HIDA scan and cared more about what happened during the test than the result. My EF was still high 75% but it replicated my pain and there was a problem filling my gallbladder during the initial phase of the test - it took almost 2 hours. So I had my GB removed 5 days later. The surgeon said it was large, heavily scarred and had been angry for a long time! On my post-op appt. he told me the pathology came back as a chronic non-functioning GB. I lived with that agony for 8 months!
Gail Seat
Glad to hear it, Gail, and thanks for letting us know!
Wow sorry you went through that, I'm going through it now! Any changes through the years
Dr Schwab
I had my gb out in April 2016. Stones were left behind within 2 weeks very sick. CT scans mri and fluids then and ercp which resulted in a stent because the dr couldn't get the basket around the huge stones. 2nd ercp in may with lithrotripsy this time got the 1 stone at thwork intersection of the bile and cystic duct. 2 stones left that they thought would never move did and had another ercp just 6 days later. The results from that one were another stent necause there were jagged stone fragments he couldn't get. Ercp just yesterday they took the stent out but nothing was really there. Dr thinks maybe it was scared tissue they seem last time and/or sone of the fragments slipped by the stent and passed. He says I am healing and cystic duct is normal size now. Just confused
Any thoughts...
Only that that's a heck of an ordeal you've been through! And that hopefully it's over, or soon will be.
And, just for the record and in case you're ever researching it, the cystic duct is the tube between the gallbladder and the main bile duct (the common duct.) Your cystic duct is, presumably, gone with the gallbladder. The stones you've been dealing with were, I assume, in the common duct.
Back in the day, when we did "open" gallbladder surgery, most likely an Xray would have been done during the operation, the stones found and removed then. With laparoscopy, fishing stones out of the common duct is a little trickier; so leaving them for the GI docs to get with ERCP is pretty common (no pun). Your saga with them isn't as common.
My original surgeon actually left a piece of gallbladder behind. He said it was too risky to cut near the bile duct when my gb was so hard and inflamed. That 1st doctor I did not like at all he didn't tell me what was going on. 2 weeks after gb removal so sick I wanted to die!! The one stone was at the intersection of the cystic and bile duct which caused the worst pain. The other 2 stones, he thought would never move down did in a week's time. It's just strange to me that when he took the stent out nothing was there. Could the stone fragments have gotten by the stent and passed or could they have mistaken the fragments for scar tissue?
Sometimes good judgment dictates leaving a part of the gallbladder behind when inflammation and/or scarring is severe. I've done it, although a somewhat different part.
Yes, depending on relative size of stones and stent, they can pass through. It's one of the reasons for placing a stent.
Thanks. I have a post op on Aug 30th. I have been having a strange cramping/spasm since the 1st ercp. Feels like something squeezing for 5 to 10 seconds. Happens about 10-15 times a day. My gastro dr is not sure what it is. I will ask him again but any thoughts or tests I could have done to see what this is. Also is there any supplements that one without gb should be taking to help with digestion. I take probiotics but there are still alot of foods that bother me. I don't eat a high fat diet. Lately coffee, grapes, lettuce/spinach and dairy are giving me problems...
I don't think there's much more I can offer from this far away, Stacy, other than acknowledging it's a puzzle and figuring it out might take time and patience. The things that are giving you problems at this point aren't the sort that I'd associate with post-cholecystectomy issues, and, like your GI doc, I don't have a ready explanation for the cramping you're experiencing. If you're having diarrhea with it, cholestyramine might be a consideration, but it sounds like that's not the issue.
These situations can get pretty frustrating, for patient and for doctors. I can only suggest hanging in there with your docs until some clarity is found.
Just an update: I was the one a few posts above with a low-functioning gallbladder (via HIDA scan result) but no stones. They thought it was a biliary issue, and I had gallbladder removal. Pain was still there post-surgery. I was finally scoped and scanned, and it turns out I have a hiatal hernia -- and my digestive issues since my gallbladder removal have just gotten worse. As the good doctor writes in his blog, sometimes this is all just a puzzle. And another doctor recently told me that "gastroenterology is more of an art than a science." I encourage those without stones to get a second opinion and get all your other tests done first. When you are in pain, it's hard to think clearly so bring an advocate along to help analyze your options. And be sure to do your homework online. Don't make a hasty decision. Still wishing I had found the good doctor's blog before surgery. Thank you!
Hi another question. I still have a piece of gallbladder left, the surgeon left it because he didn't wanna get close to the bile duct as it was inflamed and hard to get out. Okay he didn't mention to me but my gi doctor said it has the ability to make stones one day. Does this happen. Alot? Mine was full of stones before. And if it does will it be like before and cause a blockage because now there is nowhere for them to go.... I had blockage and 4 ercps the stones and fragments are supposedly gone now. Just curious if cant find any info about people that have a piece left........
Highly unlikely, Stacey. It'd depend on how much gallbladder was left, in what configuration. In most cases when a bit is left behind it's only a "patch" and not a "bag." Nor is it likely to be receiving any bile any more. If that's the case, there's no way it could produce stones. If you're concerned enough, you should ask your surgeon for more details.
Hey Dr Schwab
Thanks for your input. Update I spoke with my gb surgeon he says less than. 10 percent of the gallbladder is left.. and that to have that removed would be a very invasive surgery. I had my follow up with my GI my symptoms have been spasms, abdominal pain, bloating, indigestion. He thinks it could be irritable bowel and irritation caused by scar tissue. He prescribed anti spasm meds and fiber supplements and I go back in 4 weeks to see if it's helping. Is that a thing.. scar tissue causes pain and does it get worse, have to be removed??
Scar tissue, per se, wouldn't cause pain, generally speaking. However any time there's an operation in the abdominal cavity there's the possibility of scar tissue forming that can cause adhesions: ie, causing something to adhere to something else. If it happens and causes symptoms it's generally related to a kinking of the intestine, which can cause cramps, bloating, etc. In most cases the indication to operate is when the kink is total, ie when nothing can pass through the intestine, causing severe bloating, vomiting, and pain. When it's partial or intermittent, operating is uncommon unless it's such a recurring problem that it's necessary. In the case of presumed partial obstruction it's necessary to try to confirm the cause is adhesions, and not some form of irritable bowel, etc.
My gi that has done the 4 ercp says there is a lot of scar tissue around the piece of gallbladder that is left and some in the abdomen. I don't have intense pain but the spasms all throughout the day and some right side abdominal pain. Bloating tightness. I'm lucky to have a GI that will work with me and listens to me instead of throwing his hands up and giving up, he says if this doesnt work we'll try something else. Thanks as always for your input! Hopefully these spasms and pain go away
Here's my quandary. A non functioning gall bladder on HIDA scan. Not sick. No stones. No inflammation. So there's been right upper quadrant cramping, fatty liver, and constipation. If the pain is coming from a gb not functioning why does removing it make the pain go away? Taking it out is still a non functioning gb because there is none. Can anyone explain it to me? I'm RN but don't understand this pathophysiology.
So here's the quandary. Non-functioning gall bladder on HIDA scan. Several month duration right upper quad ache, general bloating, new onset constipation, not sick. So gall bladder is coming out. However, what difference does removing the gall bladder makes? A non-functioning gb would give secondary right pain/discomfort but having no gall bladder is also a non-working gall bladder because there isn't one. I don't understand the paathophysiology behind that and I'm RN. Why would removing the gb make things better?
The function of the gallbladder is to store bile, and to squirt it into the gut after eating, particularly after eating fatty foods. When it's not functioning or has been surgically removed, bile (which is made in the liver, not the gallbladder) steadily drips into the gut which for most people works just fine.
A normal gallbladder doesn't cause pain. When the gallbladder causes pain, it's usually when it's plugged up, typically by a gallstone. "Non-function" as applies to HIDA scan means it's plugged up; ie, none of the "dye" gets into the gallbladder. So, in a person with suspicious symptoms and a plugged gallbladder, it's evidence that the symptoms are due to the plugging up of the gallbladder.
The above is a general explanation. I can't say whether your symptoms are related to your gallbladder or not. But since the gallbladder is not functioning (or was at the time of the test) it suggests you've been doing fine without its normal function, which suggests you won't miss it when it's gone.
And in case I didn't make it clear: if your pain is coming from your gallbladder, it should be relieved when it's gone. It's not about "function" per se; it's about being plugged up and, therefore, painful; as opposed to being gone, at which point it's no longer a source of pain.
Dr. Schwab,
To summarize(not my first post, haha)
..
I had lap cholecystectomy in april, stones stuck in bile duct,very sick, 4 ercps and am now finally stone free hopefully forever. I am constantly thinking of questions for my dr's but dont go back until december so.. my question is about the clips used during surgery. Where are they exactly, do they ever migrate and if so will they cause damage, will any bile be leaking where it shouldnt be? I know it is rare but would just like to know about it... i read new stones could form around the clips, i also have a piece of gallbladder left. My dr told me i could possibly produce more stones from it but i can never find any info about people with a piece left.. i guess maybe they dont have problems...Thank you for any input
Sorry I forgot to add, one of the reasons im asking about the clips... a co-workers wife died after gb surgery, some years ago from a bile leak. Would that have anything to do with the clips or would that have been a perforation of some sort? I dont know all the details just that she had a leak and developed infection and passed.
Here's something I wrote about surgical clips: http://surgeonsblog.blogspot.com/2008/02/pleasin-squeezin.html You'll note, if you read the comments, that not everyone agrees. You can find anything on the internet. I can tell you that I've used thousands of clips and that tens of thousands are likely being used every day in ORs around the world. If there were harm greater than background noise, it'd be well-known by now.
The only way stones could form around clips would be if they were on the inside of bile ducts, which, I think it's fair to say, they aren't. For gallbladder surgery they're placed on the outside of the little artery that feeds the gallbladder and on the outside of the cystic duct. Maybe, in some cases, on other various branches. But always on the outside.
Bile leaks, when they occur after surgery, happen right away, and become recognizable within hours or days.
DEANA MCREE: I accidentally deleted your comment, so here it is along with my answer:
Can gallbladder dysfunction cause slow digestion....causing stomach to empty slower?
If the gallbladder is inflamed, the inflammation can affect gastric emptying temporarily. "Dysfunction," though, probably doesn't cause gastric delay (the official term for slow emptying of the stomach, from a disorder of propulsion as opposed to a physical obstruction, is "gastroparesis") but it's possible that the same things that might cause gastroparesis could cause gallbladder dysfunction. It's a gray area, and "dysfunction" of either organ can be pretty vague, and covers various possibilities.
Thank you Dr. Schwab. I might add that I started off with chronic gastritis and acid reflux which later progressed to erosive with an ulcer at ge junction. I'm miserable! Gb dysfunction was found before it progressed. I did not really have many symptoms as far as the gb goes....nor any reaction during Hida scan.(I was given an Ensure to drink, not the cck). I've heard conflicting reports gb dysfunction causing reflux/gastritis/slow digestion. Waiting for another Hida scan to be done. Afraid if I get the gb out that I will be worse! I tested negative for h.pylori 3 times so I know that is not the issue causing my stomach problems.
I absolutely LOVE your blog! Am getting an ultrasound tomorrow to see if there's a problem with my gallbladder and being able to read information about it from an actual surgeon is soooooo comforting! Thank you for sharing... Extremely helpful and comforting!
Thanks, Ms Gutwein. Glad you found the blog, and really glad that people continue to find it useful. Come back any time!
Hi Dr.,
I'm not sure if you still answer questions but I'm in the process of deciding if I should get my gb out. I was diagnosed with an ulcer two years ago but was also having right upper quadrant pain. I've had one full gallbladder attack prior to the ulcer diagnosis, but didn't know what it was at the time. I had a HIDA scan with normal ejection fraction rate but the scan was extremely painful and I was nauseous. The past two years my ulcer would not heal on a PPI and I had to completely change to an extremely low fat diet. My gb pain subsided due to the low fat diet, but I still suffered major discomfort every time I ate. Fast forward to today and things have really escalated. I am in constant discomfort, and a recent ultrasound revelead a mildly enlarged spleen that is giving me pain. The past two days my hands and feet have begun to itch. I'm extremely nauseous and have very little appetite. My skin looks darker but my eyes are not jaundiced. My bloodwork checked out ok but I am getting another HIDA scan this week to see if my gb is no longer functioning.
Is it possible I have a blockage somewhere causing my enlarged spleen and itchy skin? My liver enzymes were normal two weeks ago but w/ the recent development of itchy skin I'm extremely concerned.
I'm hoping the results of the HIDA scan reveal something. Are there any other tests I should request for my situation?
I do still respond to questions and comments, but I hesitate to make specific recommendations. For one thing, it's impossible to know enough about a person's situation from this far away. In your case, I don't know on what basis the ulcer was diagnosed, and on what basis it was determined that you had a gallbladder attack.
If you've read what I've written about HIDA scans, you know I find them of questionable value. If when you had your gallbladder attack you were found to have gallstones and if your symptoms were pretty typical of biliary origin, then there's not much a HIDA scan would have added then, or, for that matter, now.
Itching can be due to blockage of bile ducts; when that's the case, jaundice and abnormal liver tests would be associated. Spleens can become enlarged due to liver disease, but it's usually in the situation of severe cirrhosis causing restriction of flow through the veins that drain the intestinal tract and spleen. Again, that's not a subtle situation.
"The sad truth is that absent proven gallstones, or clear signs of inflammation of the gallbladder, our ability to be certain what's going on is imperfect at best." Wise words. Thank you, doctor.
I left a couple of comments previously about my removal for low function in May 2016. I'm just back encouraging people to really heed the doctor's caution on removal when you have low function -- with no stones, no sludge, no inflammation. I wish I had studied this blog and had done more research before removal. Retested my HIDA after a few months or something. It's been 10 months since my operation, and I'm miserable most days. I still have all my same pain as before removal, plus new symptoms from temperature control issues to weird headaches to high liver enzymes and exhaustion.
Many doctors just treat stones and low function as the same type of gallbladder disease. I found out the hard way that they aren't the same -- and the removal answer isn't as clear cut for those of us with supposed biliary issues.
Do you have any statistics on how many have issues after surgery compared with those that dont? as a lot on our health boards are claiming the majority suffer with issues and complications after gallbladder removal!
The problem with those data is that they include many people who've undergone cholecystectomy for the wrong reasons; i.e, people whose symptoms weren't due to their gallbladder and which, therefore, persisted after surgery. One source reports "5 - 40%," which gives you an idea how vague the whole category is.
What can say without hesitation, as one who did around 2,000 cholecystectomies over my career, is that when done for symptomatic gallbladder disease, patients are highly satisfied; and the comment I received more than any other was, "I wish I hadn't waited so long to have it done."
It's true that a small number of patients have digestive problems afterward. In many, it's transient. In others, it requires some dietary modification, easily managed. The number who have persisting and difficult-to-manage sequellae is, in my personal experience, extremely small.
That's the best I can do for an answer.
Hi Dr Schwab,
I hope you are doing well and enjoying your retirement!
So, I had my GB removed in June 2016 but continued to have pain - sometimes excruciating pain - every time I eat. It got so bad that I avoided eating but realized that was going to kill me when weight dropped to 100 lbs. I just had another US and asked the tech if she could take a good look at my common bile duct. I got the results today and it showed a "1-2mm echogenic focus with shadowing near the pancreatic head" along with "prominent dilation of the extrahepatic duct."
I have thought I had a blockage of the CBD because everything I eat hurts me...ugh... But where do I go from here? Everything I read sounds so scary and fraught with horrible possibilities - and I've had enough! I know it's most likely a stone but how did it get there (I didn't have stones - just a chronic non functioning GB)? Is this something a surgeon removes? Or a GI doc? Do I need a specialist like Stanford or Mayo?
Thank you again for all your help!
Gail Seat
The saga continues...
In general I'd say you should address the questions to the doc who ordered the ultrasound. But I can say a few things:
it's not uncommon for the bile duct to become dilated after cholecystectomy, and usually it's of no consequence.
A 1-2 mm spot is really tiny, somewhere around a 1/16 of an inch. If it were a stone of that size it's likely could have passed on its own. Can't say that for sure.
If the duct we're blocked, you'd have jaundice, dark urine, and pale stools.
If I'd been your surgeon and you came to me afterward with these symptoms and findings I'd refer you to a gastroenterologist, who'd likely consider doing ERCP, which is passing a scope into and past the stomach and injecting dye into the opening of the bile duct into the duodenum. It might clarify what that object is; and if there's significant narrowing of that opening (known as the Ampulla of Vater and the location of the Sphincter of Oddi) it can be enlarged via that scope.
Thank you for your input. But are saying that this tiny "thing" shouldn't be causing pain? Also, the radiologist recommended a MRCP but is this sort of redundant when an ERCP would then be needed anyway? I do have GI doc but my original question about a specialist - I meant a specialist who had experience with removal of stones (or tumors) in the CBD - if this needed a specialized dr. not just a regular GI...
Yes, the saga continues��
Gail
Unless your GI doc is pretty old, he or she should be experienced with ERCP and with sphincterotomy, it that's required. You should ask yours if that's the case.
I can't say, without knowing the exact location, whether that thingy could be causing pain. I'd say, absent evidence of obstruction, it's unlikely; but I can't say it's impossible. As usual, your docs are in a much better position to opine than I am.
While searching for info on my post-cholestectomy problems I found this post. You may be interested to know that I took part in clinical trial of Cholelithiasis. (U of I) A big mistake in my case. I had two stones, largest was 2cm, that were lithotripsied. Consequently this resulted in Acute Pancreatitis, as the shards did not go the proper route! Suffering a few more attacks while continuing in the trial which including pancreatin to help "soften" the shards that were still sitting in my gall duct, I finally begged for a cholecystecomy, much to my surgeon's relief.
Needless to say, many years later, I am still having RUQ pain and severe episodes of blocked duct. Upon further investigation UCSF, it was discovered that my gall duct has enlarged sufficiently to support more stone production. And, the spincter of Oddi has enough scar tissue to make it very difficult to pass stones. Even though it was cut to make it larger, I think the scar tissue has re-formed. I tend to keloid on the outside scars. Could it be the same on the inside?
This continuing problem makes life pretty miserable at times.
I have been through a lot worse, (sarcoma) but I wish I knew if the whole thing could be reconstructed, or conveniently bypassed, or maybe just plain "deleted" entirely.
Can you comment on this possibility?
تركيب بالون المعده بالون المعدة
بالونات المعدة عملية البالون عملية بالون المعدة
We seem to have some very unlucky gallbladders in my family, and odd too, maybe. Mother's stones were like sand sludge. Sister had no stones, but only 5% functioning. Niece had Cholecystecomy at age 28. Grandmother died of complications of Cholecystomy, but that was in 1948, so perhaps that was not so unusual.
hello doctor,
I have done lot of test having indigestion issues.
1)Ultra sound shows no stones
2)Hida scan shows 0% ejection fraction, but CCK induced did not cause me cramp or bloating - Bilary dyskensia.
3)I had many frequent episodes of diarrhea , some time it resolves on its own after having bland diet.
4)I can't eat any oily,fatty or protein related foods which causes me excessive bloating and some time pain in gallbladder area.
5)Nowdays,even a bland diet causes me lot of burping,bloating and indigestion, but no pain
6)Colonoscopy was normal and endoscopy showed gastritis.
7)My GI doctor feels gallbladder is not the issue but my general physcian recommends to remove the gall bladder.
8)Now i need to take a chance either to go with surgery or not. if you can provide % of folks who removed their gallbladder for biliary dyskensia and their success rates that will be great. I have been suffering with this issue for past 7 years and i'm at a point where i need to decide.
I can't give you the % you're looking for, because the diagnosis is such a gray area, meaning many people are told they have it who, in my opinion, didn't. As I've written here, I told my patients that if 1) their symptoms were typical of gallbladder colic and 2) the HIDA scan was abnormal and 3) the CCK reproduced those typical symptoms, then the chances were very high, but not 100%, that they'd be improved by having their gallbladder removed.
I'm not sure if you meant to write 0% for your HIDA scan emptying: if it really didn't empty at all, that's a suggestive result. But the test can be affected by various things that could make your gallbladder, at one time or another, not empty properly. As to the rest, you don't fall into my personal criteria.
However, my criteria are only mine: I don't claim to have a definite answer. As I said, the diagnosis of biliary dyskinesia is pretty iffy. under the best of circumstances.
Thank you Dr.Schwab for quick reply.
yes, My hida scan results shows 0% ejection fraction. General physician said its not working at all and recommends to remove the gall bladder. I don't have a severe pain like other who has stones, but lot of burping,belching and bloating is going on. My main concern at this moment is the dizziness,imbalance and extreme fatigue. I want to take a chance, but afraid of the complications after gallbladder removal.But at the same time if i dont go through, i have to suffer like this rest of my life.(already suffering more than 7+ years).If things work out well, then i will be my 2nd innings of my life.Due to this work,family life is heavily impacted as i'm only 36 years old.
some questions for you.
1) I started getting dizziness and imbalance since i run in to digestion issues from year 2011, If there any digestion issues for long time, will we run in to dizziness and imbalance issues , is there any connection with gallbladder and dizziness/imbalance ?
2) Atleast can you remember folks who had biliary dyskensia and no stones who got cured well after gall bladder removal? i have met around 10 folks in person who removed their GB for stones, but never met one who removed for biliary dyskensia, so appreciate your response on this.
3) what are your thoughts on Sjogren's syndrome with respect to biliary dyskensia ?
4)What are the complications after gallbladder removal?
5)Please let me know your thoughts on Probiotic,digestive enzymes and OX bile they sell online, does they really help the digestive system?
Seems to me your next step is to see a surgeon and get his/her opinion on your situation. Briefly, though:
1) Unlikely in my opinion
2) As I wrote, when "my" criteria were met the odds of relief were very high. I had many patients in that category
3) No current info without looking it up. You could google it.
4) I've written about that in my several posts and comments here.
5) Not a believer.
Dr schwab,
Thank you for all your prompt reply.
As you mentioned that the HIDA scan test is affected by various things which can show 0% ejection fraction ratio for gallbladder.
1)Can i know some of the scenarios where it can be affect the hida scan results?
2)It is better to take the HIDA scan second time to rule out for any false positives?
3)Doctor says any non working organ like gallbladder should be removed, do you agree with that?
4) What are the side effects other than digestion issues of having a non working gall bladder for a long time ? or what are the health issues that occur when digestion is not good for long time as the body will not absorb all the nutirents, in my case i have low vitamin B12?
5)I'm leaving with non working gall bladder almost 7+ years ,their are episodes where my digestion was good and bad, why does the digestion vary though the gall bladder hida scan says 0% ejection fraction ratio?
6) How the digestion will get improved after removing the non working gallbladder(Assuming gall bladder is only the issue) as any way it was not working earlier?
B.D.: I like that my blog, to which I haven't added new content in several years, is still useful, and I'm happy to answer questions and supply info up to a point. But there gets to be a point where my generosity has its limits. Your questions deserve answers, but I think at this point they're better addressed by your current docs, or a surgeon who can evaluate you in person instead of from the other side of the screen.
Dr Schwab,
some of the Gastroenterologist (Around 5 doctors) ,general physcians(around 4) and 1 surgeon i met gave contradiction answers, hence was checking with those questions to get an insight. But i understood your point. Thank you for answering all my earlier questions.
Hi Doc. Thoughts on CCK vs. Ensure drink? Seems like Ensure is the norm these days. I had a scan today and it was a breeze. I sure hope Ensure gives an accurate reading!
I can't speak specifically to Ensure, Terry, but it falls under the general category of substituting a "fatty meal" for CCK to induce gallbladder contraction and to reproduce a person's pain syndrome.
In general, fatty meal has been found in some studies to be less effective than CCK. (Cheaper, though, I assume.) So it depends on the results of your particular study: if it showed abnormalities enough to be convincing, that's significant. If it didn't, then the question for your doctors is whether it can be considered reliable. Maybe there's info of which I'm unaware showing that Ensure in particular is better than other forms of fatty meal. That I'm unaware of that info doesn't mean it doesn't exist.
hello Dr Sid Schwab,
Just want to share an update from my earlier comment. In 2011 ultrasound showed no stones and Hida scan showed biliary dyskinesia with 0% ejection fraction. Then i did the ultrasound test yesterday and got report i have gall stones. so does it mean that...
1) Does the ultrasound does not capture small stones and in the mean time the stones has grown big now to show up in ultrasound, how reliable the ultrasound ?
2) In general all folks will have gallstones in gallbladder and it passes to intestine without noticing it or experiencing it ?
3)Also now i'm wondering if HIDA scan results in 2011 if i have really biliary dyskensia or not. I know you don't like to get in to diagnosis business, but if you can please let me know your insights it will be great.
As I've written, B.D., "biliary dyskinesia" refers to a situation where there are symptoms consistent with gallbladder origin, but with no pathology (ie, stones or wall thickening) on imaging. If you have stones and suggestive symptoms, you don't have biliary dyskinesia, you have biliary colic.
No test we do is 100% accurate. There can be false positives and false negatives. In the case of ultrasound and gallstones, it's pretty clear when they're there.
And, no, most people don't have gallstones. Of those that do, most will have the stones remain in the gallbladder, causing symptoms or not. It's when they pass out of the gallbladder that more serious things can happen. It's not rare that gallstones can be present in the gallbladder and not be noticed. It's not common that they remain symptom-free as they pass from the gallbladder. But most gallbladder pain comes not from the stones passing but from a stone plugging up the gallbladder when it tries to contract. I realize there's lots of comments in these threads; but in my
original posts about gallbladder issues, this information can be found.
Dear Doctor sid,
I had a history of extreme bloating/belching and burping.Initial endoscopy diagnosis was gastritis, but after few years developed dull pain on the gall bladder and hida report said the gall bladder is not working. After few years, i got gallstones and barrets esophagus with non dysplesia.I cannot eat any fatty/oily/protein foods. I still have extreme bloating/belching and burping, will gallbladder removal will give me any relief ? I really like to know your opinion as you are a experienced surgeon who has done so many surgery. Appreciate you response.
thank you.
desiblm: I can't make any predictions on any specific case when I'm not directly involved. But I can speak in generalities: people with symptoms like yours and who, like you, have confirmed stones and, at least at the time of the HIDA, a non-functioning gallbladder have a very high chance of symptom relief.
It also sounds as if you're having reflux symptoms as well, and sometimes it's hard to tell the difference. It's often recommended that people with Barrett's and with reflux have an anti-reflux procedure done. That and GB surgery can be done simultaneously, laparoscopically in most cases.
These are things best addressed in specific terms by your doctors. If you haven't seen a surgeon, it's certainly a considerationl
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