Friday, March 30, 2007

It's Galling: diagnostic dilemmas and the gallbladder




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...

207 comments:

1 – 200 of 207   Newer›   Newest»
The Independent Urologist said...

The chapter on the VA, perfect. I spent 1/3 of my residency at the VA Lakeside, in Chicago. Like you VA, it was on the most prime of prime real-estate , with pristine views of Lake Michigan. I learned technique at the private hospitals, but I became a surgeon at the VA.
Thanks for the book.

Sid Schwab said...

Thank YOU!!

happyj said...

Dr. Schwab,
What a great post! I wondered, since I had never drunk alcohol, nor eaten fatty foods, nor are gall bladder stones inherited in my family, if my gall bladder was full of stones (7 years ago, had it removed) because of my brain injury 10 years before that? I wondered because I heard of the 'vegas nerve' (I'm sorry for the incorrect spelling) on the Discovery Health Channel, and that there could possibly be a mind-gut connection. I wondered if they meant that literally, if what happens to the mind/brain can affect the gut, or if they meant it psychologically?

Michelle said...

nice image - I live minutes away from that corner- we call it confusion corner or sometimes crazy corner.

Enjoying the blog kinda neat to see a part of Winnipeg, Manitoba on one of my blogs I like to go to.

Sid Schwab said...

happyj: there's evidence of "mind-body" connections in the gut, as relates to inflammatory bowel disease, for example. Gallstones increase in frequency in people who've had vagotomy (cutting of the vagus nerve), which was a common treatment for ulcers years ago. I'm not aware of a direct relation between head injury and gallstones, but it's possible they could relate to drugs used for treatment. Lots of people get stones with none of the well-known associations.

Michelle: we owe much to Canada.

Annie said...

Hi Dr. Schwab,

I know that you hear this all of the time, but I so enjoy your blog!! I have been nagging my students to read it ever since I happened upon it....they have no idea of the wealth of information and anecdotal gems that they are missing! I finished your book as well - awesome stuff, that. I think that you should consider a book that organizes your blogs theme-wise....something to consider as the expanse of your written word increases.

I saw the post you entered on my nascent blog...how on earth did you find it?? Truth to tell, I was hoping for a longer period of flying under the radar (like, maybe indefinitely??)..... :o) I can't seem to find the time to work on it as I had hoped I would, which is very disappointing. I resolve to try and post something substantial soon.

Sorry that I had to post all of this here...I wanted to email you directly but the computer I am on right now won't accommodate me....seems as though the hospital wants to discourage this sort of thing (can't imagine why THAT would be!)

And finally, I so wish that I could pick your brain on a regular basis....you are one special guy!

Dr. Charles said...

fantastic post, and a good point of view for us primary care docs to hear. thanks for widening and reawakening the diferential in the back of my mind.

Greg P said...

There are many patients I see in the office with entirely subjective problems. This is where these iffy diagnoses have their genesis -- we have to call it something, so we invent a name and start using it.
Generally I won't see patients with chronic fatigue syndrome or fibromyalgia, because I don't understand how to make the diagnosis.

#1 Dinosaur said...

Excuse me:

Regarding wastebasket diagnoses:

Chronic Fatigue syndrome: Yes
Fibromyalgia: No
Irritable Bowel Syndrome: Sometimes

In all fairness, you don't usually see most of the diagnostic dilemmas. The reason your job is usually so straightforward is that we've made the diagnosis for you. After that, all we need is a trained monkey (well, one of his descendents, who performs for money and not for bananas) to take that little sucker out for us. (And get paid 10X what we got.)

I posted something about the diagnostic side of things, if you're interested. Nothing new to you, but the studs may find it helpful.

Sid Schwab said...

Sorry dino, it's just the opposite: I see the diagnostic dillemmas because the primary care docs throw up their hands and send them to me hoping I'll operate and take them off those upthrown hands. Or they make one of the iffy diagnoses and it's up to me to have the judgment to point out to the patient why they don't need the operation. That's why I make the big bucks; keeping you out of trouble.

And surely you don't disagree that fibromyalgia is over diagnosed? Even I know that, and I'm just one of those unthinking cutters...

Gallgizzard said...

Excellant discussions! I am a Sonographer currently in the lecture business, and I am going to bring up your page this week on my laptop/projector and make it "Must Read" for my Abdominal Ultrasound class. I have been reading your posts for a while now Dr Schwab, and you remind me of a surgeon I worked with back in the 70's. More on that at a later time. One comment: I used to do quite a few GB Ejection Fractions using CCK. The same criterion: less than 30 percent meant a poorly functioning GB. I do not see Doctors ordering it anymore. It seems ultrasound has the same batting record, and uses NO radiation, and 15th the cost. Why don't Physicians order the ultrasound vversion of the HIDA scan more often? Thanks, gallgizzard@yahoo.com

happyj said...

Dr. Schwab,
Thank you so very much for your help in my understanding. Another perplexing diagnostic thing was that when my mom had pancreatitis and had her gall bladder troubles three or four years after my gall bladder was taken out, I got the pain again. It was so horrible that I went to the doctor because I thought I had pancreatitis again, but I did not, and afterward I was sure I had "sympathy pains," because my mom was having the same thing and I felt bad for her because I knew how painful it was. Just a guess.

Sid Schwab said...

gallgizzard: good question. The one thing the HIDA scan can tell that ultrasound can't is patency of the cystic duct. In other words, HIDA shows whether the gb actually fills or not. If it doesn't, there's no need for the CCK, because you've discovered the gb isn't working, which tells you what you need to know. On the other hand, the cost issue is an important one. Is it really 1/15th? That would be quite startling!

gallgizzard said...

Sorry Doctor Schwab, the cost (of GB CCK) is one 5th to on 7th the cost of a HIDA. BTW, if the cystic duct is not patent, I would think in many cases, the GB would show other signs such as inspissated bile (Sludge), contracted state, stones etc on the US in many (not all) cases. Of course if distal obstruction of the ampullae of Vater/spincter of Oddi is suspect, the CBD may reflect this by being in excess of 6 mm. The spiral valves of Heister are delicate, and I have found many a small stone lodged there causing both inflow and outflow obstruction. In this case, the patient is usually a very sick puppy! But even though I have practiced U/S for 32 years, I am ever the student. Keep up these great posts, my students will love them!
PS, the topic of spincter syndrome is most interessting. Peace.GallGizzard

Anonymous said...

Thank you for your post on this subject...I myself had my gallbladder removed last year, after having a few attacks that lasted only through the night.
I was great for a few months. I then had what I thought was a gallbladder attack. But how? Rather than pain lasting through the night it last 6 days. Went to ER to be sent away colace(spell). I was fine for another month, then another attack lasting almost 2 weeks. It wasn't until the final week they took blood and found the liver enzymes high! I had the ERCP and felt great! Two weeks later had another ERCP. I still continue to have pain daily, although this pain is a bit more barable. I have pain only, now and then belching.

Lisa said...

I really enjoy reading your blog; my husband just shakes his head when he sees those gallstones slide by while I read, but I love every detail!

Have you done many adrenal operations? That hits close to home, I'll be having mine out eventually. I'd be especially interested to hear about any oddities you've found in that area.

I just managed to talk one of my radiologist friends into getting online. He's a semi-retired ex-military man and hasn't much use for computers but if I can can drag him here I bet he'd find his way back. :)

ccampbell said...

Dr. Schwab,

Thank you for your post...I am one of the unfortunate folks you write about, and I am so gratified to know that there are physicians out there who will honestly evaluate a problem instead of sticking a quick label/diagnosis on their patients.

I've been told I have everything from IBS to pancreatitis, have had my gallbladder removed for dyskinesia (proven by HIDA- 9% output), and after 7 years of searching for answers am still having pain and trying to find doctors that will stick with me until we can find the real problem. Am currently undergoing testing for sphincter of Oddi dysfunction (had another HIDA just this morning), so we'll see how that goes.

But the most frustrating thing has not been the pain (although it is very wearing on me), but the attitude of many physicians, particuarly GI specialists. I've been told to take antidepressants so "it doesn't bother me as much" as well as to "wait until it develops into something worse" so it can be more easily diagnosed.

So I just wanted to thank you for putting a voice out there that encourages your cohorts in the medical community to look at their diagnoses honestly. I appreciate hearing that from a doctor, even if it's one who can't treat me!

Kate said...

I just had my gallbladder out two and a half weeks ago, so maybe it's too early to tell if I'm "unfortunate" or not. I've gone from a pain in my side to nausea and a pain in my side. I went to see my surgeon last week and he essentially told me since I wasn't yellow, feverish, or vomiting that I was probably okay. I go back to see him in three weeks, but I don't feel very okay. I can hardly eat anything without feeling sick. Our local hospital has an integrative medicine team, and I'm signed up to go there tomorrow and talk to the MD to see if she can do anything for me--basically just to have a physician listen to me and sincerely try to figure out the source of my discomfort. I never dreamed I'd enter into the world of CAM, but I'll do anything to feel better.

Todd said...

Dr. Schwab -

I love your blog. Real quick - I had a terrible "abdominal episode" a week ago and went to the local ER. They took xrays and ultrasound and found nothing unusual (no gallstones, etc.). They shot me with dilaudid and sent me on my way. Today, I had a HIDA scan that showed a 14 EF. However, the injection of the CCK did not enduce an attack for me. My primary physician has now referred me to a surgeon for removal. Do you think I should have further evaluation before removal??

Sid Schwab said...

todd: I'm really sorry, but I just can't give any specific recommendations from this far away. Seeing a surgeon certainly won't hurt; be sure you ask about the CCK. No one can operate until you feel satisfied with the advice you are getting.

Todd said...

Thanks! I'll be sure to mention it to my surgeon this Monday. Fingers crossed!

Sophie said...

Hi Doctor,
I am a 22 year old girl who recently had her gallbladder removed. I was diagnosed with biliary dykinesia, with a 17% ejection fraction rate. Before the surgery, I had severe bloating and heartburn. The gastro gave me some meds, but they failed to work; he then discovered the gallbladder problem and said the negative symptoms would resolve after surgery. Sadly, that isn't the case for me. The first few weeks, I seemed to have improved, however I've recently become worse. I have an appt with my gastro again this Wednesday. I'm now experiencing nausea and bloating after every meal, my entire stomach area burns, and I have cramping and gas along with bouts of diarrhea that come on without any explainable cause (I have been on a low fat diet). I consider myself a healthy eater, and I try to exercise when I can, even though I am a pretty petite girl. My mother, grandmother and greatgrandmother have all had their gallbladders removed, but not at my age. I am worried that I am going to continue experiencing this pain forever. It's discouraging because I am so young; a recent college graduate who lost her job because of her illness. Do you have any suggestions as to what steps I can take to figure out the cause of my digestive problems (I've already had an endoscopy, the results were normal)?

Sid Schwab said...

the main advice is to not give up, and to continue to work with your gastroenterologist. It can be frustrating and take a while. It takes perseverance on both of your parts; hopefully you have a doc who'll keep working on it with you until it gets sorted out.

Anonymous said...

Even more galling when a perfectly good gall bladder is removed due to a sluggish HIDA scan, and RUQ pain due to radicular problems from infected nerve roots.....in retrospect now....due to undiagnosed with Lyme disease!! They got their quarter pound of flesh however...or howevermuch a gb weighs in sans stones or other problems.

Then 3 yrs antibiotic and I felt well enough return to work...now 10 yrs later I still pulse with some antibiotics when sx of stiff neck etc start creeping back...but I am 99% functional and pleased to be that way.

CA Grandma

shannonv33 said...

Well I tried to post yesterday but dont see where it came through so I will try this again lol. To start out lets just say that I am one of those people who had there gb taken out two years ago and still live with pain almost on a daily bases. I have been told by a few different GIs that it sounds like SOD, but theres noway of knowing for sure without a ERCP. I found everything you wrote every interesting and told my group to come here and read and they thought the same. I cant believe thats theres so little known about SOD and how to cure it. The GI specialist I seen in ann arbor MI told me to never have a ERCP being that the risk where so high, so what do I do now. I really hate to live on percocets for the rest of my life being I am only 37 and have three kids that I have to take care of. Is the reason that theres so little known because not to many people end up with this???? Well just wanted to say thanks for the good read, and if anyone happpens to come across this and is looking for support I will leave a link below to a support group I started for SOD and pancreatitis ( seems like they go hand and hand)Hope to see more of SOD or pancreatitis in the future, will be sure to check back in.
Thanks so much !
http://health.groups.yahoo.com/group/Pancreatitis_sphincterofoddi/

shannonv33 said...

Sorry my link to come through for the support group for SOD and pancreatitis, will try posting this one more time!!
http://health.groups.yahoo.com/group/Pancreatitis_sphincterofoddi/

"Elizabliss" said...

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?

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.

Sid Schwab said...

Elizabliss: when the main bile duct is dilated and not emtpying well through the sphincter of Oddi, there are definitely surgical solutions: either making a new direct link between the bile duct and the duodenum (choledochoduodenostomy, one of my favorite operations), or the somewhat more complex Roux Y choledochojejunostomy, where a loop of small intestine is brought up to the duct. The only way to know if something like that would be useful for you would be to see a surgeon again. If by UCSF you mean San Francisco, there are some expert biliary surgeons there, including Larry Way. He may or may not be doing surgery any more, but his opinion would be valuable.

Eric said...

Dr. Schwab,
I had suffered from flu-like symptoms on and off for about 2 months, as well as the nausea, bloating and pain on right side that extend into my back. Had a HIDA scan with CCK(I guess), found gallbladder working only at 17%. My PCP is going to send me to a surgeon to have Gallbladder removed. In your post, you mentioned "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". I was not so sure the reproduction of the pain during the test. On the other hand, my pain is not as severe as before having Zegerid. What really bothers me now is the fatigue, sleepy all the time and sore legs (flu-like). Could you give me some opinion? Do you think I should go to see another doctor for a second opinion before my gallbladder is gone? Thank you very much!

Sid Schwab said...

I really hate, from afar, to render opinions about specific problems, preferring to give general information. In "grey zone" situations, it never hurts to get another opinion -- from someone who can examine you and your records, of course!

Deb from Nebraska said...

Dr. Schwab,

I am a 38-year-old female patient. I developed an Insulinoma (pancreatic tumor) during my first and only pregnancy in 2003/04. I could have had it longer, but daily hypoglycemic episodes did not begin until shortly after delivery. I had a distal pancreatectomy and removal of 1/3 of my pancreas, which has also made me a diabetic. I currently take 1,500 mg. of Glucophage daily to maintain healthy blood sugars. Anyway.... just wanted to give you a quick background.

I began to have upper right quadrant symptoms approx. 5 months following my pancreatectomy. I had a HIDA scan completed in January 2006 at the request of my GI Dr. It showed an ejection fraction of 21.8%. However, when they administered the CCK, it did NOT reproduce the symptoms of my attacks. It only made me feel very nauseous for about 3 minutes during the test. My attacks have not been regular. Approx. - 8 to 10 total attacks since on-set of symptoms. The attacks last from a half hour to two hours. They cause intense pain in the region by the gallbladder, but I don't have nausea or the shoulder/back pain. Other symptoms daily that I seem to have are: severe bloating from belly button up to chest, and just an "all-over" dull pain in the upper right quadrant. I also had and MRI completed last summer 2006 to rule out any duct blockages due to the pancreatectomy. That test was normal. My GI has told me that I may be a candidate for surgery, but due to possible adhesions from my previous surgery, I may not be able to have it done laproscopically. He also said that pain relief is a 50/50 coin toss after the surgery. I would like to have another child, but am leery of the insulinoma returning, or this biliary thing really giving me pain. Can you please give me your opinion? I already feel like quite the unusual patient after an insulinoma. Odds are 4 in a million. I was the only patient here in Omaha, Nebraska with that diagnosis. A pancreatic surgeon at the Med Center completed my surgery, however…he had only operated on 2 other insulinoma patients in his career, and they were both in Philadelphia. Can diet change a Biliary Dyskinesia diagnosis? I suspect that the Surgery has had something to do with this.... don’t both organs (pancreas/gallbladder) share the same duct? My surgeon did not feel stones; therefore he did not remove my gallbladder. He did note a hemangioma 2.5 cm. on my liver and completed a spleen preservation with my surgery. OK...I rambling now... but my case tends to be complicating. I would love to hear any advice that you may have for me.

Thank you,

Deb from Nebraska

Sid Schwab said...

deb: I'm really sorry, but I don't feel right giving specific opinion from this far away. I assume you've had an ultrasound looking for stones: feeling gallbladder at surgery isn't always accurate. And I'd think talking it all over with your surgeon would be useful as well, in terms of likelihood of your problems being related to the gallbladder, and/or to adhesions. That's really as far as I can go without actually being directly involved.

Mama Mia Johnson said...

Has anyone ever grown a 2nd gallbladder? I had mine removed after fighting the severe symptoms for two years(workaholic). When the niight came I thought I was puking my gallbladder up I went to the ER. Since I worked in the business side of medicine I was lucky and new the surgeon, who reamed me out after the fact because when he got in, it had gangreaned(sp)and he said it made his job very scary. Well I had a good recovery no post pain like alot of the post describe, except when I ate cukes. But about 6mths after the fact I felt a lump, growth in the area where my gallbladder had been. Now it is about the size of a baseball. It only bothers me when I have bad coughing spells(bronchitis ect)it will hurt some and I will feel nauseated, but other than that it just grows some. I don't have medical insurance now and I am not a great patient so I have put off seeing about it.Any thoughts?

Sid Schwab said...

Mama: gallbladders don't grow back. What you describe really ought to be evaluated at some point. It could well be an incisional hernia, or possibly a low-grade infection.

Kelly said...

I'm certainly not a doctor, but am becoming an expert in tummy trouble since my gall bladder removel (no stone present) abot 3 years ago. My doctor now tells me I may have GASTROPARESIS. (It took 140mins to digest my scambled eggs) Do you think my vagus nerve could've been damaged? Could Nexium or drinking carbonated drinks cause this problem. thank you for your considertion.

Sid Schwab said...

Kelly: it's virtually impossible that a vagus nerve could be injured in a routine (or even a pretty non-routine) gallbladder operation. Various drugs can affect gastric emptying; fats typically go slowly, too. I'm not aware of a causal issue with carbonated beverages, but they can cause worse bloating with gastroparesis. Diabetes is a cause, as you probably know.

Anonymous said...

Could you give me advice on the best diet to stick to after just having my gall bladder removed? I am a (lacto ovo) vegetarian and have been a very healthy eater for many years. I have had problems with cholesterol in the past, but not being a fan of prescriptions, I chose the easy route of lowering my cholesterol by simply adjusting my diet a bit. Cheese was the big culprit in my raised cholesterol so I've been able to cut that down. I'm also anemic (and have recently had a partial hysterectomy...with some more recent ovarian cysts) so that has made it even more difficult. Any suggestions?
Thank you!

Sid Schwab said...

I don't want to get into specific recommendations, because that's too much like prescribing for people I don't know... But in general I told people to eat whatever they feel like (within whatever dietary restraints they already had). Most people find no disgestive changes at all after gallbladder surgery, and need to make no changes. Some wil have looser stools with fatty foods. Some might find some things don't agree any more, and will need to make changes. But for most people, it goes fine with no need for change.

C.A. Cole said...

Hi Dr. Schwab,

Thanks so much for your site and posts--you've got a great writing style!

I had my gallbladder out on 1/2/08 (Happy New Year!) and have been much better off for it with the exception of the past 36 hours which have been "digestively ultra-challenging" following a high-fat traveler's diet for about 4-5 days. I've just scoured the Net, filling my head with lots of fear of this challenge becoming my daily life, and am curious if you can shed some light on your experience with some of your patients who go beyond loose stools into downright yellowed incontinence. (Also, I am only 33, female, and have no other health problems.)

Can you shed any light on other patients that you've seen who have digestive complications weeks after surgery, and what they've done to alleviate symptoms of nausea and diarrhea?

Thanks so much,
-CC-

Sid Schwab said...

CC: it's still pretty early after surgery. Inflammation in the area of the surgery can affect things, so that what's going on now may not be how it'll be in another few weeks. Meanwhile, the first thing is to identify, if possible, what foods seem to be giving you problems, and avoid them. And it's always best to be in touch with your surgeon to let him/her know what's going on.

C.A. Cole said...

Thanks for much for the quick reply, and for the good news that this may not last forever. I'll keep my eye on signs, symptoms and triggers, and my fingers crossed that this was an adjustment fluke, albeit a pretty intense one. The assisting surgeon's my point-girl, and she's been contacted.

On a comedic note, I think the highlight of my day was when my visiting grandmother asked me if I'd like to borrow a Depends. Good times. ;)

Thanks again.

K.P. said...

Dr. Schwab,
I am 10-days post GB removal, following primary symptoms of severe nausea with moderate RUQ pain. Found this site while researching GB disease (the volume of bad outcome reports is startling). My questions is: In your experience is the continuation of nausea symptoms (my are tailing off but still popping-up from time to time) a typical post-surgery recovery issue? Thanks in advance of any reply.

Sid Schwab said...

KP: the problem with "the volume of bad outcome reports" is you don't know the denominator. Around 250,000 gallbladder operations are done a year. Only the people who have problems are talking, mostly. The vast majority do just fine.

It's not unusual to have some nausea for several days after nearly any abdominal operation; but you should be in touch with your surgeon about questions, this close to surgery.

Anonymous said...

Dr. Schwab,
To close the loop on my earlier comment/report, I am now approximately 90-days post GB removal. My post-op course has not been as I would have hoped--continued pain but less nausea. I seem generally worse than before the surgery. I've had multiple follow-up visits with surgeon and GI. Have had blood work, abdominal and chest x-rays and more recently an EGD. All reportedly normal with the exception of one test (Parmethius?) suggestive of Chrone's Disease but GI feels it is "false-positive." GI has suggested I seek a second opinion because he doesn't believe there is an issue--and doesn't consider it to be SOD. Since I'm not shopping around for that diagnosis, I'm just going to try and live with it for a while.

Is there any chance I'm still feeling some lingering soft tissue and/or nerve discomfort from the lapro procedure. I've been told some folks just recover much slower.
K.P.

Sid Schwab said...

k.p: it's true there's variation in recovery rate, due to many factors. You're still in a time frame where there's potentially lots going on, so it's quite possible things will get better with time. Let's hope so! Meanwhile, it's good that you're following up with your docs.

Cici said...

Hey anonymous,

It's been about 100 days of recovery for me and there are a few things I notice that I hope you might take comfort in:

First, phantom pains are very real. I had mine checked out. Also, if you stretch your stomach muscles or work out, you may feel muscle pains in that area that mimic gallstones pre-surgery.

Second, I have strange food intolerances that set off massive intestinal disturbances that feel like Chrohn's but is not. The culprits are not fats in general, but certain types of fats in too-large quantities, such as cheese or avocado. Simply staying to normal-sized portions and walking every day helps tremendously with both dietary intolerance and internal inflammation in the colon.

A speedy recovery to you.

K.P. said...

Dr. Schwab / Cici,
Thanks for your comments! I have accepted that a responsible and disciplined diet is going to be a long-term thing. Nothing bad about that. And, I have returned to an active life style and I do think brisk exercise is helping in terms of cramps, abdominal pains, etc.

I guess I just expected too much from the surgery and under-estimated the time line for my digestive system to find a new balance.

lynn said...

After almost a year of Dr. visits, medical procedures, tests and scans
I have been told that my GB is only functioning at 14%. My symptoms consisted of constant gurgling in my stomach, fullness and feeling like there was something stuck between my breasts, like something just wasn't digesting. Many times I had severe indigestion with pain running up into my left shoulder but never any pain on my right side. I had a colonoscopy and endoscope and all was great. I was diagnosed with H-Pylori and was prescribed a 2 week round of antibiotics which seemed to help my symptoms for about a month then they returned. I am now taking Prylosect daily and 2 milk of magnesia capsules nightly and am virtually symptom free. My Dr. sent me to a General Surgeon and he is suggesting that my GB be removed. The funny thing is his CMA, while taking my blood pressure, was looking at my chart and made the comment that her GB was only functioning at 6%. I asked her what she was doing about it and she stated she elected not to have surgery. She was having constant diarrhea and she was just treating the symptom and doing great. My concern is the prolonged use of Prylosect. What are your thoughts?

Thank you

Sid Schwab said...

Lynn: Here is a list of FAQs about Prilosec, and it includes one on long-term use. As to the rest: I try not to comment on a particular person's symptoms since I can't do justice from this far away. As you can tell from my post, the diagnosis of gallbladder dysfunction when there aren't stones or inflammation of the gallbladder is difficult, and HIDA scans can be iffy. I can't second guess your surgeon because he knows more about you than I do. I can say that when I've seen patients with low "function" on a HIDA scan but their symptoms aren't typical of gallbladder problems or are well controlled by non-surgical methods, more often than not I've suggested holding off on surgery. If you feel unsure of the advice you're getting you should get another surgical opinion. Don't consider me a second opinion: I simply can't know enough about you to be specific.

Debra said...

When you say HIDA scans can be "iffy" what do you mean? I fall into that gray area..20% EF, nausea upon admin of the CCK and slight chest and shoulder pain after 10 minutes but no real recreation of the pain I've been having. I also think my symptoms are a tad atypical for gallbladder, although the doctors say there are many ways this can present. Neither the surgeon nor the GI thought the CCK reaction was unusual and both are pushing surgery. For some reason (probably all the stuff I've read online), I am paralyzed with fear and indecision. This issue has really taken over my life and I can't get past it.

Sid Schwab said...

Debra: diagnosing gallbladder problems when the ultrasound is normal is tricky. HIDA scans can be borderline. Many people get side effects from the injection of CCK that can be hard to categorize between just normal side effects, and reproduction of symptoms. When symptoms aren't typical of gallbladder disease, even if the HIDA scan is abnormal, there might not be relief of symptoms with surgery. Those are general statements. Dealing with an individual can't be done by someone like me, not directly involved. If both your surgeon and GI doc are convinced but you still have questions, you should address them with them until you feel your concerns are well-answered.

Debra said...

Thank you, Dr. Schwab. I have been asking, but questions definitely remain. I'm getting second opinions from another surgeon and GI. Because my pain symptoms are not so bad right now, it's hard to reconcile that I may, in fact, make things worse by having the surgery. And to top it off, I've never heard of anyone else with this particular problem. Stones? definitely. This? No.

Debbie said...

regretgbDr. Schwab: You mentioned to another poster that it would not be likely that the vagus nerve could be injured during a gallbladder removal-would that be open or laproscopic. I too developed severe gp after lap gb surgery and actually now live on tpn. Thanks-just wondering what might have caused gp? No narcotics

andrea77 said...

hi Dr schwab,
I had my Gb removed 2 months a go. hida scan came back at 8% with cck. I have the same problems I did when I went in , now with a little more, {terrible heartburn, bloating, rolling acid that wakes me up at night and the nausea is never ending. I want to get pregnant again but i cant hardley eat cause of the nausea,im losing alot of weight (im worried the baby would not get nuterients.) what can be done to make this go away. i cant keep living on antacids. I also get this weird squeezing inside my back on the left side bet. my sholder blade and spine, about 20 mins after i eat, what could that be?? could it be my pancreas?? i eat very low fat now, i dont know what else to do . can you give me any suggestions i can take back to my surgen for him to check. anything is appreciated . p.s. what is the best thing i could take otc for nausea?? thanks..

Sid Schwab said...

andrea: It could be a number of things. It sounds like you need an evaluation by a gastroenterologist, although starting with a revisit to your surgeon would make sense just to be sure there's nothing going on related to the operation. I doubt otc nausea meds will do much for what you describe; being re-evaluated soon sounds like the best plan.

caesars said...

I live in Louisville Kentucky how can I find a surgeon that will remove my gallbladder without me having any insurance. I have been without insurance for the first time in my life now of all times I need it the most Im sure my gallbladder would have been removed before if I had insurance any advice. also I do not and can noy get any help except medAssist. please help me find a surgeon. thanks caesars

Sid Schwab said...

I have no knowledge of the situation in Kentucky. My only suggestion is to contact the social services office of the nearest hospital, or the local medical society, and see what they can offer.

Anonymous said...

I have been dealing with a motility disorder for about a year, suspected cause is a virus. However, I have a family history of Gallbladder disorders and had a HIDA Scan in which the GB did not visualize enough that they could do the emptying test. We later did a Stomach Emptying test which showed some delayed motility. Overall I've been managing my condition with diet and can't say that I'm suffering, but I do miss my healthy days.

So, my question, are there any studies that show if the gallbladder is dysfunctional, can it be the cause of my motility disorder? My GI Doc thinks it's all realated but I've read some conflicting information on what causes what, and it appears to me as though there's no real answer.

So, while I'm sure you can't answer specific to me, I was just curious if you have any links you could share where I could read up more on the relationships between Gastroparesis, SOD, Pancreatis (Gallbladder related) and/or Gallbladder Disease (without stones).

Sid Schwab said...

anon: It's been my impression that some motility disorders can affect the gallbladder (that, after all, is what biliary dyskinesia is.) I don't believe it's the other way around; ie, gallbladder dysfunction wouldn't be the cause of other motility disorders.

Sean said...

Appreciate the time to reply. It seemed like that was the consensus (Motility -> GB not vice versa), but, I read one persons report (via the net) that they were doing much better with emptying after having it out--going by the theory that the delayed bile output from the GB was slowing digestion of food and thereby slowing the stomach down. While it seemed like a reasonable theory, I have no idea (and there could be other factors than the GB). In the interim, I am managing OK by eating healthy(er). Thanks again.

Anonymous said...

Dr.Schwab,

I had my GB removed 10/31/05, after a year of pain and testing. My liver enzymes were always normal, My hida scan showed that it wasn't functioning. To what degreee I am not sure. When they took it out is was scarred and shriveled. No stones. I was good for about 2 months. Then the pain came back.in BC Canada, it takes for ever to see a specialist, So when I finally saw him, we did a Ct, it showed a choedohal(sp?)cyst, so we relucantly did an ERCP. UGh. I guess it wasn't a cyst. He couldn't get into my pancreas duct. I then had an MRCP. It showed a diversion of my pancreatic duct. I guess my question is could this cause me pain similar to when I had my GB? I know my description is vauge. I dont have the results of the tests in front of me. He did put me on pancreatic enzymes. Theyhavent helped. Any ideas.He said there is nothing more he can do for me. Is it all in my head?? -Angie

Sid Schwab said...

angie: I really don't have enough info to make any meaningful comment. I don't know what the meaning of "diversion" of the duct is -- it could be several things. It sounds like one of those frustrating situations that will take time to unravel.

g8er187 said...

Hey doctor was just reading this post, and I found it interesting. I'm 13 weeks pregnant and have been suffering from gallbladder symptoms for 7 weeks now. I had the ultrasound and they didn't find any stones said everything looked normal but days later I had a lot of swelling on that side lasting for a few days. The doctors have done nothing about it, and my midwife doesn't even talk to me about options. I am on basically a vegan diet, no cholesterol,under 10 grams of fat,no meat or dairy at all. At first it seemed as though the attacks were subsiding and now I find myself in pain no matter what i eat.Every woman in my family has had their gallbladder removed. I was just wondering why no doctor will even talk to me about running more tests to find the source of the problem. I honestly want the surgery regardless of the outcome.( minor gallbladder attacks have set off irregular contractions a couple times) Are there any free online documents I can view on the risks and benefits of a laparoscopic procedure at 13 weeks gestation? In your experience would you consider someone with these symptoms to be a candidate for the surgery? I'm in need of some kind of relief! thank you

Sid Schwab said...

gator: most surgeons would be very reluctant to operate on a pregnant woman with no confirmatory data; it's always iffy to operate for symptoms without being sure it's the gallbladder, and much more so during pregnancy. Maybe you should see an obstetrician to see if s/he would have other suggestions. I'm pretty sure no surgeon would operate at this point, with the info you've provided.

suzy said...

This has been a very helpful site/trail. I have been coping with 10 months of GB pain (we think it's GB - but homoepath ponders a festering appendix). All tests were normal, no stones found, but HIDA scan with CCK was 15%. Interestingly, I had pain relief when the CCK was injected. Could my dyskinesia (current diagnosis) be related to loss of hormones / enzymes that are suppose to signal the GB contractions? I'm getting some relief with acupuncture, chinese herbs (diuretic & antispasmotic in nature), and osteopathic visceral manipulation. However, the pain and spasms 45 minutes after some meals continue. I have an open invitation for surgery, tho' the surgeon was very respectful of my wishes to try everything before this option. Any ideas? Thanks for your contributions for our collective health !!

Sid Schwab said...

suzy: I'm not sure what you mean by "loss of hormones/enzymes that are supposed to signal gallbladder contractions." CCK is a hormone that causes contractions; I'm not aware of enzymes that "signal" contraction, and I'm not sure if by "signal" you mean "cause" or "reflect." In any case, the decision to operate when there aren't definitive indicators of gallbladder disease (HIDA ejection fraction of 15% could be considered suggestive, but not 100% conclusive. The diagnosis of biliary dyskinesia is partly one made by excluding other explanations.

If you've looked around my blog at all you'll know I don't think much of homeopathy. The diagnosis of a festering appendix is not unheard of -- I've seen an operated on a few -- but doesn't sound at all like an explanation for the brief description of symptoms you provided.

It sounds like you've had input from all points on the spectrum. I assume it's included a gastroenterologist. That's where I'd be looking in a situation like yours: one that's not at all clear cut.

Walkingeagle said...

Dear Dr Schwab, I had gall bladder surgery in 2006 and have had complications. I have been diagnosed with two conditions. I am going to one of the best drs in the US for this and he has been great but I was wondering if you could put some of this in terms that I can understand. I would very much appreciate any help. Would you email me at walking.eagle1914@yahoo.com ? When I click on your email link my program will not pull up your email. Thank you very much.

Anonymous said...

Dear Dr Schwab,
In simple language, what does President Obama's "Evidence Based Health Care Plan" mean? I am not sure I understand and thought you could explain it.
Thank you.

Sid Schwab said...

Very briefly, the term "evidence-based" means treatments or interventions that have been tested and found to work or provide benefit. It hasn't always been the case: what is the evidence, for example, that a given pill works better than another; or that this operation is better than that one, or than no operation at all.

I was taught, decades ago, that everyone who had their gallbladder removed needed to have a stomach tube for three days. Why? Who knows? Haven't used them for many many years. Same for stomach tubes after bowel surgery: turns out people recover faster without them. Little things, big things.

Cheryl said...

Dr Schwab,
I have been doing Gb research for my abdominal pain and have few questions. 1)If the Gb is contracted on a CT and you haven't eaten for 18 hr., what could that mean?(no stones seen) 2)Is yellow stool exclusivly an indication of Gb disfunction? 3)Can journaling what sets off pain in diet be helpful in a diagnosis? 4) Can having Gb disfunction cause tiredness and not feeling well in general?
Thanks in advance for helping me to continue my Gb education.
Cheryl

Sid Schwab said...

Cheryl:

1) I don't think it means anything, absent context. Contractions don't occur exclusively after eating.

2) I don't think yellow stool reflects gallbladder problems at all. Pale stool, ie like chalk, can reflect obstruction of bile flow between liver and gut.

3) Yes

4) Depending on the underlying cause, yes. Then again, so can a few hundred other things.

Matthew said...

great blog/post - Matthew here, I'm one of those unlucky ones, I have nausea 24/7 and the slightest hint of anxiety or stress brings my nausea up the wall. Had my GB removed in 2007 with 16% ejection and no stones but it was really infected and the surgeon said it was about to rupture when it came out (couldn't even lay on my right or left side!). I feel like I have chronic pancreatitis pain (upper left and upper left back pain..not major but i've never drank at all).

Now last few months my right side feels like it did before getting my gb removed.. just had a MRCP which came back negative. I begged my GI doc to send me to a ERCP specialist here in utah and I see him on the 30th. Ever heard of anyone having SOD without major upper right pain? I can't think why the gallbladder would blow up, and all blood and imaging would be negative. Also stress adds to my chronic nausea and pain..(and doing anything physical. Feels like my pancrease is a balloon) diagnosed anyone with SOD with those symptoms?

Sid Schwab said...

Matthew: SOD is, in my mind anyway, such a difficult diagnosis to make based on symptoms that nearly anything is possible. SOD could explain your symptoms perhaps, as could a number of other things unrelated to your biliary tract, such as irritable bowel syndrome of various other intestinal problems. These sorts of things sometimes take a while and lots of patience to sort out. The main thing is to have a doc in whom you have confidence and stick with him/her until it gets figured out.

Matthew said...

Thanks doctor, It was worth a shot, I have no insurance and all this testing has drained all my life savings and 401k so.. I can't think of what else would cause symptoms of chronic pancreatitis and a gallbladder to suddenly blow up like that :S very frustrating. I hope this ERCP finds some solution, because every test has been negative (with the exeption of white blood cells found in stool and the gallbladder HIDA scan)

i'll take your advice, thanks for your time :) I feel stress and antibiotics somehow caused this whole disaster, hopefully with future research they can find a way to diagnose easier and cheaper than this. Thank you! :)

Anne said...

Dear Dr Schwab:

What are your thoughts on the idea of increased risk of bowel cancer after gall bladder removal as bile drips continuously into digestive system? One web site also
mentions the constant bile drip causes the diarrhea that so many people seem to suffer with.

If my AST & ALT were were 721 and 532 pre-surgery, should these nos. be significantly lower post op?

Your blog is interesting. Neither
my PCP or surgeon mentioned HIDA scan or EF rate or CKK. My surgery was 5/1/09.

Thank you for your service,
Anne

Sid Schwab said...

Anne: HIDA scan is generally only used when there is suspicion of gallbladder disease but no gall stones; or sometimes when there are gallstones but the symptoms aren't typical.

As to the colon cancer connection: it's one of those things that doesn't entirely make sense: having the gallbladder removed doesn't change the amount of bile that is produced and enters the bowel daily. By the time it gets to the colon, the drip vs pulse ought not make any difference, since it's passed through 15 or 20 feet of small bowel, mixed, diluted, etc. Most bile gets into the gut by steady drip anyway, since the liver makes about a quart a day, and the gallbladder generally holds only a few ounces.

The data that show anything are sort of self-canceling: a slight increase in cancer of the upper colon and a lowering of cancer in the lower colon. Finally, there are data to suggest it's not the surgery but the stones: ie, bile that forms stones is of a different chemical makeup from that that doesn't. People with stones may end up having surgery, but it's not the surgery that is the risk factor: it's having stone-forming bile. That makes more physiological sense.

In other words, I consider it a non-issue.

Diarrhea can be an issue post surgery, but it's in fact relatively uncommon and usually not hard to control with dietary measures. Some people indeed have a bigger problem with it, but that is, thankfully, pretty rare.

The enzymes may or may not return to normal. Some people have a persistent elevation after surgery. Absent other evidence of liver dysfunction, it's not considered significant. Also, the elevation might or might not be due to the gallstones; so it matter what the original cause is thought to be.

Dana said...

Hi Dr. Schwab

First of all thank you so much for your blog and comments. I am one of those people struggling with the decision whether to have surgery or not. Like many others, I was put off by all the "failure stories" on the net, and am now regaining some confidence in surgery due to your highly informative blog.

Again like many others, I would welcome any comments you might have on my situation, and I do realize you cannot have an informed opinion "by distance". Still, any thoughts would be appreciated!

I was diagnosed with gallstones about 8-9 years ago by ultrasound. At the time the symptoms were the classic "attacks" with excruciating pain that would go away after 20 minutes or sometimes longer. No vomiting or diarrhea, just pain. This lasted for a while, I started paying more attention to my diet, and then they disappeared. They occurred only twice in the last few years.

However, for the last few months, a new symptom showed up: constant, dull, pain under my right rib, followed by a sensation of swelling in my upper abdomen. It lasts for weeks sometimes, then it eases off, then it shows up again. It's especially painful at night and it doesn't seem to be connected to fatty foods. Now, I think I read something on your blog related to this, and you were mentioning that this symptom is even more dangerous than the sharp pain (if I understood correctly). It seems to happen more and more often so I'm starting to worry. Would you say this is a pretty clear case where surgery is needed?

Oh, and subsequent ultrasounds through the years confirmed the stones (many small ones - I can't remember the exact size).

Thank you very much!

Dana said...

Oh, and one more question: what are your thoughts on Mini-cholecystectomy Under Local Anaesthesia? Where I live there is a surgeon who's done some research on this (with success!) and I'm thinking of getting in touch with him, as the thought of general anaesthesia freaks me out. Thanks.

Sid Schwab said...

Dana: the more recent episodes you describe could be "cholecystitis," meaning inflammation of the gallbladder, as opposed to the earlier episodes which sound like typical biliary colic. Cholecystitis is more "serious" in the sense that it can lead to infection or other complications. Understand there's no way I can tell if your symptoms are due to that or not. It's just that it's among the possibilities.

I never tried doing minicholecystectomy under local. Whereas it would be easy to make the incision painless, rooting around inside could be uncomfortable and would require either heavy sedation or some sort of regional (ie spinal or ribs) block. Or so I believe. I've discussed it with anesthesiologists. The problem with heavy sedation is you get some of the risks of general anesthesia without the respiratory control. The problem with regional anesthesia at that level is the possibility of interfering with respiratory muscles. So, whereas the idea is appealing, I think there's greater safety with general anesthesia, which, as you may know, is extremely safe nowadays for the vast majority of situations.

On the other hand, if the surgeon to whom you refer has perfected a technique, I'd say good for him. I most certainly don't consider my view of it the last word; nor, obviously, is it based on experience.

Dana said...

Thank you so much for your quick reply Dr Schwab!

Yes, you are right, they do it under sedation if I understand it correctly from the article. By the way, the abstract is here just in case you are curious (sorry for the long link):

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B83W3-4TD4GY1-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=947680357&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6a434d8d9d94f2f4eadfff2785da7e43

And come to think of it, I don't like the idea of sedation either, especially since it doesn't work very well for me (I have chronic insomnia and most pills have little to zero effect on me!).

I think what you say absolutely makes sense, so I will have to reconsider this.

Looking forward to reading more on your blog!

Sid Schwab said...

Thanks for the link. It sounds like it works pretty well and, obviously, they have an anesthesiologist there, so they can convert to general anesthesia when needed.

Ruth said...

I had the nuclear die test done on my gallbladder and had no symptoms during the test. The technician said that everything was fine, except it wasn't emptying. He said it will need to be removed most likely.
I had this test done Friday (also an ultra sound that showed no stones) I'm American, but living in China and am suppose to return to China next week for the beginning of school for my children. My primary care physician said he will get the results on Monday and schedule me for the removal of my gallbladder on Tuesday and I could travel 1 week later.
I'm feeling really rushed into this. I am a 40 year old female, only 15 pounds overweight, but terrible diet with lots of fatty foods. My question is this; would there be any harm in postponing the surgery until December? I could come back and stay in the US for 1 month (instead of 1 week if done now) I could dramatically change my diet and try acupuncture in the mean time. Also that way I would have time to meet the surgeon and discuss this with him as there wouldn't be time for me to consult with him if I have it done on Tuesday.
My symptoms aren't really bothering me too much. Occasionally I have pain in my upper right chest (right below my breast) after eating (really bad for 2 days in July especially when drinking cold liquids, felt like I was swallowing my stomach... but better diet and loads of antacids for a couple days and it was much better), bloating after meals, a little gassy, nothing that I can't deal with until December. How likely would it be that my gall bladder would rupture in the meantime? My options in China are limited and emergency care is pretty awful. I know this sounds premature since I don't have my results back, but I know my doctor will want it out now based on our previous consultation.
I would really appreciate your opinion. Thank you!

Sid Schwab said...

Ruth, I really don't like to give very specific advice because I simply can't know enough about any case from so far away. (Over the internet is far away, let alone China!). I can make general comments.

Rupture of the gallbladder is pretty rare, especially in a non-diabetic. Most people who have symptoms without any complications, ie signs of inflammation or stones in the bile duct, etc, can have surgery (or not) at a time of their choosing.

I usually told those who can control symptoms by diet, etc, and who prefer to delay or try to get along without surgery that it's okay, as long as they realize complications could occur anytime. However, it's rare, if those complications occur, to develop a need for immediate surgery. In general, I considered the timing of uncomplicated gallbladder surgery up to the patient, unless there were certain mitigating circumstances. It's a crystal ball thing: no one can predict the outcome of any choice.

Ruth said...

Thank you for your reply. I really appreciate your time and information!

Lol Mettam said...

Dear Dr. Schwab,

This is a fascinating thread (and blog). Thank you for providing so much useful information.

I would like to ask a question on behalf of my wife.

About two years ago, having following a fat-loss diet for a lengthy period, my wife suffered a bout of pretty severe pain. After consultation with her GP she had an ultrasound scan which revealed many small gallstones in her gallbladder.

Before opting for surgery she decided to read up on the subject as much as possible. There were plenty of scary stories and advice to try all sorts of things rather than go for surgery straight away.

I wondered if it would be possible to have the stones removed but to leave the gallbladder intact? I asked a surgeon (here in the UK) and was told that it wasn't a procedure that was offered because the stones would just come back and then my wife would be back to square one. I was a bit surprised that the stones would come back quickly, seeing that they had taken over forty years to get there in the first place. (Although, I do think the situation may have been exacerbated by her period of dieting - something that she would be careful not to repeat.)

Well, my wife decided not to go ahead with a cholecystectomy at that time and has since managed her diet carefully to reduce the incidences of any bouts of pain.

Two years after her first scan, she has just had a repeat scan. The results show no obvious change in the number or size of the stones; they haven't reduced in number, but they haven't increased either. She is still getting occasional bouts of pain and would now like to get the situation sorted.

My question is two-fold:

(1) seeing that nothing much has changed (in the case of the stones) over the last two years, would this seem to suggest that if she elected to have the stones removed, rather than having a cholecystectomy, that the likelihood of the stones returning quickly would be low?

(2) Are you aware of any procedure that can be performed to remove solely her gallstones and, if so, what do you think of such a procedure?

Many, many thanks for any light you can shed on this.

Sid Schwab said...

I wrote about alternatives to surgery here. In short, any method to remove stones without removing the gallbladder is associated with a very high likelihood of recurrence of stones, as you've been told. There's no predicting a particular outcome, and I don't think the fact that the stones haven't changed, based on ultrasound, tells anything.

She may get along fine as she is; she may get severe complications of gallstones, such as pancreatitis or biliary infection (small stones are more of a risk than large ones); she might have side effects of surgery. The most likely outcome of surgery is relief of symptoms, prevention of complications, and no significant side effects.

That's really all I can offer. In my view, looking at the various odds and possible outcomes, and assuming no unusual surgical risks, most people in your wife's category are well advised to undergo gallbladder removal. Absent intolerable symptoms or the presence of severe complications which force ones hand, the decision to go ahead or not is up to the patient. There's no crystal ball.

Lol Mettam said...

Dr Schwab,

Thank you very much for your speedy response.

Oops! I had overlooked your rather useful 'Flush' page (for which you kindly provided a link). Thanks for that too.

I was always rather incredulous that someone who has a gallbladder attack following a fatty meal would somehow be fine drinking oil! :)

Alison said...

HI Dr Schwab,
I am a 45 year old scottish female who has suffered severe pain for nearly three years. My problems are still on going and this has changed my life.
My pain started with back and upper right Quad. pain, which gradually got worse when eating anything or drinking. It took six months of scans i.e. CT, MRI,endoscopy and loads of blood tests all negative. Then had a hida scan in May 2008 which showed EF. of 10 and problems with Sphincter of oddi, which was causing backed up bile, this is what they thought caused the gallbladder dysfunction. Saw a surgeon in Glasgow who gave me botox into the sphincter and this helped for about six weeks it was then decided a Sphincterotomy was the next step. This took place in October 2008, but it resulted in a perforation, which made me severely ill and was in hospital for two weeks, with lots of intervention as you will be aware of. It was not until January of 2009 I had my gallbladder removed by lap choly, as the surgeon had to wait for a while because of the perforation. Well just my luck it did not go very well either, I was in surgery and recovery a long time some six hours. By the time they did the operation my gallbladder was distended and ready to burst ( maybe it did..., not sure) they wouldn't say, and I had an infection which kept me in hospital for another ten days.It this point I just had enough and prayed it was all over and I would get my life back.
It took four months to get over the operation I lost three stone in weight over this time and was still not eating very much, also still had alot of pain under ribs and back, but by April 2009 I felt abit better and tried to get back my old life. I am A piper in a pipe band and was unable to play my pipes during this last year, so I was very much looking forward to start playing again. But this made the pain worse. I tried and played till June 2009 when things got really bad again and had to stop. I saw the surgeon for the first time after my lap choly in June and he suggested to try botox again in the sphincter, so I had this done in September 2009, but it only lasted 2 weeks. I am just back from hospital in Glasgow were I spent a week getting tests and more scans...oh joy! but the surgeon is not willing to operate any more as I am not a good candidate for these proceedures, after the perforation,so now I am going for a delayed gastric scan this week Feb 2010....what next...,they now think that the sphincter at the outlet of my stomach might also be a problem. Hope you haven't fallen asleep reading this I would appreciate you comments. Sorry its like war and peace.

I don't eat very much now I have been on protien drinks on and off for two years. so lifes great!,my quality of life is nothing as it was, and at 45 I think I should be living better than I am. I am on too many drugs for my liking, Lansoprasole, Domperadone, buscopan, tramadol, chlorphemimine, for constant itching, too much bile in blood stream they say.
thanks for reading I hope you reply.
you can also reply to piperali@ileach.co.uk thanks!

Sid Schwab said...

Well, that's indeed a sad and complicated story, Alison. I hope you understand that anything I'd say is to be taken pretty lightly, because even with your novella it's impossible to know the sort of detail one might get from a face to face consultation, with all records available.

Where and when I practiced, the surgical approach would have begun with gallbladder removal, probably. The timing and type of procedure on the sphincter of Oddi is debatable. Since it was "known" (in parentheses because of the uncertainty in diagnosing sphincter dysfuntion) in your case that the sphincter was dysfunctional, an argument could have been made for doing both things at once.

It's all past history, of course. It's my experience that the sorts of minimalist efforts at sphincterotomy are pretty temporary. That you got some relief for a while suggests a surgical sphincterotomy might be useful, were it technically possible. Sometimes, I think, we get too clever by half; there are still times when actual open surgery is best. Hindsight, as we say over here, is 20-20.

I agree it could be a difficult to do a surgical sphincterotomy now; not impossible, especially if there are people in the area with reoperative experience.

All I can suggest, which isn't much, is that you consider a second surgical opinion, hopefully at a center where there are surgeons highly experienced in biliary-pancreatic surgery.

I really don't know what I'd recommend, were I to be your surgeon. Based on what you've said, if it were possible, an open sphincterotomy would seem reasonable to try. If there's documentation of a dilated bile duct, which there might be if you indeed have too much bile in your blood, there are other operations, too, eg choledochoduodenostomy (sewing the bile duct to the duodenum, with a hole between them.)

Unfortunately, you're in one of those terrible situations where attempts to help have led to problems; attempts to fix them could lead to more. Sometimes it's best to stop trying, especially if you're getting along, even if it's less than ideal.

Alison said...

Thanks for replying so promptly,

Thanks for your comments ,I find myself in a very frustration situation, given my location here in Scotland, I am on one of the scottish islands and find it very difficult as I am the only patient on the Island who has this issue, and have to leave the island to attend appointments on the mainland this is no easy task when your unwell and struggling.

The G P.s find it challenging as I do,( specialist area of gastro.) , do you think the Sphincter dysfunction would have been the first area to go wrong and cause the Gallbladder to become diseased, as I had no stones?.

My only worry is that if left untreated, and only taking endless drugs, is there a possibility of other organs being damaged i.e. Liver, as having no Gallbladder now the next organ in line of fire is the Liver.

The Hospital I attend in Glasgow is the centre which have the biliary - pancreatic surgeons, so I am .. I think at the right place. And as a NHS patient I haven't much choice.

I think I am a bit too challenging given my pass history, and have wished that gallstones were the main issue, as this is more fixable. If I could only get to a stage where I could live with the condition better than I am at the moment, it is very unsetting when it interferes with you every day life and totally
changes you families as well.

As I am off to the mainland tomorrow for the delayed gastric emptying scan to see if this will shed more light on the situation, I can only hope that something more positive will come of it.

My general health is suffering now, with three years of limited calorie intake, its hard to keep going, getting to work every day is a challenge and coping with low blood pressure as a result of this is exhausting, but what else can I do. Lets hope something or someone comes up with a new form of treatment for this condition.

Thanks once again, its good to talk to someone who
understands.

cheers Alison.

Dana said...

Dear Dr.Schwab

Hello again, I am this time actively looking into having surgery. I have a couple more questions:

First, my feeling from reading your blog is that you think open surgery is preferable. (Sorry if you have already explained this - I can't remember exactly what I read where!)I'm trying to decide between open and laparoscopic (it looks like I would be a good candidate for laparoscopic) - the price is one issue but also does the surgeon have more control? All I can find on the internet is that it's all the same in terms of safety etc., but the laparoscopic is better due to speedy recovery and less pain. What are your thoughts on this?

The other question is related I think, I've just read that you mentioned taking out the cystic duct. Is this done only in open surgery? I this common practice and something I should be confidently taking up with my surgeon?

Thank you
Dana

Sid Schwab said...

Dana: first of all, don't let the rantings of an old surgeon confuse you.

I've said -- because it's true, I think -- that my method of open cholecystectomy is "better" than lap chole, because it's faster, cheaper, safer, and has the same recovery time. The problem is that virtually no one does it. If you could find a surgeon who is skilled at removing the gallbladder through a one or two inch incision, I'd consider it. But I doubt you can. The good news is that hundreds of thousands of people have lap chole every year and do just fine. (My sister in law just did, and she's feeling great.)

As to the cystic duct: when I trained a big deal was made of removing it well. Now, with lap chole, in which it's generally left a little longer for safety, it would seem that what I was told was wrong: it doesn't appear to be a big deal. I believe that's what I said, somewhere or other around here.

Dana said...

Thanks for clarifying that! Looks like I'll go for a lap after all.

Anonymous said...

Dr. Schwab,

I had two weeks of upper right quadrant abdominal pain, sent for an ultrasound that showed negative.
Recently had a HIDA scan and the gallbladder never showed until 4 hrs later (they sent me to work and asked me to return), at that time they never injected the CCK. I was just referred to a surgeon who said, based on my HIDA san, my gallbladder needed to come out within the next 3-4 weeks. My question is, how does the surgeon know the gallbladder is the issue when it appears there may be a duct blockage? If the latter, wouldn't an ERCP make more sense?

Sid Schwab said...

I infer that the gallbladder did show up later, since you said "until 4 hours later." It's unusual for it to take that long to fill. It could be that there's residual inflammation from cholecystitis, although usually that shows on ultrasound. In any case, with the gallbladder filling slowly or not at all, the issue would be with the cystic duct, and ERCP wouldn't add much, if any, info about that.

I don't know of any particular basis for saying a gallbladder needs removal within 3-4 weeks: usually it's either immediate, or more or less elective.

The question is whether your pain was from your gallbladder or not, and I don't have the information to judge that. Your surgeon has more info than I do.

Anonymous said...

Thanks Dr. Schwab. And yes the gallbladder showed it had filled (they injected the dye at 8am, told me to go back to work at 10am, and come back for more scans at noon). I was hoping they could remove the blockage and salvage the gallbaldder, but it doesn't sound like that's an option?

If the pain is under control (I've changed to a vegetarian diet) why such an urgency to the surgery?

I'm a healthy, 43 yr old female, normal weight, and concerned about side effects (weight gain, digestive issues, etc) from the surgery. My surgeon says nothing I try will reverse the disease.

Thanks for your comments!

Anonymous said...

Today in finding this I realise that the internet has some positive use.
I am now 3 months post lap choly with in retrospect 10 years of symptoms which did not involve pain post eating. Only twice in 2009 did I have pain symptom which lead me to treatment. They descibed me as stoaic - I thought I had an irritable bowel.
Reading this has put me in perspective with diet and ongoing self management. I was perturbed that whilst the symptoms are better they still occur at times.I thought the surgery was a one stop fix. Thanks for your insight

Anonymous said...

Hi Dr Schwab,

I had my gallbladder removed on May 28, 2010 for an inflamed gallbladder. Since then I have still been feeling nausous and have a constant dull ache in my URQ that will not seem to go away and sometimes the pain makes me want to get sick. I am really concerned that it won't go away and is really getting me down. Do you know what could possibly be causing these symptoms after laparoscopic gallbladder removal? Any advice would be greatly appreciated. Thanks

Sid Schwab said...

The main advice is to be evaluated by your surgeon. The possibilities are many, some related to surgery, some not.

I'll admit that not all surgeons are great about patients who have post op issues. But I'd think he/she would at least want to check some blood tests and maybe a CT scan or ultrasound before sending you to a GI doc or back to your primary care.

Anonymous said...

Dr Schwab,

Thank you for the fast response, In regards to blood tests they recently came back normal and also had an ultrasound last week and waiting for the results to come back. It seems whenever they went over the liver it very tender and painful. My PC doctor is not the greatest and therefore I am going back to see the General Surgeon in October because she wanted to monitor it. I must say I am getting frustrated feeling this way. Thanks!

Cindy said...

In July, for first time, I had stools that looked partilly lke seaweed. Shortly thereafter, started having periodic but minor episodes of pain under right breast, usually late in evening, but nothing unmanageable, even without pain medication (I guess I think of myself am a tough old bird of the grin and bear it vane). Then in early Aug I had a very severe case of diverticulitus which put me down for days at which time I communicated the odd stools and URQ pain to my PC who subsequently ordered a Hyda Scan. I had NO pain during scan but results showed GB function of only 06% so my PC recommended GB removal. I had hoped I could do something to save it or work it back to good health but am told that is not realistic. Do you concur that there is nothing that a person can do to recover a non functioning GB? I would like to try and keep it, if feasible and not foolish. Currently have GB removal scheduled for 10 Dec based on PC and surgeon recommendations. Two weeks ago, I developed quite a rash on my face around my mouth and upper neck. I say a few sites on-line that idicated that rashes in these regions could indicate Gallbladder/liver problems. How do you feel about that correlation?I have also started having spams again in my lower colon and am wondering if perhaps there is a relation to the GB disfunction; could food not fully digested be getting to/sitting in a color poutch and contributing to diverticulitus? I just had a followup colonoscopy and my surgeon says there are more poutches than she can count and that when I have the GB removed she will look at the outer colon, via scope, and if she doesn't like what she sees a part of the colon may need to be removed also. I mentioned that I am starting to experience the colon spasms again and she prescribed another round of antibotics which I am holding off on until 2 weeks prior to GB surgery, if pain doesn't get too bad(trying to control with BRATS diet for now). I figured if I took the antibotics the 2 weeks prior to the surgery it might help avoid any chance of infections or MRSA should there be exposure to such during surgery (my husband got MRSA in a hospital and ending up in bed for over a year trying to rid it where it settled in his spine). Is putting off the antibotics bor 10 days foolish? I am a 54 year old female, avoid ALL simply carbs and processed foods.

Sid Schwab said...

Cindy: wow, lots of questions there.

I assume you had an ultrasound that showed no stones, otherwise the HIDA scan would have been sort of irrelevant.

Absent stones, as I've said, the diagnosis of gallbladder problems by HIDA scan can be problematic. If you were in the midst of diverticulitis, it's possible that could have affected gallbladder function without there being a primary problem with the gallbladder... I'd agree that there's nothing specific to do to "heal" a poorly functioning gallbladder in general; but the question is what accounts for the poor function: intrinsic disease or something else going on elsewhere.

I've also written about diverticular disease of the colon. At the ends of the curve, decisions are easy. When surgery is indicated for a person with mild symptoms can be more difficult to decide.

I don't think it's a good idea to change the timing of a prescription from your doctor without discussing it with her. In fact, I'd say it's a bad idea.

Cindy said...

The HIDA scan was done a good 6 weeks after finishing up a round of antibotics for the diverticulitus; is that a sufficient time span to yield an accurate HYDA scan? Also, still wondering if the facial rash could be connected to gallbladder function (or lack thereof).

Sid Schwab said...

I don't know of any facial rash that would be related to gallbladder dysfunction. There are some conditions related to liver disorders that might have rashes, but those would involve pretty abnormal liver function tests.

I don't know if six weeks is enough time or not. Probably. But I can't say with certainty.

Anonymous said...

Dear Dr. Schwab,
I am a surgical circulator and I have also been diagnosed with SOD Type II via ERCP w/ manometry. I happened upon your blog as I was researching some ideas for living with this condition. I was laughing out loud at your comments about diagnosing biliary dyskinesia. Having lived it and seeing the frustration on the faces of my surgeon, PCP, gastroenterologist(sss) and numerous ER docs I can really appreciate how difficult it is to diagnose and treat these conditions.

Thank you for talking about it so openly. The answers are not always easy or concrete and I sometimes forget that when I'm in the patient role. It is hard to be patient when I am the patient.

I am wondering if you have seen a decrease in the frequency or intensity of "attacks" after women have hit menopause or had a hysterectomy with b/l salpingo-oopherectomy? I'm thinking about the effects of the female reproductive hormones on the smooth muscle of the gut.

Thanks again for making me laugh.

Carol

Sid Schwab said...

It's an interesting question, Carol. I'm not aware of cases, nor have I seen any literature to suggest there's a correlation.

Thanks for finding the blog. Receiving comments on older posts gets me to re-read them; if I do say so, this one was pretty good!

Anonymous said...

Hi, I happened upon your blog and love all the great information here. I am a 30 year old female and started having anywhere from a nagging to very painful left shoulder blade pain back in the summer. Other symptoms have come into play, diarrhea, constipation, nausea, occasional stabbing pains in gallbladder region. I had an ultrasound which was negative for stones, and HIDA was at 7%. I met with a surgeon that suggest to remove the gallbladder, nothing immediate, and left the decision up to me with the note that I would probably start feeling worse as time goes on. My question is, is left shoulder blade pain with pain under the left ribs common for gallbladder? I am asking to see if I might need to rule out other such problems. I seek chiropractic care and he has told me it is nothing related to the spine. The surgeon did say I was a little atypical with that pain and he had seen it before but not often. thank you for your time. Love all the information

Sid Schwab said...

Anonymous: First of all, I'm impressed that you found a chiropracter who said it -- or anything -- isn't related to the back. Keep the guy on your list if you ever get back trouble!

Meanwhile, yes, such pain can be due to gallbladder, and yes, it's uncommon. The intestinal symptoms are pretty non-specific.

As you can infer from my writing, when the symptoms aren't typical and there aren't stones, it's hard to be sure when surgery will help, even with an abnormal HIDA. I feel more confident when the CCK injection clearly reproduces the symptoms, but even that is far from a certainty.

When the symptoms aren't typical, I think it's important, as a general principle, to rule out other possible explanations before having surgery. As to particular situations, I can't offer much help from over here...

Anonymous said...

thank you for the quick response to my question. I did the CCK injection and yes, I was highly nausiated with somewhat intense pain in the gallbladder area- about a 6 on a 10 scale. It caused my left should blade pain to be very intense, more so than my pain in gallbladder region. I just have read so much on right sided pain that with mine being left sided-kinda just makes me wonder. My chiropractor referred to a physician, who referred me to a surgeon. The physician did say that my gallbladder could be more centralized, along with my diaphram. I guess my question now is where would I go to pursue more test and what would be other things to rule out? Also, if it is solely my gallbladder, why left sided pain?
thank you

Sid Schwab said...

Left-sided pain happens sometimes with gallbladder. Why? Don't know. Maybe differing innervation.

I generally referred people to a gastroenterologist when I wasn't convinced the gallbladder was the problem. Your response to CCK is suggestive of gallbladder source.

Andrew said...

I live in Australia and by chance came across this discussion because my issue is directly related to that with one difference. My GB performs a little bit better than the threshold.
A little bit of history. Several years ago I first felt uncomfortable around the liver area. It was just some heaviness. I have done an ultrasound with zero result. Then the uncomfortable feeling disappeared for a year or so, then came back, again ultrasound, zero result. My GP told me not to worry about, I started taking LIV52. It’s an Indian liver tonic. I’d say it helped me for about 3 years. Two months of taking it, then 6 months break, then again…However, in Sep 2010 LIV52 could not help me with my pain and it went severe. I appeared in the emergency. No vomiting, no nausea, no fever, just a severe pain and this time it was all over the place, i.e. the whole right upper part around liver and a little bit lower was affected irradiating to the back.
Strong painkillers solved my immediate problem but I decided to investigate further. I was unsuccessful. Blood and urine tests – all good. CT-scan – all good except slightly fatty liver and really small cysts in both kidneys, they are sitting in there for many years. Then gastroscopy & colonoscopy – all good, just one small polip removed and just one small beginning of ulcer, bacteria killed by antibiotics in a month time. Then urine test for blood checking to see if any stones are coming out – negative. Then CT-scan of spinal area to see if any trapped nerves are present. Negative. Then my gasto guy sent me to a surgeon. He of course was uncomfortable to operate me saying the GB test should be done first. Then GB functional test – the result is 38% which is slightly above the so called compliance threshold. Now my gastro specialist wants to send me again to a surgeon saying we are a little bit above the borderline. By the way, for the last 6 months I am having a pain going up and down but it always exists. I live with it. During the resent days it went back high and I could not handle it without strong painkillers. I use them now.
I fully realize it is not possible to diagnose being far away and, I guess, the only question is whether having a 38% result is a good idea to have a laparoscopy…I visited several GPs during this time with no result and it seems that this is the only solution. On the other hand, I am still slightly above the threshold…
Ahh, forgot to say. Probably 25 years ago or so I was pushed by chance against the track and its metal part heavily pressed my skin around liver area. It was quite painful at that time but the pain disappeared in a couple of days; however, I still remember that feeing. I was always wondering if that could cause any trapped nerve to do this to my body now…On the other hand, spinal CT does not show anything with nerves…
Anyway, what is your opinion about 38%? Is it a good idea to do a laparoscopy or continue living with pain searching for alternative solutions? Thank you!

Sid Schwab said...

Andrew, if by laparoscopy you mean having your gallbladder removed, all I can do is repeat what I've written here:

In my experience, when there's no other evidence of gallbladder problems such as stones or documented inflammation, removing the gallbladder has a good chance of helping IF the HIDA scan is clearly abnormal AND if the injection of the CCK exactly reproduces the symptoms.

If you mean laparoscopy for having a look around inside your abdomen to see if anything can be found to explain your symptoms, there are times when that's a reasonable thing. I have no way of knowing enough to say if you're there.

It sounds like you're in that category of people in whom the answers don't easily come, and it takes time and frustration and patience to solve it. Good luck.

Shelly said...

I have been reading your post, I am having severe trouble, pain every day all day. Pain in abdomen below breast bone,pain in between shoulder blades, pain in left shoulder, nausea when eating anything,weak,loss of appatite, lost a lot of weight, 30 pds in 3 months. Heart racing, and breathing, I had pain in my appendix area a year prior and then it comes and goes and now pain in gallblader and left side of upper abdomen. I had two ultra sounds no stones, Hida scan that shows funtioning gallbladder but mimic all syptoms and I took three days to feel better after the Hida scan. Two doctors have said have it removed, gastro doesn't think it is gallbladder but does not know what it is.
I have a bowel movement that was green slime, alot of it, thought it might be bile. have had some clay looking stools.Both shoulder blades burn too.
Hope you may a something to say, I am tired of being sick, I am 42.

Andrew said...

Thank you Dr Schwarb, I fully agree with you. Probably in my situation there is no evidence at all that the gallbladder is a problem taking into account no stones and 38% performance.
Have you ever saw in your surgical practice people having some sort of inflammation at the top of pancreas which was not life threatening but giving a pain in that area? I am asking because if in my case none evidence proves the gallbladder, this means that if colonoscopy revealed nothing then pancreas may be the next to suspect…So, I guess, the question is if you operated someone and instead of seeing a gallbladder problematic you saw pancreas…

Sid Schwab said...

I wish I could help, Shelly, but these problems are difficult for the doctors who are there, and impossible for those of us so far away.

Sid Schwab said...

Andrew: the pancreas can certainly be a source of similar pain. Usually it's possible to diagnose the pancreas as the origin by blood tests, CT scans, or certain other xrays including ERCP. It's unusual nowadays to stumble upon abnormalities of the pancreas during an operation, without suspecting them in advance.

chicago68 said...

Hi Dr Schwab. Excellent post. In short, in May 2010 I had low center cest pain and upper abdominal pain. Went through an arsenal of cardiac testing which revealed nothing. Since I have had abdominal CT in July of 2010, upper and lower GI, chest CT, esophageal manometry, all of which turned up nothing. In the last year I've had lightheadedness, pain primarily in the lower and upper left chest along with abdominal pain primarily on the left side, pain in the left shoulder and arm, pain in the middle back, loose lighter than normal colored stools, and 50 lbs of weight lost. All of the aforementioned pains are 95 percent on the left and about 5 percent of the time occur on the right. About a month ago they sent me for a HIDA scan which resulted in a 19% EF. The doc says my gallbladder should be removed. I have another GI that disagrees. I've never had an ultrasound of the gallbladder during this business. My question to you is should I at least be demanding an ultrasound before surgery or possibly be seeking additional opinions before consenting to have it removed? Thanks for any advice you can give!

Sid Schwab said...

chicago68: as you can tell if you've read comments here, I really hate to make very specific comments or recommendations because there's no way I can know as much as your regular docs, and, therefore, anything I say will have much less particular value.

I can make a general statement that if you were referred to me at this point I'd have some reluctance about recommending gallbladder removal, for the reasons I've mentioned before: my criteria for concluding a person has biliary dyskinesia include symptoms that are highly suggestive of gallbladder origin, lack of stones on ultrasound, low ejection fraction on HIDA scan along with reproduction of the symptoms in question when the CCK is injected.

From what you've said, the only one of the above that's true is the low ejection fraction.

Having removed a couple of thousand gallbladders, I can say I don't remember seeing that much weight loss associated with whatever process of the GB that was going on. I've seen some weight loss, but generally it's because people get gallbladder pain when they eat certain things, so they avoid them: particularly true with fatty foods.

I guess I'd be asking the GI who says no what he/she thinks is going on, what other tests need to be considered or, since it's been a year, repeated. CT? Endoscopy? Blood tests of liver, pancreas?

I guess getting ultrasound would make some sense, although if it showed stones but no signs of inflammation, I might still be reluctant.

All of which is not to say I'm sure it's not your gallbladder or that surgery is obviously the wrong option: to repeat, I simply have no way of knowing what the status is without having access to examining you and your records. So please take this as an attempt to put you in a general category, with inadequate knowledge of the particulars.

Good luck. I'd love to have a followup comment when the dust has settled, if you have the time and inclination.

chicago68 said...

Thanks for the info. I appreciate it. The GI's argument is that left side chest pain is inconsistent with a gallbladder diagnosis. Also, his feeling is that HIDA scans are not all that reliable. He doesn't have another solution in mind at the moment.

I have never found that fatty foods (pizza, etc) trigger the pain. The pain seems to be there almost all of the time in varying degrees as it seems to wax and wane. It is even there through the night and when I wake up in the morning.

I have recently had amylase and lipase tests which were normal. I have had countless blood tests, CBC's, Thyroid, etc. The only test other than HIDA that showed anything was a CPK test done about 4 months ago when I went the ER because the lightheadedness and pain were pretty bad. They ran me through typical cardiac workup and found a CPK of 3100 (skeletal). With some fluids this promptly returned to normal and has been tested below 100 3 times since then. This makes me wonder about the weight loss causes though.

Since then I was referred to neurologist who did MRI of brain and EMG, etc to test for metabolic disorders but all of that testing turned out to be normal.

So when this HIDA scan showed up with the 19% it seemed like a possiblity, but I wonder about it because of what the GI said and the fact that I cannot reproduce any "normal" gallbladder symptoms by eating fatty foods, etc. All of my pain is almost everywhere else but where you might expect it to be. It just seems very counter intuitive to me.

Thanks again for the quick response. If I find anything in the near future I will jump on here and let you know.

Thanks!

rrobelen said...

I am a healthy, non-overweight. 77 year old male. I have regular physicals with all the usual assortment of tests and always come through with flying colors. In November of 2010 I had an attack that was diagnosed as pancreatitis. I was hospitalized for two days on a liquid diet although the pain was over by the time I got to the hospital. After all sorts of tests (which showed I had gallstones something I already knew) I was told I had elevated levels of pancreatic enzymes which subsided the second day. I was visiting my family in Florida at the time and was due to fly back to the west coast the day I left the hospital which I was allowed to do. I was told my problem, in all likelihood, was a gallstone getting into my pancreas.

I know I have had gallstones for years. They were discovered back in the late 80s during an exam after an auto accident. However, this was the first time they have caused me any problems. In general I have never had problems with my gastric tract.

Recently during my yearly physical my local doctor told me that a gallstone getting into my pancreas again could be very bad. I was sort of lucky the first time. He, as well as others I visited right after my return from Florida, advised me to have my GB removed.

I am reluctant to have my perfectly functioning gallbladder removed unless other measures are not available. I can’t seem to get satisfactory answer to a couple of questions. They are:

Why not just remove the gallstones periodically with apple juice or some other non-surgical method?

About 20% of the men my age have gallstones. There is a certain probability (I will call X) that, as a person with gallstones, a stone will get in my pancreas as it has. What is the probability of a second one getting in (I will call this Y)? Is Y greater than X or the same or is it unknown? If it is the same then why are not all gallbladders removed from all men with gallstones?

I tend to think that America over medicates and over operates in general. I don’t want to contribute.

Sid Schwab said...

rrobelen: For my opinion on the apple juice question, read this. In short, it's entirely bogus, complete b.s. I can assure you the curds that people pass with those treatments have zero, zilch, nothing to do with stones. You seem an inquisitive guy: try it and have another ultrasound after (assuming you opt not to have surgery.)

There are, however, pills that can dissolve stones. You'll find what I've written about them, too, in the same article. Depending on size and nature of the stones, they might work, with a very high chance that stones will re-form eventually. It's when stones are relatively small, ie in the late stages of dissolving or the early stages of re-forming that they're the most likely to pass from the gallbladder and cause pancreatitis.

I wrote three articles on pancreatitis. Your questions are mostly addressed in the first and second.

Pancreatitis can be horrible. If one knew who was scheduled for gallstone pancreatitis in the great book in the sky, one certainly would opt to remove the gallbladder before it happens. It's a matter of potential consequences. But no one can say. Your next attack might be tomorrow, or never.

You may conclude people are overmedicated and over treated. In any given case, I can't disagree. All I can say is I agree with your docs: I left a lot of asymptomatic gallstones alone; and I rarely tried to talk someone into having their gallbladder removed, even when symptomatic, if they preferred to live with it and take their chances, eyes open.

Having seen the devastation that pancreatitis can cause, I squeezed a little harder on patients who'd had it due to stones. But all we can do is toss around a few numbers. None of us has a crystal ball.

Anonymous said...

Dr. Schwab,

Thank you for your helpful blog!

I have a question: Have you seen any relationship between biliary dyskinesia and hypothyroidism?

My Hida scan was normal and ejection fraction was 19% while low on thyroid medication. A month after my medicine was increased, the ejection fraction was 85%.

Thank you!
Jeannine

Sid Schwab said...

I've not seen it in my practice, but it makes some intuitive sense. A brief internet search didn't turn up much on "legitimate" sites, but it wouldn't surprise me.

I've always thought that ejection fraction alone was a pretty soft marker of clinical dyskinesia, because many things seem to influence it.

Anonymous said...

I'm a psych RN and this post answered some questions I had about a patient who had what sounds like the post cholecystectomy problems. (The situation happened at shift change and I was off tonight so I haven't had a chance to get an update.) Thanks for the info! :)

Sid Schwab said...

You're welcome!

Dana said...

Hello again Dr.Schwab

I came to your wonderful blog a few years ago with questions on gall bladder surgery. I haven't come back in a while but, as I'm still subscribed to it, I've just received the previous post. So I thought I'd ask another question.

I had my gallbladder removed through laparoscopy two years ago (I had lots of small stones). No complications. Unfortunately I seem to be one of these patients whose symptoms didn't go away, in fact some things got worse.

I read your articles so I understand there's no good explanations for this, but maybe you have some thoughts on this? What I have is lots of cramps and stomachaches,liquid stools in the morning, and the endoscopy showed a bit of acid reflux marks on my esophagus. Fatty foods give me some cramps but the worst pain is from hunger - I need to eat every 2-3 hours.

Could it be that the constant release of bile is just messing up the whole system? Anti-acids usually help, but just temporarily. A very bland diet sometimes helps. Buscopan sometimes helps. Proton pump inhibitors didn't help. Everything else I've tried (mostly drugs to stimulate or inhibit the colon, since of course I was quickly diagnosed with IBS) just made it a lot worse. Could it be that the acid is caused by the bile? The bile goes into the intestine, can it go up into the stomach and esophagus?

Or is it rather the lack of sufficient bile at meal times? Sooo confused and never got a comprehensive explanation from my doctors.

Any ideas what might help? Do digestive enzymes do any good at all? Keep up the antacids? How do people cope?

Thanks!

Sid Schwab said...

Dana: I've never thought -- although I don't really know -- that whatever alterations there are in bile flow after gallbladder removal are significant. That's because of the quart a day the liver makes, nearly all of it is flowing steadily, since the gallbladder usually only holds a few ounces.

I'm sorry you're having such problems. As usual it's hard to know if your pre-surgery symptoms were due to the gallbladder or something else; or the extent to which they're after-effects of the operation.

Bile certainly can get into the stomach, with or without a gallbladder: when people vomit bile is often there...

With your trouble with fatty foods and diarrhea, it's possible pancreatic enzymes could help. There are unpleasant tests (ie collecting a day's worth of stool) for fat malabsorption. Or you could just give it a try. Far as I know, the good stuff requires a prescription.

Sounds like you're in the care of a gastroenterologist, and I'm sure s/he has a better handle (or at least the opportunity to have it) on you situation than I could.

Jill said...

Hi Dr. Schwab,

Been reading all the comments here, as I am having my gallbladder removed in 2 days ( 7-3-12). I was diagnosed with biliary dyskenesia. I had no visible stones on 2 ultrasounds but my EF rate was 5% on HIDA last week.

I had been in excruciating pain for quite some time. 3 years ago, a GI dc did endoscopy/colonoscopy, CT scan and told me he couldn't find anything wrong and I will just have to learn to live with the pain. Three years later, here I am. Someone finally ordered a HIDA and the HIDA recreated the razor-like pain and I've been in great pain ever since the test. The CCK ( or maybe the radioactive tracer? ) made my poo yellow for a day. Feels like a football shoved up under my right ribs, and like I said...razor-like pain under right ribs when I walk or move around too much.

Dummy me, I started reading the internet and am now terrified that surgery won't help the pain.

I cannot imagine going through surgery only to end up with the same pain or worse. Now I am terrified after reading all these horror stories. I'm so sorry for others who struggle and hope they found relief, but wow...they sure know how to freak people out!

Any reassurance you have would be most welcome.

Sid Schwab said...

Well, Jill, you're mostly in the category where I've said the chances were good: abnormal HIDA with the injection reproducing the pain. I also include as a criterion that the pain is pretty classical GB pain. Yours is, I think, within the margins of that, if not word for word.

I also didn't operate unless a GI doc had decided there was no other explanation, which also is true in your case.

It's not a sure thing, but nothing ever is. From your description, I'd have had optimism that surgery would help. (I should throw in the usual caveat that without being directly your doc, any judgment I have is pretty far removed: it makes a difference to be able to talk face to face.)

I'd love to know how it turns out.

Jill said...

Thanks so much, Dr. Schwab.

I will most certainly let you know how it turns out.

This is my first surgery ever and the anxiety is killing me.

Jill said...

Well, I'm back. I am 12 days post-op.

It was awful. Just awful. Whomever said gallbladder removal is easy is full of beans...LOL. I had a terrible time waking up and had to stay the night, and when I first woke up, the pain hit me hard. The first week, I was pretty worthless. I can move around great now and my incisions have healed so well, you can barely even see them. You wouldn't even notice unless you were looking closely for them.

BUT ( and here comes the "but" ), I still have pressure and pain, especially after eating. Exactly what I feared would happen. Boo!!

To refresh, I was diagnosed with biliary dyskinesia and had a HIDA score of 5%. The test recreated the pain. My surgeon said my gallbladder was very inflamed and had a lot of scar tissue on it, and that it definitely needed to come out. I see him again for follow up this week.

Am I expecting too much too soon?

I have no nausea, no diarrhea/constipation, no indigestion, no acid reflux.....just this darn pressure and pain and a little bloating.

Doc did a cholangiogram during surgery and said my ducts were just fine. He is a Bariatric surgeon and that and gallbladder removal is all he does, so I trust he knew what he was doing.

I know you cannot diagnose without having ever seen me. But in your opinion, do you think I just need more healing time? My gut tells me no, my original problem is still here :(

I will say some days are better than others, and the pressure/pain is not quite as bad as it was with that nasty gallbladder. I know it needed to come out.

If you were me, and you still had pain, what step would you take next in search of the source of this pain?

Thanks Dr. Schwab

Sid Schwab said...

12 days postop is way too soon to draw any conclusions. Muscle pain, irritation in the place the gallbladder used to be, lots of things could be causing pressure and discomfort related to the operation, having no predictive value as to how you'll be with more healing time.

I'll throw in the usual caveat: since I can't really know what's going on, if you're feeling increasingly unwell, have a fever -- or are just generally concerned -- you should be in touch with your surgeon.

Dana said...

To Jill: Don't panic yet, yes it is indeed quite soon, even though some people, and doctors, expect you to be a happy flower after two days. I had exactly the same pressure and bloating feeling for over two months. It did go away VERY slowly, I still have problems but nowhere near what it was in the first months after surgery. Some of it may be due to the air trapped inside, try some AirX, that helped a bit after I discovered it. Hope you get better soon!

Jill said...

WHEW! I was hoping y'all would say 12 days is too soon to be worried.

Thanks

Melissakev said...

Dr Schwab,
I have stumbled across your blog trying to find answers to my issue. It started six months ago with a cramp on my right side that would not go away. It has now progressed into horrible pain mostly at night when i eat fatty foods which i now avoid. Sometimes the pain is followed by diarrhea,nausea,feeling of fullness after large meals. I never feel good in general have bloating, and the constant pain in the upper right side. I have had a ultrasound, ct scan and the hida scan the drs say no stones or sludge. My question is my hida scan showed my ejection fraction at 99% the first surgeon does not think this is a problem. Do you know of issues with the gallbladder when the rate is that high? I am currently in the process of getting a second opinion as i cannot continue with this quality of life as it has become a huge disruption to my life. Any of your thoughts are greatly appreciated.
Melissa

Sid Schwab said...

Melissa: I've never heard problems associated with a too-high ejection fraction; in my practice, in which I'd guess I've done a couple thousand gallbladder operations, I never saw a patient with it as a reason to consider surgery. Nor have I ever seen anything written about it in medical/surgical journals.

Looking around briefly online (I assume you have, too) I found a few claims that it's a problem, but no studies or authoritative information. Here's a forum with several comments about it. The fact that I've not heard of it doesn't mean it's not a problem, of course. Were I confronted with a patient like you, I guess I'd want to have the blessing of a good gastroenterologist who said there's no other explanation and that gallbladder removal was a reasonable thing to try.

Good luck. If you end up having surgery, I'd love to know how it turns out.

Melissakev said...

Dr. Schwab,
I obtained copies of my records today for my upcoming appointment with a different surgeon. Reading through the material it was noted that I have extremely prominent reflux down both gonadal veins, consistent with pelvic congestion syndrome. Could this be causing the same issues I am feeling? If you can could you explain what this statement means also (Within the colon there are scattered diverticular change including a prominent right sided cecal diverticulm, but there is no evidence of diverticulitis.) Then it goes on to state my appendix appears normal however, I do not have my appendix as it was removed when I was 16 years old.
Sorry to keep bothering you however in my field of science if we do not understand and research every path available we will be left with and undetermined cause.

Melissa

Sid Schwab said...

Melissa: they're all good questions, but I hate to respond very specifically because they're best addressed to the docs who know you well.

I've written here about diverticula. They're pretty common, and absent findings of inflammation or history of diverticulitis, probably not significant. Cecal diverticula are a little less common than further downstream, but I'd say the same criteria apply. With or without symptoms, it's generally recommended to have a high fiber diet, avoid constipation, which might play a role in problems related to them...

I'm no gyn, and can't say much about pelvic congestion syndrome.

Interesting about the appendix. It's possible (but not very likely) that the whole thing wasn't removed. More likely they're seeing some sort of meaningless artifact; but it's worth pointing out.

Melissakev said...

Dr. Schwab,

Thank you for your time and patience with me. I will keep you up to date. My appointment to see the surgeon is in August. I will continue to read your blog as I find it not only interesting but funny.

Melissa

Sid Schwab said...

Me too.

james said...

Dr Schwab, I recently had a hida, 98% output, but the cck reproduced my symptoms exactly! I was being hospitalized for diverticulitis but I thought there might be a second problem too. If the cck reproduced my symptoms exactly but my output was good does this mean my gb is fine, or bad? They did this test on day 11 of a hospital stay and kicked me out on day 12 with no answers. I'm so frustrated that they couldnt, or wouldn't, answer this question. Please give me some direction. Thanks,

Sid Schwab said...

You're the second person in a couple of days writing about a very high rate of emptying on HIDA (see above a couple of comments). All I can say is that if I'd seen a patient with your data (high-functioning GB but reproduction of symptoms) I'd be very hesitant to operate. Some people get gastrointestinal symptoms from the injection, like nausea, cramps, diarrhea.

If that's what happened, I'd be thinking your symptoms could be due to some sort of intestinal issue rather than gallbladder, and at the least I'd want the blessing of a gastroenterologist who felt s/he'd ruled out everything else...

But maybe there is a subset of people who have symptoms from a gallbladder that squeezes like crazy while emptying at light speed. I'd not heard of it, but I can't say it's impossible.

Anonymous said...

Hi Dr. Schwab:

I have a couple of questions for you.

#1. A study found on the web done in 2005 showed that taking PPI's can lower your ejection fraction on HIDA scan. The study showed an average of a 14% decrease. Any validity to this?

#2. I have consistent low level nausea, burping and consistent mild epigastric pain/swollen feeling in epigastric area with some referring mid back pain that may or may not be related but I have no RUQ/Gallbaldder pain. When CCK was injected the nausea and epigastric pain increased but no other pain felt elsewhere. Is this typical as I would expect to have gallbladder pain if gallbaldder function was low?

#3. Is ejection fraction affected by injection rate? Read that CCK is typicall injected over 2-3 minutes and low ejection fraction can occur if injected too quickly. Mine was injected within 30 seconds

Recent Tests: Barium CT no gallbladder findings. HIDA SCAN ejection fraction was 26%, fill was normal, no other findings on scan. High fat foods have only minor affect on nausea and epigastric pain. EGD last year revealed mild gastritis. Been on PPI for 4 weeks now with only minor improvement..

Thank you in advance for your input and time to answer these questions!

Sid Schwab said...

1) I can't comment on the quality of the study, having not seen it; but there are several drugs that can affect HIDA results, which is why I don't consider it, by itself, very definitive.

2) The GI tract has only so many tricks in its bag, by way of showing symptoms. Nausea, per se, is non-specific. Epigastric pain can be due to gallbladder, but it's also less than definitive.

3) I'd not heard about ejection fraction being affected by injection rate.

Your HIDA results, as you know, are marginal. Beyond that, I hate to make specific comments on a particular set of symptoms because I'm too far removed. It sounds like you're getting a thorough evaluation and the people in charge of it are the ones to whom to direct your questions.

Melissakev said...

Hey Dr. Schwab
I'm back from my follow up with a second surgeon and for now I guess I'm going to have to deal with this problem. He reviewed all my records and told me at this time he has nothing to point to that would have him take out my gallbladder. He did state that he has never seen a hida scan as high as mine (99%). He does not believe that a high scan is the problem. His opinion is that i most likely have IBS.
Wondering what you know about IBS and does this come on all of a sudden and will it ever go away? He also suggested that i take Prilosec to see if i get any relief. Is it safe to take for a long period of time? I know i should have asked these questions while i was there but like every other patient out there we tend to freeze up when we are in the doctors office.
Again as always i appreciate any feedback you give

Melissa

Sid Schwab said...

Melissa, in your previous comments it wasn't mentioned whether you'd seen a gastroenterologist. I assume you have, and if so, I think those questions would be best addressed to him/her. If you haven't yet seen one, I'd think it'd be a good idea.

My understanding of IBS is that it's not a diagnosis for which there's a definitive test, and its sort of one of exclusion: ie, when there's no specific answer. But I might be wrong. Another reason to bring it up with a GI doc.

Melissakev said...

Dr. Schwab,
Not sure what happened to my last post but it does not look like you received it. I have been seeing a gastroenterologist he has run a endoscopy, pill cam, blood work, and reviewed all other tests, ultra sound, ct scan and hida scan. His last conversation with me is that he still thought it was the gallbladder however without me producing the pain there was not much he could do for me. They actually asked me to eat a large fatty meal and then go to the ER, however my last attack (that is what I call it) was very unpleasent and I am not sure I would want to endure the pain again. He then prescibed me a medication that was for spasms and was not real clear and why I would need to take it. However he did say that if I had another episode with pain to try and take it to see if I get any relief.

My understanding now after seeing the second surgeon is that the medication is to see if it is IBS, this medication should give me some relief if it is. If not then it is most likely the gallbladder as he has ruled out everything else.

My question is if this is really the gallbladder and there are no definate signs for removal will the gallbladder ever rear its ugly head? How many patients if any did you see with such similar problem where you did not remove however after some period of time the gallbladder was found to be the problem.

Sorry for so many questions but I am really interested in this now and left wondering what is going to happen and when. Which I am sure you have no idea.

Thank You!
Melissa

Sid Schwab said...

I don't know what happened to your prior comment, either.

I think it's fair to say that if it is indeed your gallbladder, at some point there'd be specific signs of it, like thickening, etc.

I can't say how many people I saw where it was unclear initially but eventually became clear, but I'm sure there were some.

Brenden said...

Sid, thanks for this post, it really enlightened me. I'm 24 year old, mostly healthy male (could lose 10 pounds, but never any serious health problems). All my life I've battled what the doctors have labeled IBS, but have had a clear colonoscopy and endoscope done about 4 years ago.

Earlier last month I got a bacterial infection (bronchitis) that was treated with a 5 day zpack. It went away promptly. Shortly after that, I suspected it was returning so my doctor put me on a course of Omnicef.

The first evening on Omnicef, I started having INTENSE gallbladder pains, stabbing, rolling waves. They came and went throughout the day but the area was SUPER irritated on examination.

After 3 days, my doc discontinued the omnicef and the gallbladder pain promptly diminished and disappeared over the next 24-48 hours.

He then ordered an ultrasound of my stomach, which returned nothing out of the ordinary at all anywhere, not even inflammation, minus a fold (which they said was normal). However, on physical examination, it was really sore and the ultrasound really irritated it physically (no nausea, just pain).

I ended up in the hospital that night after the ultrasound (i think the pushing and prodding really irritated it) but all my blood tests (CBC metabolic etc) were completely normal minus low potassium (because i fasted for the ultrasound). They gave me a dicyclomine injection which calmed it a bunch, and sent me home.

My doctor decided a HIDA scan was due, so I had it today with CCK. The EF ended up being estimated at 7%, but when I got the CCK, I got literally no pain, no cramps, and maybe a 5-10 second bout of nausea, but nothing like what I experienced those 4 days on the Omnicef.

I'm going to get a second opinion from another GP I see to see what he thinks is the best course of action. I'm also having my thyroid checked because of the weight loss, chest pain, dizziness, constant urination, etc.

Have you ever heard of antibiotics causing such a reaction? I've taken other cephalospores (sp?) and been fine previously when I had a staph infection, but I honestly think since the Omnicef coincides with the timing of the pains, it did something to my gallbladder.

The tech even said he could see my gallbladder squeezing on the screen when he injected me, but I had no pain (they did a 3 minute rapid injection, don't know if this matters).

Do they base the EF solely on the pictures? Or is it just a willy nilly estimate?

Thanks for any info!

Sid Schwab said...

Brenden: I can't say exactly how they calculate the EF, but it's based on images of the full gallbladder compared to after the injection.

It's not at all uncommon that taking various antibiotics could cause a reaction like you had, for differing reasons.

I can't make diagnoses from this far away, and the doctors actually taking care of you are the ones most able to figure it all out, with your help. But I'll say this much: based on what you wrote, I'd put gallbladder trouble pretty far down the list of possible explanations.

Brenden said...

Thanks a bunch for your reply Sid. I think I'm going to be a bit more assertive. They took blood tests yesterday for my thyroid and blood counts etc.

If there was an issue with my pancreas I would probably be quite ill and having some serious issues right? Like, my pancreas failing is going to show up definitively in on way or another either on the ultrasound or blood test?

My worry is that somehow since the ultrasound was normal they missed something with my pancreas or something. They've done full metabolic panels, CBC and even a clotting test and all were normal.

I get the thyroid, diabetes etc test back tomorrow.

Anything you can tell me that might put me at ease a bit?

I had greasy pizza last night and it didn't really cause any pain or problems. This morning I'm a bit constipated and have really dark urine but -- all things considered -- I honestly don't sound much like the people with the intense symptoms. I'll see if more fluid intake solves these issues.

I know you can't make a definitive diagnosis and steer from any specific information, just looking for generalities to maybe reduce my anxiety about the whole situation. Have this fear that something's just going to happen and my gallbladder will randomly burst in a really short time span or something.

Thanks for what you do and this blog, it's really a great source of information from somebody in the field where as most providers and surgeons are looking out for their wallets and not their patients.

Sid Schwab said...

Usually pancreatitis is anything but subtle. It shows on blood tests (that's pretty much what makes the diagnosis, assuming the tests were included), and usually on imaging as well. And it's typically not "wave like" pain, but severe steady pain that lasts for days.

And when gallbladders "burst," it's after several days of severe and continuous inflammation; something which is also rarely subtle or elusive of diagnosis.

Sheila Thomas said...

Hello Dr. Schwab,

The information in these posts has been more helpful than explanations from local doctors. Here is our situation, my 23 year old daughter has had abdominal discomfort since Jan. 2012. She has always been thin, but from Sept-Dec.2011 she lost about 20 pounds from the stress of last semester college. Her symptoms began after that, with no prior stomach disturbances in her health history. In late Dec. 2011 and March 2012 she was briefly ill (less than a week) with nausea, epigastric pain after eating high fat meals. Those episodes resolved but she was left with the abdominal discomfort. Two gastro docs have diagnosed her with IBS, although she has no symptoms of constipation or diarrhea, only abdominal fullness. She has had upper endoscopy w/ biopsy, gastric emptying, abdominal and pelvic ultrasounds, liver enzyme and other bloodwork all perfectly normal. There is no evidence of celiac or ulcers. She recently had a hida scan that failed to visualize the gall bladder after four hours and they were therefore unable to inject the CCK. The gastro referred her to a surgeon who feels that she doesn't fit the profile of a gall bladder problem, too young, too thin and not in enough pain and dismissed the hida as an aberration. I'd love to know your thoughts and any ideas on how to proceed. Thanks for your time.

Sid Schwab said...

I have sympathy to go around: for your daughter, for you, and for the surgeon. These situations are tough ones for everyone.

Slow filling and emptying of the GB on HIDA scan can be due to lots of not-gallbladder related things. Complete lack of filling, however, suggests obstruction of the cystic duct, the one that connects the GB to the main bile duct. Most often, that's "anatomic," i.e. a real finding. So it's more suggestive that there's a real GB issue.

It's true that she doesn't fit the "classic" description of a gallbladder sufferer, but I'd not consider that dispositive. The range of patients is infinite.

So, if I were the one seeing her, I'd feel the need to explain the lack of filling. "Aberration" doesn't seem right. However, as always, I'm in no position to second-guess those actually involved.

If there were evidence of thickening (i.e. inflammation) of the gallbladder wall, usually seen on ultrasound or CT, I'd consider it significant. If not, then it remains a puzzle.

Maybe a repeat HIDA, done when she's on no medications at all, no narcotic pain meds in particular, would be reasonable.

But, as you can infer, I really don't know. It's hard enough when directly involved in these grey-zone situations. From afar, I'm more likely to make things worse than better.

Melissakev said...

Dear Dr. Schwab,

First off I would like to wish you a Merry Christmas. Its Melissa from previous posts.

I was referred to a third Surgeon who started fresh with all the tests once again since its been almost a year from the first initial tests. The tests all came back fine once again however, he feels its my gallbladder. He asked me to see his gastro guy that has been in the field for a long time. So of course I agreed to meet with him. I meet with him last week and after a long conversation with him he told me what I have currently is bilary colic and he has seen it before in other patients just like me and that after sometime he usually finds that if he repeats the tests in 6 months or so either stones or the function of the gallblader shows itself as a need to remove the gallbladder. I feel good to have some sort of diagnosis however I still have the problem. I feel like in order to feel good or avoid the pain I must eat the fat free diet like I have been.

My question to you is why do you think these doctors knowing are so reluctant to remove the gallbladder to give me a better quality of life????

Melissa

Sid Schwab said...

Can't really say, Melissa. But as you can tell from the comments here and all over the net, there's a subset of unhappy patients who've had their gallbladders out for what turns out to be the wrong reason.

So it's a lot easier to recommend the operation when everything adds up, when it's a "classic" situation. I don't think I ever had a patient regret it, when it all lined up.

Sheila Thomas said...

Again, thanks for your thoughtful insight about my daughter.. It has truly been a frustrating experience. At her age, she's old enough to handle it on her own, but young enough not to have much experience in the medical world. Even though she's a college graduate, she gets put off by many of the md's that she sees. Her hida scan was without any medications or narotics, but I think they would be open to a repeat scan. Could she possibly have cholecystitis? If there is a blockage, what is the usual treatment, gall bladder removal? Thanks again

Sid Schwab said...

A persisting blockage more or less defines cholecystitis. Usually, though, with that diagnosis there's inflammation, too. The difference between colic and cholecystitis is that the former implies transient obstruction, with pain that lasts minutes or a couple of hours; cholecystitis implies unrelenting obstruction that lasts for many hours or days. In either case, if the diagnosis is certain, removal is usually considered the best treatment.

Sheila Thomas said...

Hi Dr. Schwab,
I wanted to give an update on my daughter and the second hida scan and pick your brain a little more. The second hida was within normal ranges, however the surgeon (who is experienced, well regarded, etc.) said that since "everything" has been ruled out, he'd consider taking the gall bladder. He mentioned a 60% chance of that resolving her symptoms - which are mainly abdominal fullness (not bloating) triggered by eating and intermittant epigastric pain that she desribes as feeling like a rock. Everyone is still putting aside the first hida results even though all parties agreed that there was nothing in the testing process that should have caused the gall bladder not to visualize. The radiologist even indicated that all other hida tests that day were correct and that my daughter was properly prepared for the test. My daughter, of course, does not care to have her gall bladder removed if it is not beneficial or necessary. Any thoughts? This can't get any muddier than it is!
Thanks.

Sid Schwab said...

Muddy, all right. I never much liked these situations when I was face to face with the person; from this far away, it's even more uncomfortable.

I don't know data based on which odds of relief, in this situation, could be produced. Toss of the coin, more like.

Once again I must say that any opinion I have without the opportunity to have been directly involved is nearly worthless, at least as it applies to your daughter's specific situation. I really have no basis for (or business!) making a recommendation.

As a general rule, I'd say that I was generally reluctant to operate when it didn't add up; that is, when the symptoms weren't pretty typical and when the diagnostic testing was either normal or equivocal.

On the other hand, if the patient was so distressed by the symptoms that s/he wanted to go for it on the chance it would help, recognizing that it might well not and that there was some chance of having side effects afterward, and if the patient's gastroenterologist agreed it was reasonable, then I'd not refuse to do the operation.

I'd also tell the patient that since we'd not demonstrated stones or inflammation, the more serious complications of gallbladder disease weren't likely to occur (i.e. severe infection, bile obstruction) and that waiting to see if things become more clear over time was a low-risk option.

In other words, I guess I'd try to lay it all out and leave it up to the patient. Not being the one with the symptoms, it's hard to make the judgment. Despite being in the surgery game, my inclination was always to stall if things weren't clear and if I felt there was minimal risk in doing so. As a general rule. In a specific case, it depends...

Amy said...

Hi there! I am a 35 year old female and I've been having an issue that I'm not so sure now, after reading the above thread, is gallbladder related. For a very long time, maybe 5 years or more, I get nauseous and have to vomit in the mornings. I usually dry heave and/ or vomit clear fluid. My stomach is almost always empty when this happens. It happens generally each morning that I have to wake up early for work, but if I wake up past 8am then it doesn't happen. Sometimes it happens if I let myself get too hungry. I work in an ultrasound dept. and the tech scanned me and my gallbladder, as far as ultrasound can tell, is fine. I have experienced RUQ pain only a handful of times and I always just assumed that the nausea must be from a low functioning gallbladder. I am scared to go to the Dr. because I think they are gonna order the HIDA first things first. Is there anything else that could cause this chronic, early morning illness? I am slightly concerned that it could be blood sugar related. Thank you for your time!

Anonymous said...

I forgot to add that if its presumably my gallbladder that's causing the almost-daily nausea, can I just elect to have it taken out? I would take it out tomorrow if I knew I'd stop puking. Because I have to find a way to end this. It's starting to affect my back teeth (even with brushing right after the episodes) and my throat. But I'd hate to go through with taking it out if its something else. Like, diabetes or something. Sorry about the addendum but that was a main question I wanted to ask. Hope your New Year has been off to a great start!

Sid Schwab said...

Amy: if it does turn out to be your gallbladder, of course you can elect to have it out. It's certainly not in the obvious gallbladder category; but it's on the list of possibilities. Diabetes is possible, as are ulcer, gastritis, various inflammatory bowel diseases, GERD, etc.

Even though you don't want to, it won't get unravelled until you see your doctor, or a gastroenterologist.

Anonymous said...

Hi Dr Schwab,
I am an ex-gastroenterology pharmacist who worked in a downtown teaching hospital for years - just figures that i am a mystery gi case now! I am currently 50 years old. In my late 20's started having central gi pain, nausea and then vomiting after high fat meals. An abd US showed one large stone. Surgeon rec'd removal and had a lap chole. Low and behold, same exact sx recurred. After a particularly long attack i ended up in emerg with high LFTs. Went to work and my gastroenterologist got me in to the city's best thptc endoscopy centre - ercp and sphincterotomy and was fine for 9 years - when vague "pins and needles" sensations started in RUQ. Then a few mo. later had an attack after a late and high fat meal. Different sx this time - more RUQ pain radiating to back. Go for an US and they find dilated CBD and intra and extrahepatic ducts....and low and behold they see a gallbladder. Telling them that I most definitely had it out she calls the mgr in and she agrees - a fluid-filled cystic structure where the GB should be. MRCP completely normal. Pain continues.....is it possible that a cystic duct mucocele or something could still be lurking in there even though the MRCP does not detect it? Any comments would be greatly appreciated. Cheers, Lori

Sid Schwab said...

Lori: I guess several things are possible, including some sort of cystic change in a the remnant of the cystic duct; or a contained leak of some sort, maybe now sealed off. Hard to know what it has to do with your symptoms. The dilated ducts suggest restenosis of the sphincter of Oddi, or possibly stones in the system. Seems unlikely it's a separate process in the pancreas, if no mass showed up there on the MRCP.

It's not surprising that it wouldn't show on the MRCP; ie, it's sealed off from the ducts, whatever it is. Seems like ERCP with an eye to redoing the sphincterotomy is a consideration. Or, depending on the anatomy, a surgical ductal drainage procedure of some sort, which could also address that cystic thing.

Percutaneous sampling/drainage of the cystic lesion is on the table, too, for diagnostic purposes mainly. I assume it wouldn't do anything for the dilated ducts.

On the other hand, I don't know the specific anatomy, so whatever I say is probably best considered vague ruminations at best. Good luck. And I'd be interested to know what turns up...

Melissakev said...

Hey Doc
Its Melissa back from past with the gallbladder issue which i am currently controlling with diet. I have new problem. I started having a problem urinating with blood and chunks of mucus. I hav e been seen by the urologist who went inside and found a urachal cyst. Just yesterday i had a biopsy done and am waiting to see if it is cancerous. They have to take it out either way but for some reason there is not much information online in regards to adults having this. My doc says it a rare in adults have you ever seen this and do you have any information you could share.
Thanks
Melissa

Sid Schwab said...

I don't know much about it without looking it up, too; but it's true that they're fairly uncommon and, rarely, can have malignant change in them over time. Pretty unlikely, however. And they can get infected. So, yes, far as I know the best option is removal, which typically is a pretty simple and uncomplicated procedure.

Anonymous said...

Dr. Schwab,

Six months ago I saw 2 gastroenterologists and one surgeon about feeling sick 3 hours after I eat. My HIDA scan showed a 36% evacuation fraction, ultrasound showed no stones or abnormalities in the gall bladder or elsewhere, and an endoscopy showed no stomach problems. One gastroenterologist advised me not to remove my gallbladder or I would be sorry, the other gastroenterologist advised me to remove it, and the surgeon also advised me to remove it. I didn't remove it but am wondering if I should because I am still having symptoms. I get very nauseous and a burning sensation in the stomach about 3 hours after I eat. I am sick the entire day, every day. Fortunately, the nausea and sickness alleviates at night. Antacids and proton pump inhibitors do not alleviate the symptoms. I have no pain in the gall bladder area. The surgeon said he recommended gall bladder removal because a 36% evacuation fraction is abnormal, and the 3 hour delay between eating and the appearance of symptoms corroborates that the gall bladder is the problem. He said I feel nausea and burning in the stomach because it is referral pain originating in the gall bladder. Since I've had these symptoms for 6 months I am starting to think maybe the surgeon is right and I should have it removed. What is your opinion?

Sid Schwab said...

You should re-read this post to see what I said about HIDA scans and the diagnosis of biliary dyskinesia, which is what would presumably be your diagnosis if that's what's going on.

I don't make specific recommendations online, because there's no way I can know as much about a particular situation as the doctors can who are involved.

I can say that when I saw patients without gallbladder disease on ultrasound, and whose symptoms weren't typical of gallbladder origin (typical: occur shortly after eating, severe colicky right upper quadrant abdominal pain often radiating into the right upper back); and when the HIDA ejection fraction wasn't clearly abnormal ("clearly" abnormal: lower than 30%) and when injection of the CCK hormone during the scan didn't reproduce the pain, I was very reluctant to operate and not optimistic that it would help.

There were a small number of times I did, anyway; when the patient was desperate, a good GI doc had run out of ideas and concurred, and the patient accepted that the odds of helping were, in my view, less than 50%, and that surgery might make things worse. I didn't like to, though, and the results didn't change my approach as described.

That's a general comment about patients that I'd had the opportunity to meet and examine myself. As I said, I don't make specific recommendations online.

Anonymous said...

Dr. Schwab,

Thanks for your reply. Your opinion is similar to that of the first GI doctor I saw who said surgery may not alleviate the symptoms and would leave me coping without a gall bladder. However, I am getting desperate. During the past month, I've started to feel a mild colicky pain in the gall bladder area at the same time as the nausea and burning in the stomach. This has led me to believe my symptoms are due to the gall bladder as the surgeon suggested. However, If I have surgery and the symptoms remain I would have a difficult time coping psychologically with the mistake. The inexact nature of what to do is frustrating. I think I will continue to wait. If the colicky pain worsens then I will have the surgery.

Sid Schwab said...

I'd love it if you'd come back with an update when and if...

Anonymous said...

Hi Doc!

Wow this is long blog. I have been searching for answers to my SOD pain for a year.

After removal of my gall bladder (no stones or sludge or pollups), pathology showed 20 plus years of chronic inflammation. The tissue that hovers over the duodenum and gall bladder had adhered to both.

Pain episodes started 2 weeks after surgery. I was admitted for 3 days, had xrays, ct, mri with and without dye, and was released after an endoscopy.

No answers.

Pain returned, became more frequent. Every 5 days extreme pain. Learned not to take narcotic pain meds after my research taught me that opiate drugs can cause SOD spasm.

Had endoscopy with ultrasound. Showed nothing. Referred to surgeon for manometry. Normal numbers are 40, mine came back as 250, 220, and 110 in the biliary duct. Surgeon performed sphincterotomy on all three muscles and enlarged the opening of the bile duct.

Had 7 blessed weeks without a pain attack. However, always a constant twinge like a pinch. Then, bam! Pains back! Now its once a week.

Do you think its possible that the SOD problem is primary to the gall bladder problem?

So, for example, in my case, I suffered for years from cholic type pain. It came and went. What if the problem was the sphincter of Oddi to begin with. Say, each time it spasmed, the gall bladder became inflamed due to the bile back up. Now that I do not have the gall bladder to uptake the backup of bile, I experience intense pain.

My liver function goes up, so my diagnosis is type II SOD.

Since the pain is back, I am now perplexed. What do I do? Go back in for another sphincterotomy? That sounds so pleasant...

So, now I am focusing on pain management. If I take a cyclobenzaprene (sp).. I can sleep through the worst of it.

Another theory I had has to do with all the excess bile in the digestive tract. Seems to me, the diarrhea is daily. Then like magic, before a pain attack, I suffer constipation. The stool is light, and I could sit on the toilet all day during an attack. I feel the need to go, and cant. What if the body is just so overrun with bile it says Hey Sphincter, shut that stuff off!

That may sound funny but when you are searching for answers sometimes the dumb ideas make sense.

All I know is that I wish there was a good answer. I am 42, mother of 3, married, and this pain is a definite hinder to my life.

On another note, I have lost 55 pounds in a year since this all started without changing my diet. 180 to 135. I ran 4.6 miles every other night for 2 years and didnt lose an ounce.... explain that. No you dont have to.

Jen

Sid Schwab said...

Jen: your story, sadly, epitomizes the problem generally known as "post cholecystectomy syndrome." What it means, really, is that some people (a small number, fortunately for the world but not for you) have a wide variety of issues after surgery. And we don't really know what to do in many cases.

I think SOD is real; perhaps over diagnosed; not always, evidently, amenable to intervention. Or, for that matter, diagnosis. I've always had reservations about a test which measures pressure across a sphincter, whether the S of O or, say, the one in the esophagus, by passing a tube of some sort through it.

Your situation is pretty much exactly like that of the patient I described in the post previous to this.

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). So you're not correct in supposing there's something going on with "flooding" your gut with bile; as I see it, anyway.

A successful sphincterotomy can scar down; the timing suggests it might have happened in your case. If you have definite evidence not just of higher pressure, but of dilatation of the bile ducts, then a surgical decompression such as, rather than another sphincterotomy, rerouting the bile duct into the gut (choledochoduodenostomy, or choledochojejunostomy) would be a possibility.

Bottom line: I can only wish you luck; I have no brilliant ideas for you. If you haven't already, you could consider being seen at a major referral center where there are surgeons specializing in complicated biliary surgery.

Linda South Florida said...

Hello Dear Dr. Sid,

Thank you for your honest sharing...I had my gb removed laporoscopically almost 3 months ago. I'm experiencing a sense of nausea when I haven't eaten for several hours. It seems it is the bile dripping into my intestines and irritating my stomach.

Does it seem true to you that those who've had their gb removed are at higher risk for colon cancer due to the irritation of the lining of their intestines from the dripping? I respectfully welcome your thoughts.

With Thanks and Best Wishes,

Linda
South Florida

Linda South Florida said...

Hi Dr. Sid, (me again - Linda South Florida),

I wanted to ask for post gb surgery about the nausea from empty stomach symptoms I've been having (it's about 3 months post-surgery), is the treatment further surgery (ugh) or eating small amounts of healthy foods more frequently?

I'm going to start the small amounts/more frequently and see how that goes. I do eat healthy - no fried foods, no meats, little or no dairy and homemade fresh veggie meals and fruits. No caffeine and no alcohol. I exercises regularly and that definitely helps.

Again, I respectfully welcome any insights you may have...Thank you SO MUCH for taking the time to care to listen to us and share your professional opinion...it truly helps if, for nothing else, to offer encouragement :o)

Best Wishes,

Linda

Sid Schwab said...

Linda, I've written some stuff about that, but I know it's hard to find. The main point is that with or without a gallbladder, nearly all the bile your liver makes is constantly flowing into the intestine.

Of the quart or so that's made every day, only a small amount is stored in the gallbladder, and, as I've written, I think storage was necessary in the days when humans would go for a day or two without eating, hunting...

So, for practical purposes, nothing much has changed. I don't know what to make of your nausea problem between meals but it doesn't seem too likely to be related to the way the bile is flowing. I'd say you should check with your gastroenterologist about it. Ulcers, or gastritis, are on the list of possibilities.

I've read those reports about cancer in post cholecystectomy patients, and don't find it very convincing. Or, at least, I don't think it can be due to having the gb removed, because, as I've said, all the bile you ever had is still being made and by the time it's in the colon, whether or not there's the occasional pulse of it wouldn't seem to be significant. A quart day is a quart a day.

What could be a factor, if the data are true, is that people who form gallstones have chemically different bile than those that don't. That bile might affect the colon in some way. But it's not about having the gallbladder removed: it's about having the sort of bile that leads to having the gallbladder removed.

Michael r said...

Hi Dr. Schwab,
I had my lap cholein March 2013. The surgery went well but, my pain is still here. I had a EF of 6% with no evidence of stones on U/S or CT but, pathology of my GB showed several small black stones. Since the surgery I have been hospitalized for pain where my GB pain was and LRQ pain as well. CT, U/S & blood work normal. I do have diverticulosis but no evidence of an infection ie WBC elevation. I'm at the end of my rope! My surgeon thinks it's the diverticular that's causing my excruciating pain and my GI thinks adhesions may be. I'm at the point of asking him just to go back in and take a look because the pain is so bad. I think it may be PCS or something of that nature, any ideas?

Sid Schwab said...

Michael, I'm sorry to hear of your troubles. I really can't get into the diagnosis business from this far away. I can only suggest that you stick with your docs and keep working on it, or find a referral center and get another opinion there.

I'll say this much; "adhesions" is a way over-used explanation for pains of all sorts. Which is not to say it's always wrong. But in general if adhesions are causing a problem, it's intestinal blockages, and that's usually not hard to distinguish. I'd also say I doubt your surgeon, or any surgeon, would want to go back in just "to have a look" in your situation.

Things like this are enormously frustrating for patient and doctor alike (although it's the patient who's doing the suffering,) It can take a lot of persistence on both sides to get it worked out. I wish you well.

Kellie W said...

Hi Dr Schwab,

I had my gall bladder removed 6 days ago, was just trawling the web today to see if some of my post op symptoms are normal when i found your blog... basically all I want to say is your blog is the best and most insightful thing I have read about the procedure...thankyou!
Also I can't believe how you have personally replied to so many 'asking for advice' comments... it's very good of you!
Thanks again,
Kellie
Tasmania, Australia

Sid Schwab said...

Thanks, Kellie. I guess I ran out of new material, but I'm still happy to respond to comments and questions.

Anonymous said...

Hi Dr. Sid

It took me so long to get back to you because I lost the blog address.

I have less anger and bitterness now. I apologize for delivering unto you all of my frustration.

I want to thank you for your quick response to my post, that was amazing.

I guess I am the rare "less than 1%."

Since I last posted, I have been pretty much status quot. Pain at least once a week, sometimes severe, sometimes manageable. Sometimes lasts for days, sometimes just hours.

Constant pinching feeling.

My case was referred from Minnesota Gastroenterology Specialists to the University of Minnesota for other surgical options. My guess is the surgeries you spoke of. I have not made an appointment yet, I am currently uninsured.

In the mean time, I have some questions about treatment with medications. Since I am not able to take any narcotic opiate drugs due to increased spasm, I am currently taking Tramadol. The suggested dosage is 2 - 50mg tablets every four hours. It takes the pain down to a tolerable level, however, the side effects I endure are bothersome.

It keeps me awake. The dosage is every 4 hours, but I noticed that it takes 6 or more to clear out of my system.

Secondly, it makes me nauseous. To combat the nausea, I take Zofran.

So instead of the full dosage, I take on a little more pain and only use one tablet every 6 hours. I still am awake all night but it reduces the nausea.

(When the pain is so severe that I am crawling on the floor praying for death, nothing seems to work. This sometimes happens even after a full dose.)

I have an appointment with my GP tomorrow and I am wondering if there are other non-narcotic options that I can try.

Until I am insured again, I am considering this chronic and trying to cope.

Thank you in advance for any insight.

Jen

PS I hate medication and am super sensitive to anything I take, which is why I only use Tylenol, very sparingly, when needed for headaches.

Sid Schwab said...

Jen, it's getting into specifics in a way I'm not comfortable with; meaning I don't like to give specific advice, other than general information, online. But, surely, something ain't right!

I hope you can find a way to get those consultations. Maybe you'll qualify for insurance with premium support under the Affordable Care Act. And they can't deny based on your preexisting conditions.

Anonymous said...

I just had my gallbladder removed on the 3rd of October. The Dr told me because I have so many adhesions in my belly, it was gonna be a long surgery. He was right, 2&1/2 hrs to cut the adhesions away from the gallbladder. Plus he said it was like cutting through cement. I also had a bowel obstruction, so my scar goes from the top of my chest to my pubic hair line. I now have 57 staples, which were removed ten days after surgery. I feel like I'm my grandma. I walk a little hunched over. I can't help it, it still hurts. How long should it hurt? I'm walking to my Dr's appt tomorrow. I hope I make it, it's about 2&1/2 miles from my house. Oh ya, by the way my surgeon also found a piece of metal,about 4in.'s long just left on my stomach area.

Sid Schwab said...

That's a curiosity: a big piece of metal. Did he say what it was?

Anyhow, it's hard to predict how long incisional pain will last. I'd guess you're past the worst of it, but it may linger for up to two or three months, to some extent. Overdoing it too soon can prolong it. Got a friend who can give you a ride? One way at least?

Thomas Muraco said...

seI have been in horrible pain for weeks now with 4 weeks of diarrhea. I have been to my regular GI doctor who just did a sonogram of my gallbladder( since that is where the pain is and where a CT scan a year ago showed a stone which he said ( after all this and a Hyda scan a couple of years ago ) did not warrant surgery. I have had IBS most of my life and have had colonoscopies and upper endoscopies. I am at my wit's end with this sometimes excruciating pain. Do you have any suggestions?

Sid Schwab said...

Mr Muraco, I really can't be in the business of making diagnostic or therapeutic suggestions so far removed from the source, and with so little information. If you haven't had an abdominal CT scan it might be useful. That's as far as I can go; and it's really best to stick with your doctors and keep working on figuring it out. Or, if you've lost confidence in them, to get another opinion, ideally from some sort of referral center.

Anonymous said...

Dr. Schwab,

I have been having pain under right rib cage for the past two years. I underwent the series of tests endoscopy, ultrasound, ct scan and then hida scan. Found my gb was functioning at 22% so had it removed over a year ago. Pain never really went away but Lessoned after surgery. It has become more annoying over the past month so I called my gi. He wants to go down the same route we took last time. I am 43 Male and in shape I don't eat fried foods and have tried restricting things from my diet, yet pain continues. Normal blood work. Is there any additional test you could recommend to help diagnose the issue?

JB

Sid Schwab said...

JB, I really can't be in the diagnosis business from here. I guess if nothing else turns up you could raise the possibility with your docs that the pain is of nerve or musculo-skeletal origin.

Anonymous said...

Hello Dr. Schwabb,
I have had all the symptoms pointing to gallbladder problems. I was sent to get a ultrasound, at which the technician then asked if I had my gallbladder removed already...oh lordy I knew I was in for it then! Based on ultrasound results...lol if they could not find it I was asking myself how they could have results. Nevertheless the results viewed spasms of the gallbladder. Not sufficient enough evidence so naturally they had recommend a HIDSscan...I watched my gallbladder n hour n a half after drinking what appeared to be much like ensure only with higher gat content evidently there was a shortage of CCk..so that is what they substited. My gallbladder didn't have any visible drainage in that hr n a half. 8%efr...now they ate suggesting ERCP? In your experience why would you do ETlRCP when its already been established that the gallbladder is not functioning clearly? Please give me some idea as to why they would suggest that awful unpleasant test??

Sid Schwab said...

Short answer: I don't know. Which is not to say there could be no reason. You are certainly entitled to have a clear answer, though; and the best source is the doctor recommending it. Or your primary doc.

Or, if you haven't yet been referred to a surgeon, you could ask about that, and see if the surgeon feels it would provide useful information.

diana said...

Dear Dr. Schwab
Since 2003 when my gallbladder was remove I am having a billary colic exactly similar to gallstone attack once in every 2 years for 3-4 hours and its gone and no pain next day for another year or two. I had MRI, ultrasounds and even C Scan but doctors saying they don't know why. One doctor told me because of IBS (ir. bowel sindr.) but I have no other symptoms. Blood test and other tests are normal.
One doctor told me that maybe in bile duct smallest stones forming and you are passing them but by the time I have tests they are gone and therefore we can't see them.
Could you please give me advise which test should I do to find out more or do you think that my pain was triggered by food and watch my diet? Did you have any patients with similar history? I am 45 years old and constantly afraid of this pain it's like a labor pain on the right side of my ribs behind the lever and stomach. Last one was 2 years ago and 3 days ago again I had that pain for 3 hours. Please give me suggestion which tests you recommend.
Thank you very much and waiting for your reply.

Thank you very much
Sincerely
Diana

Sid Schwab said...

Diana, I really don't like to make specific suggestions because I can never know as much about the situation as your own doctors. I'd suggest this much: next time it happens arrange to be seen by your doc or in a walk-in clinic while it's happening so blood tests, including tests of liver and pancreas, can be drawn. It's possible that could provide clues and help decide what other things might be useful.

It's not very common for stones to form in the bile duct after GB removal, unless they were there at the time.

Erin Thomson said...

Hi Dr Schwab! What a great blog, I just found it yesterday but I've enjoyed the articles I've read immensely so far. I know from reading these comments that you don't speculate on any diagnosis, but I do have a question. Have you ever seen gallbladder complications related to appendicitis and/or appendectomy? I live in Canada and was visiting California when lower abdominal pain struck, and after some blood work and a CT they determined my appendix was inflamed and performed a laproscopic appendectomy.

Erin Thomson said...

Continuing from my last comment (sorry!)... So the appendectomy went fine as far as I know and I flew back to Canada a week later. Almost immediately I began having extreme abdominal pain after eating. I ended up in the ER several times because the pain was worse than anything I'd experienced (including labour and delivery!) but all further bloodwork, ultrasounds and additional CT scans showed everything to be mostly normal. I say mostly because my lipase was slightly elevated during one episode but not enough that they thought it significant (ie not pancreatitis levels, I guess).

Anywho, I really struggled with extreme pain for a few months and lost a bunch of weight as I was scared to eat. The extremes of the pain seem to have mostly subsided since then although I do still experience bouts of abdominal pain and go back to the doc everytime for more bloodwork and ultrasounds to have everything come back normal.

So I guess my question is have you ever seen Gallbladder complications/reactions after an appendectomy?

Sid Schwab said...

I'm unaware of any connection between the two, and can't really think of a reason why there'd be one. It's possible that as a result of the appendectomy there were adhesions that caused intermittent twisting of bowel; if so, having occurred early after surgery, it'd be expected to go away on its own in most cases.

Erin Thomson said...

Thanks Dr Schwab. Do you think location of the laproscopic incisions would influence that at all? For whatever reason my incision locations for the appendectomy were 1. Along the pubic area, 2. Umbilical and 3. Upper epigastric (like 3 inches below my breast bone). From my googling, an epigastric incision location for an appendectomy doesn't seem to be the norm.

Sid Schwab said...

I don't think so.

Robert Lerma said...

Dr. Schwab,

Need advice, have had right upper quadrant pain for bout 4 year, however the pain for the most part is more annoying, I do have right rib and bottom of shoulder blade pain. It was tolerable but now I have other issues including bad constipation/nausea. Had endoscopy recently with just acid damage to end of stomach and slight gastritis, I have had 5 ultrasounds in last 4 yrs. I just im confused gonna now get HIDA scan now but Im just afraid that it will be normal and then comes the SOD issue to wonder :-\ I have noticed the pain is usually the same just annouing dull, I used to eat very greasy foods but never experienced a full blown GB attack. Ive now dieted better and still have symptoms, it only gets better if I use a xanax for therapy which I vaguely use. Any thoughts another thing is my blood work is always good.

Robert Lerma said...

Sry one more thing, Usually when I eat it does feel better, but when i eat or on empty stomach I always hear alot of rumbling coming from the upper quadrant. Also im a 28 year old male, 5'11 bout 183 lbs, have lost weight 15lbs since nausea/constipation bout 3 months. Thank you in advance for some your words. :-)

Sid Schwab said...

Robert, I'm sorry but I always hesitate to get into the diagnosis business. It sounds like your doctors are working on it and, as frustrating as it can be when diagnosis is elusive, it's best to stick with them. If, at some point, you feel you need input from other sources, it's far better to see someone who can examine you directly and review all the records.

Good luck.

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