Wednesday, March 28, 2007
Slippery Stones: more about the gallbladder
"If you don't have a pretty good idea what's going on with your patient after a thorough history and physical," I was told in medical school, "you probably never will." It's a wise -- if a little dated -- statement. Most of the time, diagnosis isn't all that hard. Rare things are rare. Common things are common: another med-school pearl of wisdom. Figuring out the problem in those outlier situations can be frustrating on each side of the white coat and, in the case of surgery, can lead to errors in both directions: doing operations that don't help, or deferring ones that otherwise might. The gallbladder has been the source of more than its share of such scenarii.
Delicate and robin's-egg blue, the normal gallbladder is startlingly beautiful. Out of place among the muted earthiness of the rest of the abdominal anatomy, it peeks above the lower edge of the right lobe of the liver, demure, nearly luminous; typically you see only the top of it, the rest hidden by the colon and omentum. It's as if the body is shy about revealing such surprising and incongruous loveliness. Aiming to remove it, seeing that color signals a likely easy time; hoping to help a person with grey symptoms, finding a blue bag makes you wonder what you're doing. With significant chronic gallbladder disease, the organ generally is thick and reddened, although in between attacks it can resume its avian amiability.
"Well, doc, whenever I eat freedom fries, few minutes later I get this horrible pain right here [pointing just below the right rib cage]. Goes right through me into my shoulder blade. Hurts like hell. I get to writhing around, puking my guts out, can't stand up, can't sit down. After twenty minutes it starts to go away, and I'll feel fine again. Oh, and my doc asked me to bring you these [shows me ultrasound images of his gallbladder, full of stones.]" No brainer. Textbook stuff. That man is going to love me for liberating him from the clutches of his gallbladder. The preceding, by the way, is a classic description of "biliary colic," resulting from a stone plugging up the outlet of the gallbladder when it's trying to empty itself of bile. It differs from "acute cholecystitis," which is a more severe situation, resulting from the stone lodging in the outlet and not letting go. Instead of just hurting like hell for a few minutes, the gallbladder gets inflamed, swollen, sometimes infected. It's potentially more dangerous than colic. The distinction, I'd have to say, is often lost on non-surgical medical doctors. But I digress.
"Well, doc, whenever I eat french fries..... [repeats the above story including handing me the ultrasound, which is entirely normal.] That's a diagnostic problem. Or this: "I get heartburn a lot. Sometimes I'm nauseated for no reason. [Shows me repeat of the first ultrasound, stones aplenty.] I've heard variations on those themes countless times, and it's a dilemma. Many tests follow, but explanations remain elusive. Operations may or may not ensue. The sad saga of one of my patients is illuminating. Since it's complicated, maybe I'll just tell the story straight through, and consider the implications later.
I'd operated on her for another reason in the past. Now under the care of docs at a hoidy-toidy medical center, she came back to me when surgery was recommended. She'd been through an extensive workup for abdominal pain, not typical of gallbladder origin, but conceivably so; her gallbladder was, by all measures, normal. At the mecca of medical mastery she'd undergone a test on the basis of which it was decided she had problems with the valve at the end of the bile duct (sphincter of Oddi dysfunction -- more about that little gem, later) and she'd been advised to have her gallbladder removed. I called her gastroenterologist: why, I asked him, had he not cut the valve (the usual treatment) when he was there with his scope? Wasn't taking out her gallbladder attending to the wrong end of the stick? Removal of the gallbladder, he said, was curative sometimes (for unknown reasons); and it was their protocol not to cut the valve (papillotomy) in people who hadn't had cholecystectomy (official and impressive term for gallbladder removal). OK, I said. You're the professor.
The operation went fine. (I've always said unnecessary surgery gets a bad rap: it's easy, and people recover faster than when they're actually sick.) Her pain persisted. From her Meccanized professor, she then got her papillotomy, after which she in fact felt better for a while. When her symptoms recurred, a scope showed the sphincter had scarred down, so it was re-cut, after which she was better again, but for a shorter time, after which it was again scarred small. At that point her gastroenterologist recommended surgically cutting the sphincter; that made sense to me, because it seemed the "medical" cutting had helped, and I knew the surgical approach was more definitive and permanent, if a bigger deal. So I did it, a major procedure involving opening the duodenum and carefully (so you don't cause a leak) slicing the end of the bile duct and tacking it open with sutures. Once again she seemed to have been improved, for a while. When her pain returned, her umpteenth scope Xray showed my operation to be wide open, but her doc had her see Supersurgeon at the mecca. He recommended going back in and cutting her pancreatic duct where it joined the bile duct, figuring that in some way I'd compromised its drainage with my operation. I hadn't. (Below is a diagram that shows the relationships. Ignore the stone, in this case.)
Had I somehow interfered with drainage from the pancreas, and were that a cause of her problem (which didn't make sense, since her symptoms were the same as those before any of these procedures were done), that duct would be seen to be dilated on Xrays. It wasn't. My patient wanted me to do the operation if it was do be done, but that's where I drew the line: for one thing, it made no anatomic sense to me in her situation, and for another, I'd never done it -- at least not that way. I told her both reasons. So Supersurgeon did it, finding no operative evidence of a problem, but soldiering on.
When there was no improvement at all, so my patient later told me, and when she had another scope-Xray to check it out, the surgeon entered the exam room, walked past her to the Xray, looked it over, said "Well, my operation isn't the problem," turned on the heel of his bootie-covered shoe, and walked out without ever having said hello.
I tried everything remaining: wound injections and scanning for hernias, pain clinic referral, obtaining opinions from all sorts. The best I could do, at some point, was to assure her that whatever else was true, it was possible to be sure there was nothing going on that was dangerous to her. She continued to visit the clinic, and finally found some sort of equilibrium with her pain. In my next post, I'll try to deal with some of the issues raised. (The assholery of the surgeon will have to stand on its own, addressed no further...)