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.)
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...