Gallbladder seems fine but PCP recommends removal

[misha50]

Had a full GI work up: CT scan, Hida scab, ultrasound, endoscopy, blood and stool tests.  A few years ago I also had an endoscopy, colonoscopy, x-rays, and blood and stool tests.  Results of all the tests do not show any problems with my gallbladder, and also no gallstones.  There is some family history of gallbladder issues.

I have acid reflux for at least the past few years and, per my GI at the time, slow motility in my digestive tract.  Per my current GI I may have IBS also.  Most of my symptons were diarrhea, stomach aches/discomfort, and soft and black stools.  Prilosec has made these symptons bearable and has helped relieved them to some degree, however still have some of the above symptoms and gassiness.  In truth, I never really felt that I had classic traditional heartburn or had problems eating certain foods, such as I could eat spicy foods and not have much change in my symptoms.

However,  in the past year I have developed additional painful symptoms:
Alternating pain between my right chest muscle and right under my right rib, like a throbbing or someone grabbing me under the rib - this initially started off as pain in my right upper back, but now it's rare to have the pain in the back.  The pain definitely tends to happen after eating, but also when laying down to sleep and when waking up in the morning.  Pain killers, such as Advil and Vicodin do almost nothing to relieve the pain, however once I tried Vicoprofen and it helped a little, but this is a very potent drug and it felt very addictive as I enjoyed its effect on me, so this drug is out.  I also have nausea, a bitter bile taste in my mouth, a feeling of fullness due to the nausea, some heartburn.  Fatty/Oily foods tend to inflame the pain the worst, but eating in general tends to aggravate it.  The pain is debilitating as I can't concentrate, am ultra sensitive to any noise or stimuli, and in general am not able to function.

My PCP says I have classic gallbladder symptoms and wants to remove the gallbladder.  A GI and a surgeon that removes gallbladders will remove the gallbladder if I insist as I'm at my wit's end, but they think it could be musculo-skeletal, which my PCP says doesn't make sense as I get the pain after eating.  After discussing this with the GI and surgeon, they agree that musculo-skeletal doesn't appear to make sense either.

I will be seeing another GI for a second opinion, but at this point I'm ready/willing to have gallbladder removal surgery.  Thoughts or suggestions on this?  Thanks so much!

[boron]

It's not a dumb question, and I can only answer by using a logic, not experience...

When liver enlarges, it extends up and down, left and right...and the gallbladder is... behind, or if you want under the liver. There is soft intestine below the liver and gallbladder, and it moves away easily with liver enlargement.

Enlarged liver can put some pressure on the gallbladder, but the pain comes from  gallbladder/biliary duct muscle spasm, not pressure from outside. Abdominal tumor, pressing on the bile duct from the outside, or adhesions (after surgery or in endometriosis) could press on bile duct and block bile flow though...

Enlarged pancreas should not touch gallbladder or biliary duct.

Images:
http://images.search.yahoo.com/search/images;_ylt=A0WTbx__y5FIfTQB70GLuLkF?ei=utf-8&fr=sfp&p=gallbladder+pancreas&iscqry=

[misha50]

Boron, I'll bring up the biliary dyskinesia with the GI.  I did a google on this, and the below looks like it's telling me that a low EF % and post-GB surgery are common for coming up with this diagnosis.  


Biliary Dyskinesia

James Toouli, MBBS, PhD, FRAS  

Current Treatment Options in Gastroenterology 2002, 5:285-291
Current Medicine Group LLC ISSN 1092-8472
Copyright © 2008 by Current Medicine Group LLC


Opinion Statement
Biliary dyskinesia is a motility disorder that affects the gallbladder and sphincter of Oddi.
The motility disorder of the gallbladder is called gallbladder dyskinesia. Patients with this condition present with biliary-type pain, and investigations show no evidence of gallstones in the gallbladder. The diagnosis is made by performing a gallbladder ejection fraction, which is a radionuclide investigation. An abnormal gallbladder ejection fraction has a value less than 40%. Patients with an abnormal gallbladder ejection fraction should undergo cholecystectomy. This procedure has been shown to be effective in curing the symptoms in over 90% of patients.
Motility disorder of the sphincter of Oddi is called sphincter of Oddi dysfunction. This disorder is categorized as two distinct types--biliary sphincter of Oddi dysfunction and pancreatic sphincter of Oddi dysfunction.
Typically, patients with biliary sphincter of Oddi dysfunction present with biliary-type pain on average 4 to 5 years after having undergone cholecystectomy. Sphincter of Oddi manometry is essential in making a diagnosis of abnormal motility of the sphincter. On manometry, diagnosis of a sphincter of Oddi stenosis should lead to division of the sphincter. Sphincterotomy results in long-term relief of symptoms in more than 80% of patients.
Pancreatic sphincter of Oddi dysfunction clinically presents with recurrent episodes of pancreatitis of unknown cause. Having ruled out all of the common causes of pancreatitis, sphincter of Oddi manometry of the pancreatic duct sphincter should be performed. When manometric stenosis is diagnosed, these patients should undergo division of both the biliary and pancreatic duct sphincter. This treatment results in relief of symptoms in more than 80% of patients.

[Tom7335]

I like this last gastro Doc. Pesonally, I would avoid taking
antibiotics for your RUQ pain. Wont do any good plus will
wipe out friendly bacteria in colon. Since you have a sensitive
colon anyway, this may cause loose bowels.

Boron-dumb question-say liver or pancreas were enlarged, would
this put pressure on GB possibly causing pain ?

TOm

[boron]

This another GI seems to be very cooperative. Indeed, liver enzyme GGT is obviously increased in bile duct obstruction. But, you may have biliary dyskinesia, which is a motility disorder, which not necessary causes any obstruction. Colic, cramping pain comes from hollow abdominal organs with smooth-muscular wall (gallbladder, bile duct, pancreatic duct, the whole gut from esophagus to anus, and urethers.

I believe that the following discusion with your new GI can help
1. Is this what you're experiencing a cramp?
2. Is it possible that "cramps after the fatty meal"  would originate from any other organ, beside gb or bile duct?

About HIDA. As mentioned above, and as I know, ejection fraction (EF) of 30-35% is considered abnormal, 35-50% is debatable, and > 50% is normal. On the other hand, normal EF only means that gallbladder ejected contrast substances normally, what can be interpreted as "no stones", but...it still doesn't exclude gb motility disorders. Many patients with gb disease reported strong pain during CCK stimulation in HIDA.

There's only one thing in life which can't be canceled. Surgeon is your servant, he may become mad when you cancel 23th time, but hey...what harm can "one operation less today" do to him.

Gas in the colon, yes, it could cause pain. Breath tests are: for fructose or lactose intolerance, and for small intestinal bacterial overgrowth (SIBO), and of course for H. pylori in the stomach.

[misha50]

Saw another GI today.  He said that biliary pressure would've been detected with elevated liver results from my blood work (I believe I have this correctly paraphrased), thus he strongly did not recommend an ERCP.  He said that he has done many of these and that's his opinion.  He said that GB removal has 20% of improving my symptoms, 20% of making things worse (as I already have a problem with fatty foods), 60% of keeping things as they are.  He also said that biopsy was done on the left side for my colonoscopy, while he would've preferred my right side (I suppose I could have another Colo, not fun.).  This GI also said that in cases like mine, the RUQ pain is much more severe for those where he was Ok with GB surgery.

He suggested a blood test (Prometheus Testing: IBS Diagnostics), a breath test (not for HP, but for bacteria [don't remember if this is overgrowth or what type of bacteria to test for]), and a barium study with x-rays.  I'll do all of these starting tomorrow.  He was thinking of an antibiotic (I believe for the bloating and gas).  Thought that JimK3145 above was saying that he read that gas/bloating might cause RUQ pain.

Question: I feel bad for my surgeon as I already cancelled 1 appt. for the gb surgery.  I currently have it scheduled for Sept. 10, how do I nicely have it cancelled again if need be?  Perhaps I just postpone it for a couple of months.

[misha50]

Thanks for all the detail Jim.  35% EF seems to be borderline from what I've read.  The GI journals usually look to include in their sample size those with EF less than 35% for GB removal studies to test for improvement.

My docs keep telling me that maybe the RUQ pain will go away, and it seems to be what is happening to you more or less.  They want me to wait out the pain as they think it's related to something else.  The right chest muscle pain they believe is musculo-skeletal, however this pain alternates with the RUQ pain, so I don't know what to think.

Keep us informed with your progress.