its galling diagnostic dilemmas and

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...

Posted by Sid Schwab at 7:40 AM

Labels: biliary dyskinesia, biliary manometry, HIDA scan,

post-cholecystectomy syndrome, sphincter of Oddi dysfunction

43 comments:

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.

3/30/2007 12:25 PM

Sid Schwab said...

Thank YOU!!

3/30/2007 12:34 PM

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?

3/30/2007 3:55 PM

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.

3/30/2007 4:49 PM

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.

3/30/2007 5:26 PM

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!

3/31/2007 10:43 AM

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.

3/31/2007 2:21 PM

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.

4/01/2007 7:06 AM

#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.

4/01/2007 6:40 PM

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...

4/01/2007 7:26 PM

Gallgizzard said...

Excellant discussions! I am a Sonographer currently in the

lecture business, and I am going to bring up your page this