Please need help with MRCP Image...Gap in the common hepatic duct?

[Trinity93]

I was told that my MRCP is normal (among a bunch of other tests), but I want to be absolutely positive, since I have been having digestive problems for over two years. My current symptoms (abdominal and back pain, belching, constant bloating, pressure in upper abdomen) started when I began having gallbladder attacks every few days, and I was taking antibiotics for H. pylori (which was found before the gallstones were). The first ultrasound showed innumerous gallstones in my gallbladder and 17% EF on HIDA scan.  The second ultrasound showed no gallstones 6 months later and 64% EF on HIDA scan. I want to make sure that this is not a gallstone, so I can cross this off my list of possible causes. My gastroenterologist said it's probably air and to ask the radiologist, and the radiologist would not comment and told me to ask the gastroenterologist. I would like to know what the gap (arrows) in my common hepatic duct could be. I have posted two 3D images of my MRCP, one is with contrast and the other is without. The common hepatic duct measures about 3 mm at the widest point, and the gap measures approximately 4 mm long. This gap is present in all of the images in this area.

Here is the link to the images:
http://www.flickr.com/photos/87611248@N03/

Thank you for your help.

[Trinity93]

The dissolution therapy did work by dissolving the gallstones and thus the gallbladder returned to proper function based on the HIDA scan.  Based on the symptoms, there's no way to know for sure if the gallbladder is even the problem unless it is removed, or another abnormal test points to something else. Thanks again.

[Christopher R Watters, MD]

We base recommendations on statistical data. Plenty of patients ignore our recommendations and live long lives but the odds are that not removing a gallbladder that is producing symptoms will shorten your life. This is not a recommendation to merely relieve symptoms. Many assume that they can beat the odds. I guess that's why so many people continue to smoke and drink despite seeing numerous folks die early because of it. Denial is a powerful thing.

The reason that dissolution therapy has fallen by the wayside is that it only treats a symptom of a bad gallbladder, not the problem.

[Trinity93]

Over the past two years, I have had many blood tests, and only the initial one was abnormal with elevated liver enzymes (and positive for H pylori). All the blood tests that followed have been normal. The most recent abnormal tests were positive for SIBO, increased split fats, increased neutral fats, and steatorrhea. I thought that since the gallstones are now gone, and gallbladder function improved, that my gallbladder cannot be the cause of the current symptoms, even though those symptoms started somewhere in between many gallbladder attacks. Also, I do not have a family history of gallbladder disease, but I was taking medication that I believe caused the gallstones to form. All of my current symptoms are the same every day whether I eat fat, no fat, or nothing at all.  

Thank you for all of your help.

[Trinity93]

You are not missing anything. Basically, I have been trying to save my gallbladder. After I went to the first surgeon, I was not fully convinced that the gallstones were causing the problems. I told her I wanted to be sure that the gallstones were the problem, and I showed her the palms of my hands which had tiny bumps all over them, and she said that I probably got a mild case of pancreatitis from a gallstone. After the first HIDA scan, I went to another surgeon and asked if I got rid of the gallstones, was there a possibility that my gallbladder function would improve, and he said yes and he did not believe that the bloating, belching, reflux, gas were due to my gallbladder, but said that the vomiting and severe abdominal pain definitely were. So, I went to the gastroenterologist, and she disagreed with the surgeon, and said it will not work, but I told her I wanted to try it anyway. I took Ursodiol for 6 months (vomiting & severe abdominal pain stopped) and had another ultrasound ordered to see if the medication was doing any good, and the radiologist could not find any gallstones. I read that the medication should be taken for another 3 months after all the gallstones are gone, so I did that. After this time, I have jumped from doctor to doctor to doctor and had many digestive tests, some they requested and others I demanded, like the last HIDA scan and MRCP.  

[Christopher R Watters, MD]

There is a lot here that makes no sense. Maybe I am missing something. First, a HIDA with CCK should never be done if there are documented gallstones as you can readily push one down the common bile duct causing the most life threatening complications of gallbladder disease. Every radiologist that I have worked with requires a negative ultrasound within 90 days before administering Kinevac (CCK analogue). Further, gallstone dissolution was basically thrown out with the 1992 NIH concensus report on the management of gallbladder disease in everyone except those with an unexcepatably high surgical risk. Even if this was done, you are the proof that the gallstones are merely the evidence of a bad gallbladder and not the primary problem since many of the symptoms have remained. There is significant evidence that biliary pain, whether or not gallstones are present, has it's origin in dyskinesia. Part of the problem with dissolution therapy is that only  about 15% ever have success and if the Actigal is stopped they return.

As for your MRCP images, there is also a segment of the distal common bile duct that doesn't visualize on either of the images. Why was the study done? Were your liver function tests elevated? I would reiterate, the fact that there is no proximal dilatation argues against there being any significant lesion in the common hepatic duct. Your symptoms are consistent with gallbladder origin.

[Trinity93]

The gap is present in every picture at different angles of this duct. Is it possible to appear as a gap in all of the pictures (even in the one with contrast) because the duct is not straight? My symptoms of severe abdominal pain and vomiting were reproduced after the first HIDA scan. However, after starting the medication to dissolve the gallstones, those symptoms disappeared, but all the other symptoms that I currently have remained. Therefore, during the second HIDA scan, I did not experience the severe abdominal pain and vomiting.

I appreciate your quick response. Thank you.

[Christopher R Watters, MD]

You must realize that the image represents a slice through you. If the duct is not straight and leaves the plane it will appear as a gap. The fact that there is no proximal dilation would argue that there is no blockage there.

Were your symptoms reproduced during the HIDA scans?