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Prominent Biliary Tree, Common Duct, Distended Gallbladder-No Stones. P...
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Prominent Biliary Tree, Common Duct, Distended Gallbladder-No Stones. Phlebitis.

I am a 43 year old, Caucasian female. Medium build, 135lbs. 5' 7".  5 months ago I looked healthy, fit, had admirable definition in my arms; and now I look very sickly- skeletal from the waist up but have a distended stomach.  I'm in constant pain or discomfort and nauseated much of the time.  I had my blood test results posted for you but was over my 'limit'.  My entire situation has perplexed my doctor to no end.   But it is my recent Ultrasound results that I really would like deciphered if you could?  

Gallbladder is distended and Common Bile Duct is prominent at just under 9 mm. Some prominence of the Intrahepatic Biliary Tree as well.  This should be correlated with the patient's liver enzyme profile. No gallstones were identified within the biliary tree. Spleen, kidneys, liver and visible portion of the pancreas and abdominal aorta were unremarkable.  

I've developed Terry's Nails in the past 4 months too.

Had a sudden, acute attack of Phlebitis on April 15th, from my hips to my feet. Forearms to my hands. Still in pain from this. Legs feel very heavy.  My AlkPhos(ALP) is Low. Potassium is Low. Iron is Low.  I either have no Hep B Immunity or had an acute infection at the time of blood work.  No Antibodies. There's a lot more but I won't take up more of your time.  I just really want to know what my Ultrasound Results mean.  I have ideas but want professional ones so I know what I should be doing with regards to my diet.  Currently, I haven't eaten in 2 or 3 days because I can't so if you can tell me what I have, I'd appreciate it very much.  Thank you.
2827584_tn?1340583296
They are correct in suggesting to correlate with liver function tests. The only one you mentioned is the alkaline phosphatase. The question is whether the dilatation could be secondary to obstruction. An MRCP would be a good idea to rule out mass / obstruction lower in the duct.
7 Comments
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Avatar_m_tn
Thank you for your response, Dr. Watters.  I'm not familiar with MRCP, but I will research it.  I've heard of ERCP.  I'm sure you are very busy and this isn't a back and forth forum, but if you find it in your schedule, your opinion on my blood work and developing symptoms would mean a lot to me.
  
My dad was diagnosed with colon cancer at 54 and died 2 weeks after his 61st birthday.  Can you tell me, if my symptoms can be connected to colon cancer?  Pressure from the colon?  Infection from my bm (bowel movement) habits? My normal bm are every 20 - 30 days.  For several years. Until 12 hours of diarrhea yesterday, I hadn't had a bm since April 11th.  Colonoscopy in July 2009 showed no polyps at all and all good.

I have a lot of bone pain and purple spots near my spine where there is a lot of sharp pain and a hard lump.  And my abdomen pain now starts at my sternum and radiates down to my umbilical area and right all along my ribs. The technician had to stop several times.  I have unbearable pain in my ribs.  Can't even brush against my skin lightly.

I've just spent a few days at the Emergency Department since a call to my doctor revealed he hadn't called for a GI consult or ordered any tests.  His nurses urged me to go to the hospital.  There, I was given an IV drip with morphine, gravol, salt/saline (?) and potassium pills.  They ordered an Urgent GI Consult - for him to call me Monday but I haven't heard back.
  .
The chest x-ray (for sharp chest pain) ruled any lung issues out.
Re: Phlebitis - My blood might connected to everything. I'm bruising easily and my veins are swelling, protruding. IV site for example.
D-Dimer, P    < 150            Sodium:  Low  134       Potassium  *C  2.4
MPV:    Low  at 6.8            Chloride  Low  93  

A second Ultrasound confirmed the first but still no 'cause' for inflammation of my biliary tract. I've gotten worse.  My common bile duct measures 4.8 at the portis hepatis and is now dilated to 10.1mm.  From just under 9mm on April 30th.   No thickening of the gallbladder or bile duct walls.  No stones or shadowing. No abdominal or pelvic free fluid.  Kidneys, spleen, liver, aorta all unremarkable.  No definite mass is evident in the head of the pancreas, pancreatic duct is not dilated. Pancreas otherwise unremarkable. Intrahepatic duct is not dilated.
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2827584_tn?1340583296
I'm not sure of the benefit of the ER visit for a chronic problem but a thorough and thoughtful GI evaluation is needed. The labs are consistent with electrolyte loss from the diarrhea. It is hard to ignore such abnormal bowel function as a possible cause of the problem. Google Ogilvie's syndrome.
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Avatar_m_tn
Thank you, Dr. Watters.  Ogilvie's syndrome does indeed sound like a missing link for me.  Something that has troubled and concerned me almost my entire life.  I have never come across Ogilvie's in all my searches.  Thank you so much for bringing it to my attention.  Hopefully, in a day or two I can mention it to the GI Specialist.

I am incredibly grateful for your direction and expertise with my case  If you have just a bit more time for me, I do have question or two more and that should be it.  I really do appreciate all the time you've given me.

You'd mentioned my electrolyte loss being consistent with diarrhea and I just wanted to clear up that all my blood work was done before any diarrhea had started.  I have only had diarrhea once or twice in my adult life actually, unless brought on by laxative use which has been necessary at the 25 or 30 day mark, out of desperation.  

Thank you for confirming that a GI evaluation is needed.  My doctor has, for years, not taken me seriously.  Even after reading my ultrasound, he hadn't called in the consult he said he would.  His nurses urged me to go to Emerg on night but I had to wait since I had my daughter with me.  

And to clarify, the reason I went to the ER wasn't for my chronic bowel problem but for pain in my lower ribs in January of this year that quickly progressed to my mid to right quadrant (gallbladder area) and became very painful, in addition to many other symptoms.  I've been tested for so many things the past 5 months but with no resolution, only more symptoms.  I think there are a lot of things at play here and my bowels are definitely one of them but it wasn't that kind of pain that brought me in.  This is new pain.  

I've gotten much more sick.  I had no choice but to go to the ER that day.  I was urged and actually brought there by another physician who was concerned but not connected to that type of work.  I can barely walk (I shuffle) or breathe (I run out of air talking at a whisper), can't lean or bend forward or stretch my arms up for that matter (without incredible pain), I feel on the edge of death and I'm told I look like it too.

The Emergency Department did however give me Potassium and draw blood for testing, do a chest x-ray and another ultrasound for which I am very grateful since it was much more detailed than my first one and showed something I think is significant but maybe you can tell me?  My common bile duct went from being dilated 9mm to 10.1 in just 2 weeks.
It's 4.8mm at the Porta Hepatis then dilates to 10.1.  Things are getting worse quickly aren't they?  

I'm in a lot of pain and very often (like last night) I couldn't talk, move or take even a medium breath in, for about an hour because of intense, sharp, right side chest pain which got unbearable if I even attempted to speak.  I'm nauseated from the moment I wake up.

New Pain - under right breast, close to arm pit area makes it hard to breathe and back pain is really, really bad.  Around both sides of me, to my back.  In addition to pain I have just above my umbilical area and right quadrant, I have a lot of pain all around me now.  My ribs on both sides really hurt, like I'm being squeezed.  I can barely tolerate it.  I have Scoliosis in the Thoracic and just recently developed in the Lumbar region.  This new pain is in the center of my back and nothing like what I'm familiar with. Nothing alleviates it.  

The diarrhea continues. I can't eat more than a few tablespoons of rice or broth or a couple cucumber slices each day and still there's urgency and frequency of my bowels as soon as I eat anything.  

I'd forgotten to mention the swollen glands I feel I have in my chin/neck and armpit areas.  And I should have had a mammogram a few months ago when I noticed something that is much more noticeable - also on the right side of my body.  

To you, Dr. Watters, I wonder if knowing all my varied symptoms, do you think an MRI would be warranted first?  Or if I as a patient, could ask for an MRCP instead of the more invasive and riskier ERCP?  

Thank you so much for your expertise and time.

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2827584_tn?1340583296
I am sorry to hear of your misery. You clearly have multiple issues that require thorough and thoughtful evaluation. A GI workup is certainly in order as your bowel function is grossly abnormal. The negative colonoscopy in 2009 is reassuring from the standpoint of your family history of colon cancer. You mentioned that your alkaline phosphatase is low. If the bilirubin is also normal the chances that the bile duct diameter is significant becomes low. A dilated bile duct raises interest for the possibility of obstruction. If these blood tests are normal this is unlikely to be the explanation making it an interesting but probably insignificant finding.
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Avatar_m_tn
sir  i have been diagnose with my ultra sound  showing multiple small echogenic adherent to the wall mostly polyps versus  stones sir just want to know what is the meaning of this and what is the best solution to my problem hope you give me a answer to enlighted me because i am worry about my kids they are verry small
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