Bile duct injury

[Jane-B]

  In April I underwent laparscopic cholecystectomy in which the surgeon transected the common bile duct at the level of the porta hepatis.  A second surgeon assesed that roux-en-y choledochohepaticojejunostomy was to be carried out with stent placement.  The only post-operative complication was the falling of the stent which resulted in a small bile leak.  The leak was managed with conservative treatment and  I was released 3 weeks later.
  Since then I have experienced periods of lower abdominal pain with diarreah and also upper stomach pain with vomitting. The lower abdominal pain is associated with eating fat, the stomach pain is not associated and can come anytime.  I have been hospitalized often and had several hida scans, ultrasound and a small bowel series that show no abnormalities.  The most recent hospitalization was for septicemia.  My liver enzymes were elevated and there was right upper quandrant pain when palpated.  Again, hida scan, ultrasound were normal, with no signs of dilation or stricture or obstruction.  My Drs. have said after each attack, especially the most recent that it must be the FLU.  I think that the attacks are related to the surgery in some way.  Can you elighten me in any way what type of long term affects that this type of surgery usually has?  I have tried Questran and cisapride but have had attacks anyway.  Are they related to eating fat ( I have practically eliminated fat from my diet and still the attacks occur).  Any advise would be appreciated
____________
Dear Jane B,
Patients with hepatojejunostomy can have episodes of bile duct infection which could explain the elevated liver tests and the right upper quadrant pain.  Liver enzymes, however, could be elvated for other reasons.  If there is a narrowing of the anastomosis, you could have elevations of the GGT and alkaline phosphatase.  It is also necessary to exclude viral hepatitis.  Given the complexity of your surgical procedures, I would be reluctant to attribute any of your symptoms to the flu.
The abdominal pain and diarrhea with eating may be the result of fat malabsorption secondary to a low bile acid concentration in the duodenum, where the pancreatic enzymes are secreted and are active.  If you are losing weight, I would be even more suspicious that you have fat malabsorption.  There are two approaches to test whether your symptoms are related to fat malabsorption.  You could go on a special diet in which all fat is taken as mediun chain triglycerides.  A second approach would be to take bile pills.  If either approach improves your symptoms, we would have indirect evidence for fat malabsorption as the cause for your pain.  I would not try Questran, a treatment for bile acid-induced diarrhea.
We would be happy to see you in the Division of Gastroenterology at Henry Ford Health system.  We would review all your records and determine which tests are needed to define your problem and then initiate therapy.  You can arrange an appoinment with Dr, Fogel, one of our experts in the treatment of gastrointestinal disease, by calling [phone].
This information is provided for educational purposes only.  Always consult your personal physician for specific medical questions.
HFHSM.D.-rf
*keywords: cholecystectomy, fat malabsorption
0.4