Digestive Problems--HELP!!

[bkay]

Last October I had to have an ulnar nerve transpostion to correct an elbow problem resulting from a fall. That was my first surgery ever in my life. I am a 40 year old active female who is slightly overweight. In December I started to have upper abdominal pains located in the mid epigastric region and the right side. Throughout January and Feb. these attacks started to become more frequent. After a trip to the ER for an attack I was diagnosed with gallbladder disease. The ultra sound showed no gallstones but the HIDA scan with CCK showed that my gallbladder function was a 23. I was advised by my doctor and surgeon to have my gallbladder removed. It was removed Lap. on March 2nd. The pathology report indicated that I had cholecystits. About 2 weeks later I started to have upper abdominal pains located once again in the mid-epi. region. My surgeon ordered an abdominal CT which showed nothing out of ordinary. During the follow-up appt. with my surgeon he discovered occult blood as well as upper adominal (abdominal) tenderness.He put my on prilosec and ordered an upper endoscopy which took place April 16th. This revealed I had a hiatal hernia, bile reflux, and gastritis. He put me on 5mg of metoclopramide 4 times daily along with the prilosec 20 mg once a day. During my next visit I learned that the gastritis was not caused by a bacteria but by an erosive agent such as bile. My surgeon indicated that there was "a lot" of bile in my stomach when he went in and took a look. Do to these findings and my continued problems I am to increase the metoclopramide to 10 mg 4 times a day and to stop taking the prilosec. He is hoping that by increasing the acid in my stomach by eliminating the prilosec that the acid will take care of the bile. Unfortunately after 72 hours of no prilosec I am having problems with acid reflux that is resulting in a lot of acid indigestion, burning throat, and heart burn. My surgeon plans to do some investigating and consulting with colleagues to find out what he can do to help me. My questions are...

1. Can the cause of the gallbladder inflammation be the cause of the bile reflux.

2. What else can be done for this disorder besides medicine?

3. What causes this to happen in persons who have not had gastric surgery?

4. Could something have gone wrong during the gallbladder removal to cause this problem?

5. Can bile reflux lead to other problems besides gastritis and ulcers?

6. What signs and symptoms should I watch for that will show if my hiatal hernia is causing any problems?


Thank you for your help and input.

bkay

[Kevin Pho, MD]

To answer your questions:
1) It may be possible that the cause of the inflammation is responsible for the reflux.  Further evaluation to evaluate the bile ducts (i.e. with an MRCP or ERCP) can be considered.

2) I would suggest a 24-hr pH study to evaluate for GERD.  If medications cannot control the symptoms, surgery may be considered (i.e. a fundoplication).

3) A hiatal hernia can cause these symptoms.  It doesn't have to happen in those who have had gastric surgery.  

4) It is possible but less likely that the symptoms are related to the gallbladder surgery.  One possible cause would be Sphincter of Oddi dysfunction - which can be evaluated via ERCP.

5) Patients with mixed acid and bile reflux may be predisposed to worse esophagitis compared to those with acid reflux alone.  Bile acid reflux does not appear to be an independent risk factor for the development of Barrett's esophagus or esophageal adenocarcinoma.

6) You may want to consider a 24-hr pH study to see if the GERD caused by the hiatal hernia requires a surgical evaluation.

Followup with your personal physician is essential.

This answer is not intended as and does not substitute for medical advice - the information presented is for patient education only. Please see your personal physician for further evaluation of your individual case.

Thanks,
Kevin, M.D.

Bibliography:
Bonis et al.  Treatment of refractory gastroesophageal reflux disease.  UptoDate, 2004.

[surgeon]

HIDA scans are helpful but not always accurate in diagnosing gallbladder disease. An ejection fraction of 23 is low but not dramatic; it's also helpful to know if when the hormone is injected to make the gallbladder squeeze, your pain is reproduced. In any case, it seems more likely that your symptoms are and have been due to reflux, and it's very unlikely that the surgey had anything to do with causing it. There are operations (particularly laparascopic fundoplication) which are very effective in controlling reflux. The reflux is caused by having a non-functioning "valve" between the esophagus and stomach. Whatever caused inflammation in the gallbladder would have no relationship; and it's an open question as to what degree the inflammation in the gallbladder was significant. It's not rare that some degree of inflammation is found in the gallbladder; what the significance is depends in part on the nature and degree of the inflammation, as well as the context of the symptoms. Reflux occurs unrelated to whether one has had gastric surgery. Many factors are involved: hiatal hernia, weight, gastric function, esophageal anatomy, etc.

[lildonner]

I was diagnosed in Jan 2004 with gastroparesis. I had been trying to eat for over 10 months but vomited everything I ate that was solid. Sometimes at first it might take up to three days before everything came up and then I would vomit for DAYS..My stomach would swell up like I was nine months pregnant and it burned so bad and hurt a lot before I finally got relief vomiting. I have not been able to eat anything solid since then and I am dying for real food!!!! Are there any foods at all that my stomach might digest with this condition? I have considered gastric pacing but want to hear from people that have had the procedure. Also,I had cervical cancer in Nov of 2001 and was over-radiated along with extra chemotherapy. Could this have been a cause for the gastroparesis? I was under alot of stress for years and blamed that for it. I want to EAT!! I only weigh 90# and am 5'5", 56 years old.I live off of malts and BoostPlus and clear liquids. I was always healthy and energetic before the cancer, then THIS. I normally weigh 117# and got down to 84# when I went to the ER in January..Please help with any input you can. God bless......

[lildonner]

Another question...Is Gastroparesis ever,or often,misdiagnosed?

[lildonner]

Is it safe to sit in a jacuzzi when you have a gastric pacing done? Can it harm the unit or cause other problems?

[MOONGLOW]

I have gastroparesis also.  There is a website out there called Gastroparesis Patients United.  Get on that and you will have a lot of your questioned answered.  If it were not for these wonderful people I would be lost.

Good luck.  

P.S. I am scheduled for the Cleveland clinic for the pacer evaluation on May 26.

[lildonner]

Thank you, moonglow, for the reply!!!!You are the first peson I have heard from that has gastroparesis...FINALLY someone to identify with...I appreciate the link too and will go there next..Are you near the Cleveland Clinic? I live about 100 miles from Vanderbilt and was thinking of going there for the pacing. You can email me at ***@**** ...If I get it done we could compare how we are doing, if you want to. The good thing is, the procedure is reversible, so I will probably go ahead and try it. I was up again all night last night, vomiting, and hadn't eaten anything....That was the second episode in a week. I am hoping it was just a bug...I sure don't want tubes put in~ Good luck in Cleveland. I will be thinking of how you're doing. (I used to take my sister there for Chrons.) She is doing pretty good and has had it for over 30 years..Take care, Donna