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Gallbladder seems fine but PCP recommends removal
Had a full GI work up: CT scan, Hida scab, ultrasound, endoscopy, blood and stool tests.  A few years ago I also had an endoscopy, colonoscopy, x-rays, and blood and stool tests.  Results of all the tests do not show any problems with my gallbladder, and also no gallstones.  There is some family history of gallbladder issues.

I have acid reflux for at least the past few years and, per my GI at the time, slow motility in my digestive tract.  Per my current GI I may have IBS also.  Most of my symptons were diarrhea, stomach aches/discomfort, and soft and black stools.  Prilosec has made these symptons bearable and has helped relieved them to some degree, however still have some of the above symptoms and gassiness.  In truth, I never really felt that I had classic traditional heartburn or had problems eating certain foods, such as I could eat spicy foods and not have much change in my symptoms.

However,  in the past year I have developed additional painful symptoms:
Alternating pain between my right chest muscle and right under my right rib, like a throbbing or someone grabbing me under the rib - this initially started off as pain in my right upper back, but now it's rare to have the pain in the back.  The pain definitely tends to happen after eating, but also when laying down to sleep and when waking up in the morning.  Pain killers, such as Advil and Vicodin do almost nothing to relieve the pain, however once I tried Vicoprofen and it helped a little, but this is a very potent drug and it felt very addictive as I enjoyed its effect on me, so this drug is out.  I also have nausea, a bitter bile taste in my mouth, a feeling of fullness due to the nausea, some heartburn.  Fatty/Oily foods tend to inflame the pain the worst, but eating in general tends to aggravate it.  The pain is debilitating as I can't concentrate, am ultra sensitive to any noise or stimuli, and in general am not able to function.

My PCP says I have classic gallbladder symptoms and wants to remove the gallbladder.  A GI and a surgeon that removes gallbladders will remove the gallbladder if I insist as I'm at my wit's end, but they think it could be musculo-skeletal, which my PCP says doesn't make sense as I get the pain after eating.  After discussing this with the GI and surgeon, they agree that musculo-skeletal doesn't appear to make sense either.

I will be seeing another GI for a second opinion, but at this point I'm ready/willing to have gallbladder removal surgery.  Thoughts or suggestions on this?  Thanks so much!
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With 2-3 bms a day you obviously don't need laxatives - these would trigger even more bms.

I was suggesting MRCP, since you were reluctant to have ERCP, which, by my opinion can detect motility problems in biliary tree. ERCP is done during esophago-gastro-duodenoscopy, and a contrast is injected through the duodenal bile duct opening into biliary tree. During the same procedure, manometry of sphincter of Oddi (measuring of pressures) can be done to evaluate SOD. And if some obstruction is found, it can be sometimes removed right away.

None of investigations you listed can determine dysmotility of biliary ducts. You are searching for dysmotility now, not for stones. HIDA would show some gross duct motility disorder, but HIDA is basically done for gallbladder function, and to determine patency of biliary ducts, but not really for dysmotility. Experienced gastroenterologist can give you more reliable information though.

ERCP sometimes causes mild transitional pancreatitis, but this should not distract you from the procedure itself. It is eventual cutting of sphincter of Oddi (in order to releave increased pressure), which has more complications, so speak with GI about that.
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I've been following these posts with interest. I know that you've said that your PCP would like you to have your gallbladder removed, but the surgeon will have the final say. Based on your HIDA scan results and other gallbladder tests, I think that the surgeon would not recommend that your gallbladder be removed. I've been having similar RUQ pain but I've had an abdominal sonigram, CT scan, MRI and Hida and they all said that the gallbladder was fine. The surgeon told me that based on my results, he can't remove the GB just because of pain. I should say that my original HIDA scan was not done with stimulation so I don't know what the ejection fraction was. But I've had another HIDA done but this time with stimulation so I should be getting the results back any day now. Unless I get a really low ejection fraction, I know that the surgeon will not recommend removing it. The surgeon told me that a good functioning GB has an ejection fraction of about 70% max, so your value of 62% looks really good. Hope this helps.


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My PCP talked to my surgeon, and the surgeon agreed to do the surgery if I want.  That's probably what will need to happen in your case as well.  My surgeon says that about 50% of cases such as mine feel better after surgery, so they're trying to keep me realistic about any success of such surgery.

The question is: with all this pain that you're having, what other options are they suggesting.  They've been telling me to live with the pain, sometimes it goes away, and eat a high fiber diet.  However this has gone on for ~9 months now, and it's a daily occurrence to have discomfort/pain, so I don't find their suggestions helpful since I'm doing everything by the book.  Let me know what your ejection fraction % is.
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I've been following this as well and I'm curious: what will you do if after having surgery you still have symptoms?  Of course this is my case and many others.  I did not have stones but a non-functioning GB.  My symptoms were way worse after surgery and now are back to the same as before.  Now that the doctors have removed my GB and they don't know the source of my pain, they seem to just want to ignore me... and I'm still paying for the GB removal (financially).
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It seems to me that next steps are ERCP in your case.  I asked my surgeon about this and this is one of the possibilities.  Fortunately I have insurance to help with the financial part.
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I have insurance, there is a deductible which is very high.

An ERCP would be OK although I did not have any stones, so it's not likely to have anything stuck.  Maybe some strictures, but this isn't something that had time to develop after surgery - it was obviously present beforehand.  A recent MRCP came back clear.  I am convinced I had my GB removed unnecessarily, even though the EF was 0.  I wonder too if painkillers or whatever other meds I was on at the time gave it the result and if having a HIDA scan med free would have shown a functioning GB.
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ERCP also used for detecting/relieveing pressure in the biliary ducts I believe.  So stones is one potential issue, as well as sludge, but pressure is another issue.
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Just received my HIDA scan results: 36% ejection fraction. The report said that anything anything above 33% is considered to be normal.
The bottom line with me is that my current Gastro Doc (he's the 2nd one I've been to) thinks that what I have is Non-ulcer dyspepsia (essentially indigestion with no known cause). Tomorrow I'm getting a capsule endoscopy to rule out any blockages in the intestinal tract followed by a normal endoscopy as a follow up to the one I had a year ago. My main problem right now is general bloating with slight nausea. To give you some background:
Last summer I started to experience stomach pain and bloating. Never had had any abdominal/gastro problems before that (I was 57, now I'm 58). Went to first gastro doc in Aug 07. He put me on Prilosec, then performed endoscopy in Sep 07. I was found to have mild gastritis and also Barrett's esophagus. Negative for H. Pylori. He then upped the Prilosec to 2x daily. By Oct, stomach still hurt, Zegerid was then added. Still no help. In Nov 07, had sonigram of abdomen (no stones found, all organs looked good) and in Dec 07 had barium swallow test (showed reflux still occurring). Reglan was then added to the meds. During that time, I was switched from Prilosec to Prevacid. My PCP thought I had IBS. He gave me Donnatal for bloating. In November 07, the RUQ started. It was about 1-2x a week. Usually if I laid down, it would go away after a few hours. If I took the Donnatal, the bloating would decrease, but the RUQ seemed to be enhanced. In Jan-Feb 08, the RUQ increased in intensity. It would come and go during the day. It didn't appear to be related to any type of food that I ate. I should mention, that I am very regular as to bowel movements. No diarrhea or constipation. In March after still complaining about RUQ, I had a CT scan (without contrast) and the first HIDA scan (without stimulation). Both results said GB was fine. Also had blood work done (liver enzymes fine, Sed rate good, no abnormalities). Was given Bentyl, Levsin, and Levbid to use for bloating. Found that If I took any of these for a few days that my ankles and calves would swell up, so I stopped. By the end of Mar 08, first Gastro doc said that he was stumped and that I should go seek help at a teaching hospital. First gastro doc had reduced my meds to just 1 Prevacid daily at the beginning of Mar. Made appt with new Gastro guy for end of May. Before that I met with Surgeon at same teaching hospital in mid May 07. He told me that he wouldn't remove GB based on CT and Sonigram results. Suggested that I ask new Gastro doc to order new HIDA scan with CCK stimulation. At beginning of April 07, noticed that bloating was becoming more prevalent and that RUQ pain was changing into a more general stiffness. Sometimes feels as though someone has placed a piece of cardboard around right side. Also noted that sometimes while swimming felt as though skin over right ribcage was tearing as I swam. Would usually stop after I finished swimming. Also noted that area above right hip felt as though I was wearing a weight. Also noted that right front RUQ would start when I started eating and would stop after I was done. Seems to be related to act of eating rather than what I ate.
When I met Gastro Doc No. 2, we reviewed past 10 months of data. He ordered a celiac  disease test (came back negative). MRI with contrast ( came back and said GB was fine as were other organs) and a breath test for bacteria overgrowth. (came back slightly positive, was given 1200 mg daily of Xifaxan for 10 days). This didn't seem to stop the bloating. Was still getting the RUQ pain. Saw Gastro doc again on July 16th. He ordered new HIDA scan with CCK stimulation (came back at 36% EF), capsule endoscopy (having it done tomorrow) and follow up endoscopy for early Sept. (To check up on Barrett's diagnosis from last year). He also told me to take Probiotics till I see him and he wants me to see a dietician/nutritionist in August. He did not address the RUQ. I think that he wants to see what the HIDA results would be. He said that he wouldn't want to see my gallbladder be removed and for me to still have the RUQ pain. At the end of the visit was when he thought that I might have non-ulcer dyspepsia. In the last few weeks, the RUQ pain has diminished slightly. I've noted that if I'm sitting in a chair and bend my right leg towards my body, that I sometimes get the right front RUQ and if I lie on my bed at a 45 degree angle, I sometimes start to feel the RUQ on my back. I also noted that when I lie on my stomach while sleeping, I sometimes feel as though I have a muscle pull in my right groin and I sometimes get a slight throbbing on my lower right side near where the appendix is located. I was reading about bloating and gas on the internet, and one article mentioned that sometimes gas that is trapped in the ascending colon on the right side can mimic gallbladder and appendix symptoms. I thought that was very interesting. Looks as though I'll have to wait till mid September when I see the Gastro doc again to discuss all the new tests results and dietician visit results. I'm starting to wonder as to whether my RUQ pain is related to the GB or rather to gas and bloating. Hope you get something out of this. Be careful about extended use of Bentyl, Levsin or Levbid.
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Thanks for all the detail Jim.  35% EF seems to be borderline from what I've read.  The GI journals usually look to include in their sample size those with EF less than 35% for GB removal studies to test for improvement.

My docs keep telling me that maybe the RUQ pain will go away, and it seems to be what is happening to you more or less.  They want me to wait out the pain as they think it's related to something else.  The right chest muscle pain they believe is musculo-skeletal, however this pain alternates with the RUQ pain, so I don't know what to think.

Keep us informed with your progress.
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Saw another GI today.  He said that biliary pressure would've been detected with elevated liver results from my blood work (I believe I have this correctly paraphrased), thus he strongly did not recommend an ERCP.  He said that he has done many of these and that's his opinion.  He said that GB removal has 20% of improving my symptoms, 20% of making things worse (as I already have a problem with fatty foods), 60% of keeping things as they are.  He also said that biopsy was done on the left side for my colonoscopy, while he would've preferred my right side (I suppose I could have another Colo, not fun.).  This GI also said that in cases like mine, the RUQ pain is much more severe for those where he was Ok with GB surgery.

He suggested a blood test (Prometheus Testing: IBS Diagnostics), a breath test (not for HP, but for bacteria [don't remember if this is overgrowth or what type of bacteria to test for]), and a barium study with x-rays.  I'll do all of these starting tomorrow.  He was thinking of an antibiotic (I believe for the bloating and gas).  Thought that JimK3145 above was saying that he read that gas/bloating might cause RUQ pain.

Question: I feel bad for my surgeon as I already cancelled 1 appt. for the gb surgery.  I currently have it scheduled for Sept. 10, how do I nicely have it cancelled again if need be?  Perhaps I just postpone it for a couple of months.
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This another GI seems to be very cooperative. Indeed, liver enzyme GGT is obviously increased in bile duct obstruction. But, you may have biliary dyskinesia, which is a motility disorder, which not necessary causes any obstruction. Colic, cramping pain comes from hollow abdominal organs with smooth-muscular wall (gallbladder, bile duct, pancreatic duct, the whole gut from esophagus to anus, and urethers.

I believe that the following discusion with your new GI can help
1. Is this what you're experiencing a cramp?
2. Is it possible that "cramps after the fatty meal"  would originate from any other organ, beside gb or bile duct?

About HIDA. As mentioned above, and as I know, ejection fraction (EF) of 30-35% is considered abnormal, 35-50% is debatable, and > 50% is normal. On the other hand, normal EF only means that gallbladder ejected contrast substances normally, what can be interpreted as "no stones", but...it still doesn't exclude gb motility disorders. Many patients with gb disease reported strong pain during CCK stimulation in HIDA.

There's only one thing in life which can't be canceled. Surgeon is your servant, he may become mad when you cancel 23th time, but hey...what harm can "one operation less today" do to him.

Gas in the colon, yes, it could cause pain. Breath tests are: for fructose or lactose intolerance, and for small intestinal bacterial overgrowth (SIBO), and of course for H. pylori in the stomach.

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I like this last gastro Doc. Pesonally, I would avoid taking
antibiotics for your RUQ pain. Wont do any good plus will
wipe out friendly bacteria in colon. Since you have a sensitive
colon anyway, this may cause loose bowels.

Boron-dumb question-say liver or pancreas were enlarged, would
this put pressure on GB possibly causing pain ?

TOm
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Boron, I'll bring up the biliary dyskinesia with the GI.  I did a google on this, and the below looks like it's telling me that a low EF % and post-GB surgery are common for coming up with this diagnosis.  


Biliary Dyskinesia

James Toouli, MBBS, PhD, FRAS  

Current Treatment Options in Gastroenterology 2002, 5:285-291
Current Medicine Group LLC ISSN 1092-8472
Copyright © 2008 by Current Medicine Group LLC


Opinion Statement
Biliary dyskinesia is a motility disorder that affects the gallbladder and sphincter of Oddi.
The motility disorder of the gallbladder is called gallbladder dyskinesia. Patients with this condition present with biliary-type pain, and investigations show no evidence of gallstones in the gallbladder. The diagnosis is made by performing a gallbladder ejection fraction, which is a radionuclide investigation. An abnormal gallbladder ejection fraction has a value less than 40%. Patients with an abnormal gallbladder ejection fraction should undergo cholecystectomy. This procedure has been shown to be effective in curing the symptoms in over 90% of patients.
Motility disorder of the sphincter of Oddi is called sphincter of Oddi dysfunction. This disorder is categorized as two distinct types--biliary sphincter of Oddi dysfunction and pancreatic sphincter of Oddi dysfunction.
Typically, patients with biliary sphincter of Oddi dysfunction present with biliary-type pain on average 4 to 5 years after having undergone cholecystectomy. Sphincter of Oddi manometry is essential in making a diagnosis of abnormal motility of the sphincter. On manometry, diagnosis of a sphincter of Oddi stenosis should lead to division of the sphincter. Sphincterotomy results in long-term relief of symptoms in more than 80% of patients.
Pancreatic sphincter of Oddi dysfunction clinically presents with recurrent episodes of pancreatitis of unknown cause. Having ruled out all of the common causes of pancreatitis, sphincter of Oddi manometry of the pancreatic duct sphincter should be performed. When manometric stenosis is diagnosed, these patients should undergo division of both the biliary and pancreatic duct sphincter. This treatment results in relief of symptoms in more than 80% of patients.

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It's not a dumb question, and I can only answer by using a logic, not experience...

When liver enlarges, it extends up and down, left and right...and the gallbladder is... behind, or if you want under the liver. There is soft intestine below the liver and gallbladder, and it moves away easily with liver enlargement.

Enlarged liver can put some pressure on the gallbladder, but the pain comes from  gallbladder/biliary duct muscle spasm, not pressure from outside. Abdominal tumor, pressing on the bile duct from the outside, or adhesions (after surgery or in endometriosis) could press on bile duct and block bile flow though...

Enlarged pancreas should not touch gallbladder or biliary duct.

Images:
http://images.search.yahoo.com/search/images;_ylt=A0WTbx__y5FIfTQB70GLuLkF?ei=utf-8&fr=sfp&p=gallbladder+pancreas&iscqry=
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Yes, it's good to have some research to be prepared for discussion with GI...

Questions for GI:
- are liver (GGT) OR pancreatic (amylase, lipase) enzymes increased in ALL cases of biliary dyskinesia, or only in some people, or only during pain attack?
- the same for increased pressures detected during manometry: are high pressures always detected or only during pain attack?

With other words: what is possibility of false negative results of manometry?

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A litle more precise answer:

Pressing with fingers on a gallbladder with stones, can (not necessary) cause pain.
Enlarged liver could cause pain in gallbladder with stones, bot not likely in healthy gallbladder.
Enlarged liver is often painfull by itself, or by pressing on it...
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Actually you opened an interesting question: can gas in the colon press on the gallbladder and cause typical gallbladder pain? Hm, hm.
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Do not have your GB removed.  Try visceral manipulation to have it drained.  If it is functioning okay-you probably have SOD.   The only way to find out if you have SOD is with ERCP w/manometry.  Do not believe any GI/or other doctor that tells you differently.  I had my GB removed last year for the same exact sxs as you describe.  What I ended up with is severe gastroparesis (I did not have this before) living on TPN for the past year.  I belive I had SOD-no I know I had SOD to begin with and when the GB was removed the SOD became worse.  AS for the gastroparesis-I'm not sure if the surgeon cut my vagus nerve but that is my suspicion.  Had I had an ERCP in the first place I would not now be waiting to die on tpn complications.   Most doctors don't have a clue about SOD and many don't even think it's a real condition.  If your GB is functioning on a HIDA then there is nothing wrong with your GB.   Go to a biliary expert and have an ERCP.  
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I had posted earlier to Misha50 and had mentioned the possibility gas in the colon causing pain. Below is an excerpt from the brochure "Gas, Bloating and Belching".

"Gas and Abdominal Pain:

Abnormalities of motility are thought to be associated with abnormal
sensitivity. This increased sensitivity to normal volumes of gas may
result in pain. For some who suffer with (pain that has no known cause), it is believed that abnormal motility and sensitivity may be the source of pain.
Splenic Flexure syndrome is a chronic abdominal pain disorder triggered by trapped gas at the left flexure (bend) of the large colon. This flexure is located where the large colon runs horizontally then bends downwards towards the rectum. This bend occurs near the spleen--hence the name ‘splenic flexure.’ Trapped gas in this location can cause pain to be felt in the chest region. Called ‘referred pain,’ since the pain is felt in a region distant from the source, it can mimic heart disease. Gas trapped in the right flexure can mimic pain of gallbladder disease or appendicitis".
This was from the website: www.digestivedistress.com
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Here's an article that Calgal had sent me some months ago concerning Proton Pump Inhibitors. I had mentioned that I've recently gotten my HIDA scan results (EF was 36%) and I've been on PPI's for about 11 months. My RUQ pain started about 2 months after starting the PPI's. I have sent a letter to my Gastro doc asking to whether I could stop the PPI's for about a month to see if that makes any difference, before I sit down with him to discuss the HIDA results. Thought you might find this interesting. I am also experiencing a lot of bloating also so I'm not sure if gas is not the cause of the RUQ pain.

"Proton Pump Inhibitor May Reduce Gallbladder Function

April 21, 2005 — A short course of proton pump inhibitor (PPI) therapy may result in a significant reduction in gallbladder motility and new-onset biliary symptoms, according to the results of a preliminary prospective study presented at the 2005 annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons in Fort Lauderdale, Florida.

A previous study has shown that discontinuation of PPI therapy after fundoplication for reflux disease results in normalization of preoperative biliary dyskinesia in a significant number of patients, coauthor Mitchell A. Cahan, MD, told Medscape. "Our study looked at the converse of that — what the effects of PPI therapy would be on gallbladder function in healthy volunteers." Dr. Cahan is a clinical instructor of surgery at the University of North Carolina School of Medicine in Chapel Hill.

In the study, gallbladder ejection fraction (GBEF) was assessed by cholecystokinin (CCK)-stimulated hepatobiliary (HIDA) scan at baseline and after one month of omeprazole therapy (40 mg/day) in 19 volunteers with no history of gastroesophageal reflux disease, biliary disease, or chronic abdominal pain.

Results at 30 days showed that omeprazole therapy was associated with a decrease in gallbladder motility in 79% of patients; overall, mean GBEF decreased by 13.6% compared with baseline (42.8% ± 32.3% vs 56.4% ± 30.0%; P < .01).

"Even more telling is the fact that before they started on omeprazole, five individuals had ejection fractions of less than 35% (biliary dyskinesia) — and at the end of the month, that number had doubled to 10," Dr. Cahan pointed out. "Moreover, of 15 patients who completed a symptom survey at the end of 30 days, four had symptoms that were compatible with biliary pathology such as nausea and vomiting, increased flatus, and right upper quadrant pain."

Although these findings are preliminary and larger studies are needed to determine clinical implications, Dr. Cahan recommends that healthcare providers seek objective evidence of reflux prior to initiation of PPI therapy and that they remain aware of evolving data regarding the effects of such therapy on biliary function.

"Given the fact that PPIs constitute the eighth most prescribed class of drugs, providers need to be cognizant of these potentially adverse findings leading to abnormal gallbladder function that could promote cholelithiasis or biliary dyskinesia," Dr. Cahan said. "Patients receiving escalated or long-term PPI therapy are potentially subject to these adverse effects."

The investigators report no pertinent financial conflicts of interest.

SAGES 2005 Annual Meeting: Abstract S120. Presented April 15, 2005.

Reviewed by Gary D. Vogin, MD"

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Thanks for the info on PPI`s. If you read my earlier posts, I suggested that Misha
go off Prilosec. I still maintain a course of 6-8 weeks max is best . It is a
terrific drug, but in recent years has become overused. I believe the key is
weening off it very slowly. While on prilosec, I felt nauseated and weak. My
research led me to DGL. Once again, thanks for this important info.
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Thanks for the info on the DGL. Not sure if you read my post to Misha 50 on 30 July. That explains my current medical situation. My post about the PPI's is the reason I would like to get off of them for awhile to see if it makes any difference. The reason that I've been on PPI's since last August 07 is that I was diagnosed with Barrett's esophagus by my first Gastro doc. I'm now on my Gastro Doc No.2 and am scheduled for a follow up endoscopy for Sep 2. Now that I have my HIDA results back (36% EF), I need to discuss this result with him also since I get intermittent RUQ pain.
One last item: Do you have any recommendations for anything to treat low level nausea? Thanks!
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read "alternatives to medications and surgery" in this Mayo Clinic link:
http://www.mayoclinic.com/health/barretts-esophagus/HQ00312/DSECTION=treatments%2Dand%2Ddrugs

Discuss w/Gastro Doc. You cant go on w/PPi`s the rest of your life.

Avoid all soda type drinks, Coke etc + coffee.

ARe you still on the PPI`s right now ??

Seek out a dietician or nutritionist w/certicifaction and Masters Degree.

EXplore the lef.org site.
from health concerns, drag cursor to disease prevention , then under gastrointestinal.
, click on Gerd. read about Baclofen.

dont lie down after eating. wait one hour, this causes reflux.
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I went off Prilosec for about 3 weeks and noticed that heartburn started bothering me, not killing me, but annoying enough.  I had no change in my RUQ symptoms.  I've been back on Prilosec for a couple of weeks and things are a little bit better.  Since I've taken Levsin, the RUQ pain seems to have dissipated a little bit so that it no longer really bothers me too much.  The biggest change is at night as it's not an overwhelming sensation.  There is still some RUQ discomfort that I notice, but so far seems manageable, not worthy of surgery as of this moment.  But the RUQ has dissipated in the past and came back with a sharp vengeance, so I'm hopeful that it really is going away.

The other products, such as pepogest and DGL so far have had no impact for me as I've tried them for a few weeks.  Not to say that they don't help others as I can only speak for my own experience.  I'm still taking my probiotics, which I find to help, even though all my docs seems to scoff at this motion.

JimK3145 - Water with a lemon always helps nausea.  You'll find it to be a natural wonder drug.  
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Re PPI's: There are folks who have been on Prilosec for over a decade and report no problems,  There are no long-term studies that I'm aware of, so my info is from docs and other folks I know who take Prilosec.  In regards to your comment that one can't be on PPI's for the rest of their lives, while I agree with your sentiment, reality is sometimes different, so we all need to do what works for us.
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To answer your questions: yes, I'm still on PPI's (Prevacid, 1x daily 30 mg since last Aug. 07 because of the Barrett's). The Barrett's will be re-discussed after my upcoming follow up endoscopy in early Sept, 08. The first endoscopy was performed in Sept, 07. I gave up carbonated drinks and soda last Sept '07. Also gave up caffeine at that time. I don't smoke or drink either. Now I drink decaffeinated iced tea. Also raised my bed's headboard about 9 inches. Usually don't lie down for at least 2 hours after eating. I have an upcoming appt with a dietician/nutritionist at the urging of my new Gastro doc. He also told me to start taking probiotics. My quest is to find out what is causing my bloating/nausea besides just treating the symptoms.

Misha 50: About the lemon: I was told that lemon bitters sometimes helps.
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I meant Swedish Bitters, not lemon bitters. Have either of you any experience with digestive enzyme supplements? Thanks!
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I`ve had good success w/digestive enzymes. I dont use on a constant basis.
I take w/meals,not 1/2 hr before or after, usually just w/main meal of the day.
THe theory is that they are useless because the enzymes will be destroyed
by the stomach b4 entering the small intestine. There are many brands
avaialable, I use Pancreatin., item # sw285 from Swanson. this is Enteric
coated which seems to help better than if not coated. Helps a lot w/gas
after meals. Try different formulations and brands and you`ll find that some
work betrer than others.

Misha-glad your feeling  a little better. I`ll have to do some research on Levsin.

Jim- let me do some research on nausea-I`ll try the Swedish Bitters if I can
find it, do youn have a brand?
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I don't have any particular brand for the Swedish Bitters. Thanks for the info on the enzymes. My experience with Bentyl, Levsin and Levbid have been that if I use them for a period of over 3 days, my ankles and calves start to swell. My PCP said that he could give me water pills to reduce the swelling but that in addition, I'd have to take potassium pills to replenish the potassium that I would lose from the water pills. I figured that that was too much aggravation so I've tried the herb fennel which I make as a tea. I've gotten my fennel from: www.helpforibs.com It works in reducing bloating about 80% of the time and there are no side effects that I've experienced.
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Many drugs carry with them serious side effects.Supplements offer risks too.
People reading this should always be aware and do the necessary research.
Also, folks reading these posts should not think I`m hell bent on vitamins-herbs
etc. I try to keep an open mind but do seek out alternatives to prescription
Meds where possible.

THe Chinese have ben using herbs for thousands of years. Now their
population explosion has caused terrible pollution which no medication
can cure. The Chinese have a high rate of liver cancer. I`m also noticing
increased cases of Bronchitis in the U.S during the winter.
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Wow - everyone has an opinion!  I had severe pain for quite some time before being DX with gall bladder and stones (many years ago).  Felt alot better after the surgery.  Going against what others are saying, I would have done anything to get rid of the excrutiating pain of stones passing out of gall bladder.  I was never so happy to have surgery!

Assess your pain,and YOU decide.  
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If I had stones it would be an easy decision.  But I have no stones and no sludge, so it's difficult to make a decision.  Of course the poor gb gets blamed for everything that can go wrong.  My latest GI says there's 20% of getting better, 20% of getting worse, 60% chance of no change ... so what to do, what to do.  I'll keep getting more tests, eat well, see how things go, and drive my poor docs crazy :-)
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Misha, if you'll still see your new GI, ask him, if gastric biopsy excludes H. pylori infection, or breath test is more reliable (as I think). I think it's possible that H. pylori doesn't occupy the whole mucosa (gastric + duodenal), so it can be false negative.
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Just had a quick talk with my latest GI.  The results of the breath test for bacterial overgrowth were positive.  I believe he said that this was in the lower colon/bowels (not too sure as I didn't write it down).  I have a barium x-ray test next week, and with results from this he'll be able to advise how to treat me.  I also had a blood test done last week, I believe it was called the IBS Kit on the lab sheet.  Looks like there's some rays of hope here after all.  To me the bacteria overgrowth makes sense: about 10 years ago I had a couple of bouts with H.Pylori and successfully treated them.  Then I had symptoms making me believe that I had a similar infection, but the antibiotics I was given only worked a short time.  All my blood and stool tests since then have been negative, but if it walks like a duck and quacks like a duck, then I'm inclined to believe that this is a duck.  I've basically been on Prilosec since five years ago.

Otherwise, my PCP wants me to try to trigger the RUQ to prove or disprove that my pain is GB related.  Well today I had a strawberry ice cream to test this out, with a couple of lactaid pills as I'm lactose intolerant.  So far no problem with RUQ pain or right chest muscle pain ... there was a little discomfort under the surface, but very mild and had already been there throughout the day, so I should say that the ice cream resulted in no additional discomfort.  Perhaps later there'll be some diarhea, but we all have to live a little and suffer the results of eating ice cream.  My PCP recommends something greasy and fatty to eat in order to really test out the gb, which I can do, but as I have been diagnosed with colitis, IBS, I know that this will cause other problems, but I'm game for this.  My RUQ discomfort/pain has been more manageable the past couple of weeks, although this morning it was a little more uncomfortable, which I attribute to eating chicken last night ... may not make sense but this is a pattern that I've noticed.

Anyways, will report on what this GI says after my x-ray next week.

Otherwise, I have an appt. with another GI tomorrow who's the chief of GI at his hospital.  I figure one can never have enough second opinions.  At this point I'm not sure what to ask him, other than inquiring about what I've done so far and what his thoughts are on the next area of investigation, such as biliary dyskinesia.
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Misha,
What antibiotic are they going to give you for the bacterial overgrowth? I had this test done in June, was tested positive and was given Xifaxan, 200 mg tablets, 6x daily for 10 days. Xifaxan is a synthetic antibiotic which doesn't dissolve in the stomach but rather goes to the small intestine where it can do its thing. After the 10 days, I was still getting bloating and a queasy stomach so it really didn't work for me. I've attached a weblink to the use of Xifaxan for the treatment of IBS. The Doctor who is pioneering this drug also has a book out on IBS which I bought on Amazon. The book is pretty interesting. Here's the link about Xifaxan: http://www.cbsnews.com/stories/2006/10/16/health/webmd/main2096522.shtml
My current GI was familiar with this Doc's work. Hope this helps.
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Jim, won't know which antibiotic till the x-ray results are in, which will be next week.  However, I go on vacation for a week a couple days after my x-ray, which leaves only 1 business day to get the results to my doc and to see him.  So realistically I'll have to wait till after my vaca.  Thanks for the info on your experience, I'll look it up and take a read.
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Misha,
Since your gallbladder is okay so far by the testing test on it and since your ejection fraction is very good (in the 60's), I'm wondering if that would qualify as biliary dyskinesia. I'm under the impression that if there was sludge in the common bile duct that it would be really hard to get a high ejection fraction like yours. I'll be interested in what this new GI chief has to say.
I had a capsule endoscopy done last week. (the one where you swallow the camera capsule). It takes 8 eight hours to complete. I got the results back today. My GI doc says that everything was okay, nothing out of the ordinary. So now, there's only 1 test remaining which will be a 1 year follow up endoscopy which I will have on Sep 2.  Even though my ejection fraction is 36%, my Doc says that my GB is okay. (I think it's borderline biliary dyskinesia) and I still don't have a good explanation for the bloating/slight nausea and intermittent RUQ that I still experience. Since my earlier post about the use of PPI's on ejection fraction and possible, RUQ pain, I convinced my GI doc to let me stop taking the Prevacid that I've be on for 11 months until the endoscopy. (that'll be about 4 weeks) to see if it makes any difference with the RUQ and possibly stomach pain. Hopefully between the 2 of us, we'll get some answers about the RUQ. Keep me posted.
P.S. Could you ask this new Chief GI the following question: Could biliary dyskinesia cause stomach bloating and or nausea/general queasiness and the RUQ and if one doesn't have dyskinesia, then what causes the bloating, RUQ, if all tests say the GB and other organs are all fine. Thanks. I'm looking forward to see what his answer will be.
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Jim, my last GI says that liver enzymes would be elevated if blocked bile ducts.  Will let you know what GI tomorrow says.  Misha
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I'm not sure how a biliary pain could be triggered with food, since fat causes contraction of gallbladder, but opens a sphincter of Oddi, not contracts it. So, this is one question for GI: With which food trigger biliary pain (not gallbladder pain).

Gb/biliary disorders can cause: nausea, RUQ pain, biliary reflux (from duodenum into stomach) - what can trigger or aggravate GERD.

Bloating in gb disease would occur only, if a stone was preventing a bile flow into intestine, so fats weren't absorbed in the small intestine, reach the colon, where bacteria would ferment them and produce gas.

So, bloating ( lower abdominal bloating) obviously is from bacterial overgrowth. I personally don't recommend treatment with antibiotics, since these can lead to more problems (Clostridium difficile...).

Misha, since you're lactose intolerant, it's posible you're also FRUCTOSE intolerant. Treatment is with a diet. You can try to exclude some fruits (appleas, pears, mango, prunes), all fruit juices, honey, foods with sorbitol and high fructose corn syrup (HFCS) for few days to see if it helps. I think you should temporarily exclude sucrose also, just to starve those bacteria. I think this is safer approach than with antibiotics. So, this is another thing to discuss with your GI.
More about fructose malabsorption and low fructose diet:
http://www.allhealthsite.com/212/low-fructose-and-fructose-free-diet/
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Boron, saw my GI today, who has as one of his special interests IBS.  He was very very nice, understanding, and helpful.  Talked to him about my whole history, as well as biliary dismotility and fructose intolerance.  For the time being he recommended staying on Levsin a few times/week, or as needed if I have a severe inflammation.  He also recommended thinking about some chronic medications,which are older depressant meds, for the future if I find that I have severe attacks.  He also provided a sample of Align probiotics to try, which contain Bifidobacterium infantis, also suggesting that I can try Florestor (sp?) probiotics.  He definitely does NOT think that GB surgery is a good idea, and thinks that it may make matters worse.  He didn't think that I have a biliary motility issue nor a fructose issue, partly because my symptoms appear to be getting better, but he was very open to revisiting these topics.

I shared with him my eating ice cream yesterday and he doesn't believe I need to try eating any fried, greasy, fatty food to try to trigger RUQ pain.  So far no probs from eating the ice cream from yesterday.  He believe that my right chest muscle pain is probably musculo-skeletal, which I've heard before, and that this can be looked at separately.  My only notion with this is that the RUQ pain started at the same time as the right chest muscle pain, these two pain/discomfort points usually have alternated with one another, but seem to coexist with each other at this point.  Anyways, that's the update for now, will let you know how the Align stuff works.
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Muscle or rib pain (costochondritis) get worse by pressing on the spot. This spot is on the chest (over the lowest rib or higher).

Align and other probiotics help ONLY in intestinal infection (food poisoning) and in antibiotic-associated-diarrhea. Not in IBS, Crohn's, or whatever. This is my opinion after thorough research of probiotics.

The only food to provoke gb issue, would be a high-fat food, like chocolate, cheese. Pain would appear within an hour after a meal.  

30% of persons diagnosed with IBS have one of food intolerances.
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My GI doc had given me some samples of Align to take when I saw him in July. I've just finished my 3rd week of them. I haven't really felt any change however.
As to IBS, one theory as to the cause: it's either bacteria, parasites or food allergies. Here's a link: http://www.ibstreatmentcenter.com/
Since you've been on PPI's for about five years, do you take any vitamin supplements to offset any deficiencies in calcium, B12, etc which can be caused by the PPI's? I've noticed that even though I've only been on the PPI's for 11 months, I can definitely hear the difference in my bones, especially in my legs when I get out of bed in the morning or when I get out of a chair and even when I'm swimming. (by the way, I'm 58). I had never heard some of these sounds before.
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Jim,

On my 3rd day of Align, not sure if I have any improvement or not at this point in time.

For the website you mention, it looks like a promising and hopeful medical center for IBS.  I always find it interesting that a lot of these websites sell related products, which of course makes sense in many ways, but it does make you wonder about their intentions.  But anyways, I've had tests for bacteria, parasites, food allergies and so far very little 'positive' test results, so far only the SIBO test has resulted in positive.   I'm wondering if there are other tests for other types of bacteria and parasites.

I've taken B vitamin supplements for awhile, but my sense is that it made me want to urinate frequently and urgently: my experience is this when I took it, since I've been off of it this problem has diminished greatly.  I do detect a slight issue in my hip bone, but part of what we're experiencing is age related as well, so it's difficult to truly distinguish what's what.  I think that also what we experience, as my GI doc that I saw this week explained to me, is that IBS people tend to be more sensitive especially in the gut area, meaning that we're probably more sensitive in general, such as to cold and heat.  We can choose to accept this as normal for us or not, but ultimately if all the tests come back negative, it proves that we're healthy and have an issue that we need to manage, for example if we wake up on the wrong side of the bed and have a muscle ache, then that's just what that is and we just need to accept that that's what we have and need to adjust accordingly, which in this case would be stretching the muscle or whatever helps to deal with the ache.  If the gut is sensitive, we can't truly feel it until we eat something, so it's hard to deal with and accept this.

I admit that it's frustrating to not have an 'answer', but medical science in many cases does not have any answers.  I find the ibs website that you mentioned providing a ray of hope, but I'm also very skeptical of it.  If there really were solutions out there, I believe that these would have been propagated throughout already.  I suppose it depends on what we define as a solution.  Ultimately our experiences are valid for each of us and we each need to find the answers that work best for us.
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Misha,
I'm curious after the barium x-ray test that you have coming up as to whether your doc will give you the Xifaxan med to take. If you like I could send you a couple of the chapters in a PDF format from the book that I bought from Amazon about the use of Xifaxan for treating IBS. Maybe you could show this to your doctor. If you're interested, I'd need an email address. Thanks!
My Gastro doc has let me go off of the PPI's that I've been on for the past 11 months to see if that makes a difference as to my RUQ pain. I just stopped them on Monday. I have the upcoming endoscopy on Sep 2, 08.
I just started to take a general multi-vitamin plus an additional one for calcium and vitamin D.
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Re: Muscle or rib pain getting worse by pressing on the spot - this is not the case with me.  I've tried it and docs have tried it.

Re: Align and other probiotics help ONLY in intestinal infection and in antibiotic-associated-diarrhea. Not in IBS, Crohn's, or whatever: I can only tell you what my and other people's experiences are, which is that taking these probiotics does help many people, including myself.  So maybe I have an infection of some sort, can't medically say for sure.

Re: The only food to provoke gb issue, would be a high-fat food, like chocolate, cheese: my GI from yesterday said not to try to invoke pain with problem eating foods, but to use my reasonable judgement to determine what should be Ok to eat, based on various factors, such as stress level, latest experience with certain foods, etc.

Hopefully I'll know more after I take that barium uptake x-rays next week.
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Misha, I have checked ingredients of Gas defense on digestiveadvantage.com

Beside bacteria Geneden BC30, it includes endo-Cellulase, exo-Cellulase, Hemicellulase, Invertase, which are ENZYMES, which break down dietary fibers. The point of this drug is that it breaks down fibers instead of bacteria. When bacteria break them down, they produce gas, and when the drug break them down, it doesn't produce gas. They are enzymes in this drug and NOT probiotic which help you. So, I think other probiotics also won't help you.

But now you have the proven cause of the gas - SIBO. It is small intestinal bacterial overgrowth. If you can get rid of these bacteria, you will no longer need Gas defense.

Now, you can go with antibiotics, but before doing this, ask how long this would take. Antibiotics can kill one type of bacteria and cause overgrowth of others (Clostridium difficile)...sometimes. Then you have deal with that...with another antibiotics.

I'm not against using antibiotics in your case, just providing some info.

The other possibility is diet, which should be low-fiber (low celullose, which would need exclusion of legumes - beans, peas, soy, lentils...), and low-sugar (low sucrose, fructose, lactose). This is diet treatment, not long-life diet.
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Misha,
When you start your treatment for SIBO, let me know which antibiotic is prescribed and how long you will have to be on it. Also, when you are finished with the antibiotic, will there be any follow up testing to see if the antibiotic effectively killed the SIBO or will you have to undergo a second round of treatment and if so what will be the antibiotic and for how long? Is there any protocol that your Doc will be following? Thanks!
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Jim,

My GI gave me Xifaxan, 1200 mg day for 2 weeks.  Then in 4 weeks he'll give me something else to try to provide further assistance, not sure if this will be something different or more of the same, but it sounded like something different to try.

I did the x-ray barium uptake test about 2 weeks ago, and it was painful to drink the stuff, and it also caused pain in my stomach, also causing a little flare up in my side.  The radiologist doc said I had a lot of reflux, which of course is nothing new, but that this might explain why I have discomfort at night when laying down, again this is nothing new.  A few days after the x-ray my symptoms calmed down a bit, but never completely.

Anyway, I've read some on the antibiotic and will see what happens.  My GI also recommended probiotics, which I take, and also yogurt.  However as I'm lactose intolerant I have to avoid the yogurt, and I've tried the soy yogurts and they are nasty.  If anyone has any good suggestions, such as goat's mile yogurt if there is such a thing, then that would be greatly appreciated.

Also if anyone has any suggestions on how to stop burping, which I do after I eat or drink anything, then that would be very very helpful too!  They can be a little on the loud side and it doesn't feel healthy to suppress them.  

Misha
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Misha,
Thanks for the update. My first round (10 days at 1200 mg/day) with Xifaxan didn't do much for me. I'm on a second 10 day Xifaxan round but so far I haven't noticed any real improvement. I'm still getting a lot of bloating. Next week I get an endoscopy.  Do you have the headboard of your bed elevated? I put blocks under the headboard feet on my bed and I was able to raise the headboard about 8 inches. It definitely puts you on an angle. I think that you can get blocks or even a wedge to sleep on at Bed Bath and Beyond or other places similar to that. It might be worth a try!

Jim
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Finished the Xifaxan treatment, not sure if it helped or not, but don't feel any worse for it, so worth trying it.  The GI that I finally like, as he tells me that there are many options, wants to do another Enodoscopy as he does a little extra looking and takes a biopsy that he says most other GI's don't do.  He explained it to me and I don't really know the difference, but these are easy procedures after you've had everything else done including these.  He says that he's found things that other GI's haven't found, so worth going for it.

He also mentioned Lotronex if I have severe diarhea and cramping.  This is a very interesting and powerful drug per my research and fortunately I don't think that I'm that bad off enough to take it.  I still have dull aches in URQ and muscle tension/pain in upper right chest muscle, but perhaps I'm just used to these by now.  Interestingly enough, I get cramps when I eat chicken, which is easily solved - I don't eat chicken anymore.  I've been able to eat most other foods, while taking it easy on meat for dinner, as it tends to cause some inflammation.  

I think I've been to about 4 GI's at this point, and it is very frustrating to hear, "Sometimes these things go away on their own", "These things go in cycles", "Try yoga and other techniques to reduce your stress", "You're a sensitive Type A personality so you're prone to extra pain", etc.  Well of course all things in life go in cycles, stress is a part of our life, personally and career-wise, and we all need to work, so I'm not sure that these statements actually do me any good.  I truly believe that I've researched IBS and other related issues pertaining to me extensively and have actively tried to modify my life to improve symptoms, so it feels frustrating to hear some of these things.  All we're looking for are options, which luckily I've found 1 GI who believes in trying different things, such as a SIBO test, which the other GI's didn't find any value in, and other tests.

Anyways, I'll let you know how the next Endo goes.
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