Possible Diagnosis, Further Steps

[BBender716]

Hello, I'm actually writing on behalf of a friend of mine who has been struggling with what we think is some sort of gallbladder or bile duct ailment. She has been having severe nausea, diarrhea, back pain by the right shoulder blade with pain on the front as well on the middle-right, and heartburn. Over the past year this has caused a significant weight loss of 25+ pounds. It seems that the only thing she can eat without severe nausea and heartburn following are cherriors. The nausea and overall pain is worse if the food is either very rich or fatty.

As far as previous diagnoses and tests are concerned, following a meeting with the GI, a colonoscopy, and a celiac sprew test she was thought to have IBS. Following the administration of an anti-spasmodic and another IBS drug, these failed and further treatment included fiber, which made things exponentially worse. She was then tested for an ulcer by first a blood test and then an endoscopy to confirm. Both of these tests were negative. After finally convincing the GI (who is insistent on his IBS diagnosis) to perform some kind of gall bladder test, he ordered an abdominal ultrasound for gall stones. This came back negative. Then more convincing was needed to test for a HIDA CCK scan. This is where it gets interesting.

The follow up meeting has not yet taken place yet the nurse has stated that the results were negative. However, during the actual test, my friend noted that the CCK caused the exact same nausea and pain as after a meal, and it was extremely severe. She also noted that her sharp pains correlated with the contractions of her gallbladder and that the bile was released in clumps and not a steady flow. Also, 10 minutes passed after the CCK was injected and when the gallbladder contracted.

My questions are as follows: first, does this seem like a gallbladder/bile duct tract issue? If so, what possible problems could it be (gallbladder related, bile duct related, sphincter of Oddi related, etc.)? Lastly, what further tests would you suggests to pursue in order to narrow the possible diagnosis?

Also, considering the extremely conservative nature of her GI and his unwillingness to budge from his IBS diagnosis and mis-administration of fiber to a patient with severe diarrhea has convinced her to get a second opinion.

Any suggestions on next steps or conditions would be extremely helpful. Thanks!

[boron]

GI may be a problem. When things come to bile ducts, even a willing doctor has a lot to think.

Right shoulder pain, and pain after the fatty meal are typical for gallbladder disease. Ultrasound is pretty unreliable, it may miss even large stones.

HIDA should be explained by a "willing GI". Negative HIDA still doesn't exclude sph. of Oddi problems, and even not gallbladder problems.

It is very likely, that the problem is within gallbladder (stones, biliary sludge), bile ducts (lodged stone, stenosis, inflammation), pancreas (stone from pancreas lodged on the exit of the biliary tree, so blocking the flow of bile, or pancreatic cyst pressing on bile duct from outside), biliary dyskinesia (impaird contraction of biliary ducts) or sphincter of Oddi dysfunction.

Proposed tests:
1. Liver AND pancreatic enzymes in blood: GGT is elevated in even slight problems within biliary tree. This is not specific test though. Bilirubin would be elevated, if a blockage within bile duct would cause biliary stasis in the liver. Pancreatic enzymes would be elevated, if a stone would block pancreatic duct, or in pancreatitis.
2. CT can show gallstones much better than ultrasound. On the other hand, if there is only a biliary sludge in gb (dense bile which may cause symptoms like stones) CT may not necessary show it. CT can also miss gallblader stenosis.
3. ERCP is classical method to check bile ducts, but it has some risks, so MRCP can be done instead. I'm not sure, if this MRCP could also serve as a MR of the gallbladder, so maybe it could be used instead of CT.
http://www.allhealthsite.com/32/tests-to-find-causes-of-diarrhea/#ERCP
4. If nothing physical (stones...) will be found, then a manometry of sphincter of Oddi can follow.

Heartburn is not the direct consequence of gallbladder disease, but of GERD. If there is also burping present, this is possibly from H. pylori inf. of stomach. Breath test reveals that, treatment is with antibiotics.

Diarrhea could be from blockage of bile; fats can't be digested without the bile. In this case the stool would be whitish or grey, pale, foul smelling, sticky and floating. If diarrhea occurs also after non-fatty foods, the cause could be the pancreas or small intestinal inflammation.