Post Gallbladder Surgery Pain

[TotallyConfused]

I have been experiencing pain in the URQ for the past 2 years now.  I have had my gallbladder removed (laparoscopic) 7 years ago.  The pain seems to be in the same area as where the gallbladder was and goes up into the shoulder, neck and upper back.  I have had no signs of jaundice, but have some nausea (without vomiting).  I have GERDs and take medication for it.  This pain is different than the GERDs.  While waiting for a referral to a GI, I changed GP’s and had to start all over again.  I had a complete physical, and now have additional concerns.  I’m not sure if they could be related or not (probably not).  My blood pressure, which has always been in the range 110-112 over 80, is now 140-150 over 90-100.  A spot showed up on the chest x-ray – just below the heart, but on the  right side, close to the aortic artery.  It is small  but I have pain in the general area when I press down.  It has been more painful since I had an abdominal ultrasound (which showed nothing, for this area or the liver).  I’m scheduled for a CT scan, but that’s still several weeks away.  Now, I’ve just been told that something showed up on my mammogram and I have to have a breast altrasound.  When the mammogram was done, they had to take a second x-ray, thinking it might be a fold in the skin (same breast that is being questioned now).

I am really confused and not sure what to think.  Is it possible that these conditions could possibly be related?  I have a family history of aneurysms and cancer.  I’m probably over reacting, but I’m scared and soooooooo confused.  Can you help???

[Kevin Pho, MD]

There can be many possibilities.  Although possible, I am not aware of the breast issues being related to the RUQ pain.  Other possibilities would include GERD, an ulcer, gastritis/duodenitis (i.e. inflammation of the stomach or small bowel), or Sphincter of Oddi dysfunction.

The latter disease can be present in greater frequency in those who have had their gallbladder removed.  It typically presents as similar to gallbladder-like pain.  If this disease is considered, you can consider an ERCP with Sphincter of Oddi manometry.  

An upper endoscopy or 24-hr pH study can be considered to evaluate for inflammation/ulcers or GERD respectively.

You may want to discuss these options with your personal physician.

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.

Kevin, M.D.
Medical Weblog:
kevinmd_b

[medical_questions]

Surgeon, are you around?

Regarding SOD manometry, you said that the test is not very reliable or reproducible.

Why doesn't Dr. Kevin ever make that point about it? I mean he always suggests it like a normal next step. But it doesn't sound very normal to me if the test is itself not reliable. It sounds like a "out on a whim" next step, not a normal next step.

How reliable is the test? Do you know of people getting the test, proceeding with the sphinterotomy (one, or several) then in the long run feeling all, or even mostly better? There MUST be people like that, right? Othewise Dr. Kevin wouldn't suggest it as such a run-of-the-mill, normal next step.

My mom is just so scared it's not going to work. She should hold out some hope? The specialsts are shruggling their shoulders at this point about her serious, debilitating pain, and saying, "yeah, I guess it could be SOD."

[CalGal]

Hi Everyone,

I'm not a medical professional, I just a fairly regular person who reads this board frequently. I know that you're extremely upset about your mother and I don't blame you. But maybe you're being a bit hard on Dr. Kevin and the Surgeon? SOD seems to be a difficult condition to diagnose as there appear to be so few direct markers that medical professionals can use to actually find out if that might be the problem. And if the docs have tried everything they can possibly do to try to find the cause of your mother's problem and are really down to 'it might be,' well at least they're being honest.

If you read the medical literature you'll see large numbers of statistics on the outcome of cutting the muscle when the pressures appear to be high and the statistics don't seem to be too bad. But they aren't 100%, which I'm sure that everyone would wish. And those statistics will vary depending upon which paper you're reading. I'm not sure if there has been a large scale study of the outcome, or if anyone may have put together all of the information into one gigantic statistic/outcome. They may have and I'm not aware of it. But there is also the problem in trying to do that (pull together all the information together) in that the varying conditions underwhich the surgery is done may not fall into, or within, certain parameters and studies have to be put aside. This reduces the actual numbers of studies that can be viewed. So it's very possible that no one, including those on this board know whether the technique is X% successful.

I think the other confounding factor may be that - if you read posts on a number of boards - one of the things that is said is that 'no, the manometry was not done, but the muscle was cut.' And when that happens, based upon what I've read and heard from those who that has happened to, a successful outcome is not often found. There really does seem to be a correlation between high pressures, cutting the sphincter and some viable relief. And the manometry may be a specialized technique that not all GI persons are trained in doing.

If you add on top of that that some drugs that may be routinely used may actually change the pressures in the sphincter, well, you've got more problems since I believe they're only starting to work their way through testing which drugs do and don't - meanwhile trying to help those with this problem to have a decent quality of life by actually doing something. If you're interested in finding out more about the statistics and in finding out about the impact of the drugs on this procedure, try going to pubmed.com put in some relevant search terms and any number of abstacts will start to give you an idea of the scope of the problem.

How is Dr. Kevin supposed to make those points? It's up to the doctor that your mother is working with to spell out all the good and bad points, to fill in the blanks. Based upon what you wrote Dr. Kevin suggested the most logical step, which in itself is nice to have. It's an option, something that it appeared that the docs your mom had worked with up until this point had discounted for whatever reason. At least aremed with that you should be able to go back and say, 'well, what about this?' It's the opening for a discussion, especially when you have practically no options left.

Are there people who are helped? Yes. If you look through some other boards you'll find there are. Are there people it doesn't help? You'll also get a yes answer to that question. But from my reading of the posts most of those seem to happen when the manomentry isn't done before the sphincter is cut. But again, even when the pressures are found to be high and the sphincter is cut it's not 100% perfect.

I can understand you mom's fear and your frustration. It's got to be miserable for her to be living with that condition and for you to be watching it. Make sure whomever your mom is working with understands SOD (as well as anyone can), and will talk to you fully and frankly about the sphincter cutting procedure and about trying other alternatives like botox and  stenting. Nothing is 100% in this life, but it kind of sounds like your mom has few options at this point - unless another cause is found.  

[CalGal]

Sorry, I meant to direct my comments, above, to medical_questions.

[medical_questions]

CalGal,

In short, get a life. I had no mal intentions towards Dr. Kevin or the surgeon. None whatsoever. For you to interpret that and decide to give me a long lecture, is, well, the reason I started this with the sentence I did. If you had ANY idea the amount of frustration it causes a family to be in this situation where medical science is running out of answers, you may have better understand why I may APPEAR to have come off sounding flustered. I COMPLETELY UNDERSTAND Dr. Kevin is giving a sound, reasonable, answer. Where did I suggest otherwise?? When I refered to Dr. Kevin in what I wrote to the surgeon, it was out of a desire for things to be more clear in my mind, NOT out of a desire to attack Dr. Kevin's answer(s). And did I appear to be hard on the surgeon? Asking him to give me a ballpark idea as to what he means by a test "not being highly reliable?" If you interpret my asking him to give me an idea about what he means when he says something as "being hard on him" I don't know what you're smoking. So again, in short, get a life.

I know it sounds harsh me to write "get a life" but I really feel aggravated and offended by your MISinterpreting my writing and sticking your neck in where it doesn't really belong.

HAVING SAID ALL THAT, it was helpful to read what you wrote about SOD. According to you Im sure I could have gotten all the same information from various forums and what not (why do I feel like part of your point was to take a jab at me for not getting all this information on my own?) but if you had any idea what my family was going through, you would know that it's always helpful to hear MORE insights about something, to get MORE ideas about it, to have MORE minds drawing from what they know or what they've read, etc, etc. So it was helpful, despite how annoying your premise was that I'm "being hard on Dr. Kevin and the surgeon."

[medical_questions]

Wow. I just read what I wrote again (to the Surgeon) and am totally shocked and amazed you interpreted it as you did. Amazed. I was writing fast, and was trying to get at the SUBSTANCE of what the surgeon was saying, as in NUMBERS, PERCENTAGES, if he had them, because such information is very HELPFUL. I was not trying to attack the surgeon or treat him with disrespect or ANYTHING. When I said, "you're painting a bleak picture" give me a break! That's called THINKING OUTLOUD more or less, it was NOT meant to be a attack against the surgeon's advice. I was looking for more clarity, more information, if that to you is "being hard" on a doctor, again, I really don't know what you're smoking. And are you aware of the fact that when I wrote "still awaiting Dr. Kevin's answers to my questions 1 - 4" do you REALIZE that Dr. Kevin, at THAT point, at the time I wrote that, HAD NOT ANSWERED YET?? Do you think I was writing that AFTER he gave his answer? IT ONLY APPEARS THAT WAY because Dr. Kevin's answers are INSERTED into the place they are in, they don't come that was chronologically!!! If you were really that rehearsed in this forum, I would think you would have known that. So I was NOT, despite the appearance, suggesting that Dr. Kevin answer questions that he ALREADY answered. And dear, dear CalGal, your comment about if doctors are saying "well, it could be ___" that "at least they're being honest" sounded really absurd to me. First of all, Im an educated adult, not a five year old child, so intellectually speaking, of COURSE I know doctors can only offer so much. Secondly, my father IS a doctor, so again, of COURSE I know doctors can only offer so much. Third of all, I find it a little absurd to say "at least" with reference to honesty. At least??? At least??? OF COURSE DOCTORS SHOULD BE HONEST. You're suggesting that I should be GRATEFUL for that? Come on! You're suggesting that some doctors like to give false hope or lie? SUCH DOCTORS SHOULD BE REMOVED FROM THEIR PROFESSION IMMEDIATELY. So all in all, your lecture was rather misguided, though, again, the SOD information was helpful.

[medical_questions]

After thinking about it and settling down for a couple moments, of course I realize, like any reasonable adult would, that my comment "get a life" was over the top and uncalled for. For that I apologize. However, I essentially stand by everything else I said to you.