Recurring blockage of common bile duct in 25 year old woman.
My 25 year old daughter has suffered with similar issues. She began having intermittent abdominal pain attacks at the age 15. Our doctor did a sonogram and barium swallow follow through test and found no issues. Put her on meds for indigestion. Symptoms increased gradually and tests were repeated at age 17 and 19 when he referred her to a general surgeon. Surgeon said images of her gallbladder showed sludge in the organ and that it seemed to have shrunken and had thickening in the walls. Her gallbladder was removed in Jan 2009. Symptoms returned in late 2009 and family doctor put her on omeperazole. She suffered with intermittent attacks again for a couple years and in a 2010 physical had a slightly elevated ALP.
In September 2011 she began having multiple moderate pain attacks and then while visiting in Phoenix AZ suffered a massive pain attack that took us to the ER. All three liver enzymes were in the 200 to 400 ranges, she was admitted to the hospital and an MRI showed gallstones blocking the common bile duct. An ERCP and spincterotomy (sp) was done to remove stones with the GI specialist stating that he thought they had been left behind when her gallbladder was removed.
Our family physician checked the surgical notes and found that a dye test to check for stones in the common bile duct had NOT been done after the gallbladder was removed. In fact, I distinctly remember being concerned as my daughter was only in the outpatient surgical center for about 45 minutes from the time she went back to the time they were rolling her out to my car to discharge her. The family doctor felt the stones were in fact left behind by the surgeon.
In December 2011 her pain attacks returned and in February 2012 an MRCP found a 4mm "defect" in some of the images and all three enzymes were moderately elevated. She saw a GI specialist who reviewed the images and performed another ERCP and spincterotomy removing the stone and sludge. He said the stone had been hard to find but did finally get it and thought it had been missed by the GI in Arizona as it was difficult to find.
Within weeks her pain attacks returned and she suffered a major attack in late April that took her to the ER where her white blood count was high and all three liver enzymes were "mildly" elevated. The same GI did an MRCP that did not show stones but with all symptoms pointing to a blockage he did another ERCP finding thick sludge and multiple small white stones. At this point he became concerned she was creating new stones and sludge and started our daughter on 600mg Actigall to help prevent sludge and stones. He also followed monthly checks on a liver panel to check enzymes. Two enzymes did return to normal but her ALP has remained mildly elevated in the 150 to 190 range.
November 2012 her pain attacks returned accompanied with dark urine and watery stools. Now living in Tucson, she was referred to a GI at a teaching hospital there who did an MRCP that found three .5mm stones. He did an ERCP and removing sludge and small stones. He increased her Actigall to the maximum dose of 1200mg a day and has now ordered lab tests to screen for multiple cancers and immune diseases. She continues to suffer from mild pain and loose stool.
I know this has been a long post, but I have learned that information is key to diagnosis. Any advice from medical personnel or people that have had similar experiences would be greatly appreciated. My daughter is otherwise healthy, exercises regularly, seldom drinks and has a BMI of about 20. Her overall blood cholesterol is in normal limits and she has never had an elevated bilirubin in any of her lab work.
Well, without a detailed clinical evaluation it would be difficult to for me to comment specifically on the situation. What really concerns me with the information provided, is the repeated formation of stones and sludge despite regular medical care. In the situation I would like to have a look at the hepatic and metabolic profile, if we can pick up any clues to the repeated formation of stones. Management would largely be symptomatic and treating the primary cause, if identified. I would also suggest discussing with her treating gastroenterologist/ hepatologist if dilation and long term stent placement would be a suitable option.
Hope this is helpful.
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