post sphincterotomy trouble

[medical_questions]

I've written in here before asking you questions about my mom. She went about 15 months after having a cholecystectomy with pain in her RUQ, and some in the lower, before deciding to go through with the manometry and spinchterotomy. The manometry found very high pressures (up to 100, normal less than 40). The sphinchterotomy was done on the common bile duct, and a stent was placed. What was found, in addition to high pressues, was that "the distal bile duct was acutely angulated and folded in on itself." Her bile duct was dilated to 15mm. The GI doctor who did it said if it's going to help her, she should feel relief typically within a week, but it could be a month. Today is the 6th day since the sphincterotomy. She has been doing horrible since the procedure. The first night it seemed pretty certain that she got the dreaded pancreatitis from the procedure, as she was in horrible pain in the middle of her belly. Yesterday (day 5 since the procedure) they did an amalase test and found she did not have pancreatitis as of yesterday, but of course that doesn't mean she didn't have it the first night. Pancreatitis or not, she is doing horrible. Her pain is even worse than it was before the procedure. She feels a little better in the mornings, and it gets worse as the day goes on and worse about 15 minutes after eating (this was the same pattern as before the procedure, just now it's even more intense).

Questions...

1) Do you know anything about "angulated bile ducts?" (The two local GI docs here (not the one who did the procedure) say they don't really know anything about it.)

2) Since her ducts were angulated, dilated, with high pressures, all for 15 months since the cholecystectomy, could that be a reason why it may take her longer to feel the benefits of the sphincterotomy, compared to someone who didn't wait that long and who's ducts weren't in that bad of condition (between dilation and angulation).  

3) If she is feeling this bad today, 6 days after the sphincterotomy, is that an indication that the procedure did not help her? Or could it be that she may start feeling better weeks after the procedure?  

4) If she is not having pancreatitis pain anymore (or ever), can you explain why she is having MORE pain now than before the procedure?

4) The GI doc said she has to have the stent out in a month. He said if she's not feeling better within this month, or if she goes back to feeling bad after the stent is out, that we might then consider an operation called a choledochojejunostomy, which is where they go in and literally change the anatomy and move the bile ducts altogether, or something. Do you know anything about this surgery?

5) My mom's pretty against the major surgery option. After what's she been through already, she just doesn't like the sound of such a major surgery. We're waiting for a call back from the GI doc who did it to see if he can answer any of this himself. Do you have any other thoughts for us?

Thanks

[Kevin Pho, MD]

To be honest, some of these questions are beyond my area of expertise and I will defer to surgeon's answers in his comments below.

1) If the bile ducts are angulated, it is less likely that an endoscopic approach will be successful.  Surgery would be a consideration.

2) Being the 6th day after sphincterotomy, it is too early to tell whether this was a failure or not.  Most cases of endoscopic sphincterotomy have success rates ranging from 60 to 90 percent (admittedly a pretty wide range).  Angulation of the ducts would be an obstacle against a desired result.

3) The studies demonstrating the success of sphincterotomy showed possible success at 3, 12 and 24 months.  Thus, 6 days out is too soon to make a conclusion.

4) I will defer to surgeon's experience with this (in the comments below) as this is out of the scope of my knowledge.

5) Again, I would give it more time before determining if the procedure was a failure.  If the symptoms do not improve, then surgery can be considered.

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

[surgeon]

It's too soon to decide it's not going to work; however, with high pressure and dilated duct it seems likely than an adequate procedure to decompress the duct would be of benefit. If indeed the distal duct is angulated in such a way that the endoscopic procedure was compromised, then surgery is strongly to be considered. Of the surgical options, choledocho jejunostomy is the most complex and would rarely be the first choice. Sphincterotomy, wherein the surgeon does what the gastroenterologist tried to do, but does so over a longer distance and sutures it open, or choledochoduodenostomy, wherein the duodenum is sewed to the duct (it's by far simpler than jejunostomy: it's simply creating a direct opening between the two and is quite easy, whereas jejunostomy usually requires disconnecting and reconnecting the jejunum into a Y-shape). In experienced hands, and given the proper indications, the results would likely be very good.

[medical_questions]

Surgeon - Thank you very much for taking the time to lend your insights on the matter. I know you aren't paid for your contributions here, so we really appreciate it. If you have a moment to follow up again...

You're right, I didn't mean jejunostopy, I mean the duodenostopy. So it's good to hear you say that that is relatively easy in experienced hands and that the outcome would likely be good.

But as far as when you say "the right indictations," what would those be exactly? The nurse of the GI specialist who did the procedure spoke with us on the phone today. She mentioned the choleduodenostopy as an option that would make sense IF my mom felt temporary relief from the spchinterotomy. That would be the right indication, right? Temporary relief from sphincterotomy. However, since she hasn't felt relief, that would not be the logical option right now, right?

She also said, like you, that since the pressures were high and the ducts dilated, relief should have been felt from the sphincterotomy. So then why is my mom doing do bad? The nurse said in her experience they see problems sometimes with the stent itself. That is, sometimes it causes trouble and pain in itself. However, she doesn't think the stent is blocked, because she said my mom would be turning yellow as things would be "backing up." So she said the doctor, when he finds out what is going on, may recommend the stent come out sooner than planned.

Is it possible that all this trouble is coming from the stent? She's been in a lot of pain. The stent was placed to open up and straighten out the ducts. Is it possible if the stent comes out the duct will just close twist right back up? Or is it possible the duct WON'T twist back up and her problems could be resolved just from 1) the sphinterotomy itself (release of pressure) and 2) the stent no longer being there to itself cause trouble?

[surgeon]

High pressures and a dilated duct are generally pretty solid indications. The issue is why she stil has pain after the procedure she had. I inferred from the comments about the anatomy of the duct that maybe they felt they hadn't been able to accomplish adequate sphincterotomy; if that's the case, then surgical relief would be the next thing to try. The question is why she still has pain with the stent in place; it's hard to answer from afar. But it's possible the stent itself is causing some pain. So, if it's the case that the endoscopic sphincterotomy was inadequate, and that persisting pain is related in some way to the stent -- perhaps it's only partially functional -- then there'd be reason to be optimistic about the surgical result. When operating to relieve pain, it's always difficult to make perfect predictions. Where to go from here requires a collaborative approach, especially between surgeon and gastroenterologist: they need to be talking to one another. And of course to your mom. If the doctors are reasonably sure her pain was originating from bile duct obstruction, and if it's questionable that she's gotten adequate drainage from what was done, then surgery is reasonable. But she and you need to rely on the opinions and recommendations of those most directly involved in her care; comments from this far away are of limited value.

[surgeon]

I should add this, just to make matters more confusing: some people develop enlarged bile duct after cholecystectomy, so diameter per se doesn't always indicate disease. If she had dilatation but all her liver blood tests were normal before the sphincterotomy, it could be that it's not of significance. As you've seen if you've been reading various threads, post-cholecystectomy pain is a serious challenge for everyone. Sometimes it's clear-cut and responds to a particular intervention; other times it never gets fully understood or corrected. Sometimes it means the gallbladder/bile ducts were never the problem. Other times, it indeed results from dysfunction of some sort and the end of the bile duct.

[medical_questions]

Thanks, surgeon.

Remember, not just dilated bile ducts, but high pressures from the manometry (80-100, normal 40). So we're really scratching our heads why she hasn't felt more relief yet.

We did finally speak today with the gastroenterologist who did the procedure. He says it's too early to feel the procedure was not a success. He says it is possible the stent is causing pain, but nonetheless, we should try to keep it in as long as possible because that would mean that greatest chances of the stent doing some good (straightening out the duct).

Like you said, the stent could be the cause of some pain. But this much pain? She's in a lot of pain, worse than BEFORE the procedure (again, pancreatitis us ruled out at this point).

So we're trying to be patient, but feeling pretty frustrated the results aren't better yet. If the pressures were high and the ducts dilated and "angulated," why WOULDN'T cutting the sphinter to relieve the pressure and placing a stent to straighten the duct cause immediate relief of pain?

You are right that post gall bladder removal surgery pain is challenging. Very challenging.