Hida-scan ejection 21% - No Stones - Surgery?

[angelabrams]

I am a usually very healthy, athletic 35 year old female. 5'7" 130 lbs. I have suffered with on and off pain under my right rib cage for several months. In the past, 3 months, it has happened more often and radiates into my back. I found a correlation to eating that triggers these attacks of pain but not always. Sometimes I wake up in a painful spell. Today, my gall bladder area is very tender to the touch. My internal specialist diagnosed me with Biliary Dyskenisia. My hida-scan showed an ejection rate of 21%. My symptoms with the injection of the CCK were an immediate rush of acid into my throat (acid reflux) and no worse pain then what I was already experiencing at the time.  An ultrasound in October showed slightly echocentric portal triads- no stones and an ultrasound last week does not show any stones but no problems with portal triads and everything normal size.. All we have to go on is the hida-scan and my symptoms. I have been miserable and have lost 13 lbs. So, they send me to a general surgeon for removal. This surgeon decides he wants an endoscope done (orally) by a G.I. to rule out anything else. This comes back negative and the G.I. refers me back to the surgeon. After 3 weeks waiting for surgery, he then tells me that he dosen't want to do the surgery because there are no stones present. I asked him what else it could be, and he said he didn't know but wasn't the Dr. for the surgery. I have had tons of blood work for hepatitis, etc. all normal with the exception of low white cell count (3.5) Low neutorphil, and High Lymphocites. My Internal Specialist seems irritated at this (still believing the gall bladder needs to come out due to inflammation or infection) So now they are sending me to another surgeon which I can't see for 2 weeks. In the meantime, I suffer and don't eat much. What is your opinion of this? Should I be seeing another surgeon? Am I some wierd case?  Thank you for any advice you can give me. Angel

[Kevin Pho, MD]

I would consider a second surgical opinion.  The gallbladder ejection fraction is low - so certainly biliary dyskinesia is possible.  As mentioned in the comments below, since the pain didn't appreciably worsen with the injection of CCK, there is no guarantee that removing the gallbladder will improve the symptoms.

This can all be discussed with another surgical opinion.  There may be some who would agree that taking out the gallbladder is a reasonable step in this situation.

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]

Biliary dyskinesia is a tricky thing to diagnose; the best test is a low ejection fraction AND reproduction of the pain syndrome with the CCK. Your ejection fraction is low but not dramatically so; and the CCK injection, it sounds like, didn't exactly reproduce your pain. So it's a bit iffy. The same is true with SOD; I think it's diagnosed way more than it actually exists; there's a lot we don't know about measuring pressure in the bile duct, and how much the pressure is affected by the measurement itself. Personally, I believe more in dyskinesia than SOD, but the diagnosis of each can be wrong in both directions: diagnosing when it doesn't exist, and ruling it out when it does. I understand the reluctance of the first surgeon; as a surgeon who's operated many times for dyskinesia, it always bothers me if what I do doesn't help. It does most often when the criteria are clear-cut. You represent a case wherein I wouldn't refuse to do it, since the test is not normal, and since your GI doc supports the decision as well. But you have to accept the possibility that it won't help. So yes, you ought to see the second surgeon.

[angelabrams]

Thank you so much for all of your comments and help.  Specifically, "surgeon" you really gave me a better understanding of my situation.  Unfortunately, the first surgeon I saw didn't have the time to explain it to me.  I'm scheduled to see the 2nd surgeon on Feb. 11.   THanks again!

[Afair]

Your situation sounds very similar to mine (except my ejection was closer to 16%). However, my GI doc was the one dragging his feet on the surgery (since I didn't have stones); instead I agreed to have an ERCP in which he diagnosed me as having Sphincter of Oddi disfunction (SOD) and did a sphincterotomy. Needless to say, that procedure did absolutely nothing to relieve my symptoms and I'm somewhat skeptical as to whether it was warranted. In any case, after that - with all records in hand, I went to the surgeon and he immediately agreed that I was a good candidate for removal. So, had the gallbladder out in June and have been pretty good (more or less) since then. I guess I'm wondering if the SOD avenue may or may not apply for you (not to say that this helps because it didn't for me, only got me closer to the desired outcome which was removal!)? Or, maybe a different surgeon?

[2207lg]

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[sunny_one]

I had similar symptoms and low ejection fraction - but other complications with parasitic infection and electrolyte imbalance. I finally had mine out against two GI opinions and am so happy I did - no more pain or weight loss and diarrhea has improved! I can eat anything without reflux or pain.

[CJolly]

I recently had surger to remove my gallbladder.  I had two MRI's specific for the gallbladder, the radiation injection test, two ultra sound tests and they were all negative - except my liver enzymes showed there was a problem and I had almost constant pain in the area just below my right rib cage.  The pathology report of the gall bladder showed 4 areas of scarring due to previous infection and lots of sand like stones, all were .3 cm and smaller in size - diagnosis is: chronic calculous cholecystitis.  The point is this - if you are having the pain, you aren't feeling well and the tests are negative - it doesn't mean that nothing is wrong, or that they can't do surgery for you.  My doctor warned me that taking out the gallbladder might not solve the problem, and I stated to him that I understood and wanted to do the surgery - I knew how I'd been feeling and anything to fix the problem would be welcomed at that point in time.  The surger went really well and I'm feeling good, but I'm now starting to once again have symptoms.  I'd still do it all over again, but now I'm worried that the liver bile ducts may be having a problem - which is why I was checking out this med site.  I really hope you get better soon and know how frustrating and unhappy it is to feel sick all the time.  CJ

[ranger1]

I have been tested positive for H-Ploria.  What the chances of getting stomach cancer?  I just turned 42, non smoker, non drinker, My recent symptoms are on the left side under the breast, by rib cage I've been having a fluttering, girgling, muscle twitching sensation. Sometimes with pain.