What if...?

[Banned1]

I'm worried.  I'm a 42-year-old woman who had a hysterectomy several years ago.  14 months ago, I had some discomfort in my left side below my ribcage (ULQ).  An ultrasound was done on April 19, 2007 and the opinion was: "dilated common bile duct, intrahepatic ducts and pancreatic duct." My GP [who is amazing] then ordered at CT-Scan of Abdomen and Pelvis with Contrast.  This was done on June 20, 2007 and the opinion was: "An obstructing biliary system as above.  An ERCP is recommended."  At this point, moderate pain started on my right side as well, just below my ribcage (URQ).  My GP sent me to a Gastroenterologist who ordered an ERCP and Colonoscopy.  The colonoscopy was done on August 31, 2007 and was relatively normal.  The ERCP was done on September 7, 2007 and the ampulla was normal but they could not get into the bile duct so they had to order and MRI.  The notes are pages long or I would provide them.  I has post-ERCP pancreatitis for five days after that procedure.  On October 10, 2007, I had an MRCP [MR/MRI Liver With/Out GAD] and the opinion was: "Cholelisthiasis.  Otherwise unremarkable."  I went back to the Gastroenterologist on October 29, 2007 and he had no specific intervention planned.  At this point, my pain is intense and it's getting difficult to get through the day at work, my lower back is killing me and I still have discomfort in my left side.  I went back to my family doctor and she decided to send me to a surgeon.  The surgeon did a GRD [laparoscopic cholecystectomy] on February 4, 2008 to rule out H. pylori bacteria and to double-check the findings of the GI Doc.  There was no evidence of H. pylori infection. When I saw the surgeon on February 26, 2008, she suggested a HIDA Scan.  Two days later, I went to Emergency with an attack [acute pain, high blood pressure, rapid pulse, trembling and, oh, the nausea!].  They put me on Morphine and Gravol and re-did the CT and the Ultrasound with negative results this time [although I was really squirmy during the Ultrasound].  They sent me home with a stronger prescription after 14 hours.  I was asked by my employer to take a leave of absence because, even though I would get to work everyday, I couldn't always get through the day due to pain.  The HIDA is scheduled for April 8, 2008 and I'm terrified.  I'm in SO much pain and what if it comes back negative?  Will anything be done?  I've had to stop work, which I love.  I dropped out of school, which I loved.  My husband and son are incredibly supportive but it can't be easy for them to see me in bed every day, all day.  Any insight would be appreciated.


This discussion is related to Gallbladder disease without stones.....

[CalGal]

I've got a couple of questions for you. When the ERCP was done, was it done with manometry? Was the sphincter cut (sphincterotomy) during the ERCP?

Just as a general note, if they couldn't enter the duct, it would suggest that your sphincter of Oddi pressures were high (but that can only be verified via manometry - which could be important). However, if those pressures are high, you could be experiencing SOD (sphincter of Oddi dysfunction), which is a condition that can show up in some after the GB is removed. It's thought that SOD is 'uncovered' when what was 'thought' to be the source of the pain (the GB) is removed. In your case, they may have found the source of the pain 'early on.'

SOD (again, determined via manometry) is approached by the non-use of narcotic-based meds. Those meds increase the ductal pressures and can make things worse. Yes, the narcotics can dull the CNS so that the pain is perceived less, but it does not help. Specific calcium channel blockers can be uses, and there are also some anti-spasm meds that can be tried. If it is SOD, the typical approach is to cut the sphincter (but ONLY if the pressures are high) and to stent the duct/sphincter to hopefully reduce the chance of pancreatitis.

It's possible that the dilation of your ducts could be due to previous spasms of the duct/sphincter and the 'backup' of bile/pancreatic fluids into the ducts.

When you had the attack, did they measure your liver enzyme and pancreatic enzyme levels? If not, why not?

Whether or not the HIDA scan comes back 'normal,' which I doubt will happen, you should be working with someone experienced with SOD and the biliary system. IMO the GI doc you're working with now/or the surgeon (or both?) leave a lot to be desired as far as their diagnostic capabilities go.