recurring stones/sludge in bile duct

[Natalino]

I'm 62, male and aside from my blocked bile duct problem, in good health except that I have hemangiomas in my liver.  

After a gallbladder (GB) attack I had my GB out in 1998 but the stomach pain resumed shortly thereafter.  The GB did not have stones in it when removed, though it was described as "strawberry" -- (what does that mean?).  I had 2 ERCPs before having the GB out and 5 ERCPs since then (with stones/sludge found some times, but not others).

I have ultrasound tests done regularly.  They usually show a dilated duct with stones or sludge present.  I don't think I have ever had a "normal" ultrasound.  

My GI dr wants me to have roux-en-y operation.  He thinks there may be a kink or sag in bile duct.  My research suggest that recurring stones after GB removal are common either because the stones were there before the operation or developed later and that the duct sometimes develops a sag, or pseudo GB where bile accumulates just like it did in GB.    He also thinks it may be possible that bacteria is getting into the duct (past the now-cut sphincter) and that this bacteria is contributing to the formation of stones or sludge.  He also thinks I may have an "inherited abnormality in hepatic metabolism" (what is that?).  Or sluggish bile flow.  I'm reluctant to do the operation.

I've tried an acupuncturist and he prescribed a chinese medicine called Lidan which seemed to cause the same sympoms as a GB attack caused by a blocked duct -- pain and discomfort.  But a subsequent ERCP showed "no stones" were present in the duct.  


A few months ago I began "alternative treatment" with an MD(ATMD).  She says I'm dehydrated, too much coffee & alcohol, not enough water.  I'm changing my drinking habits and doing a kind of "hydration therapy" (more water, less coffee & alcohol) I seem to have improved and have had no symptons since begining this treatment.   She also suggested an herb called "fumitory" (taken as a tea)that increases bile flow.   The ATMD says it's ok to use it & Lidan but I'm afraid of these medications because they are not tested, though they do seem to give relief.

I'm not sure what to do.  Is there a bile duct specialist at Ford that you could recommend for a 2nd opinion?  
If I have the roux-en-y, what's to prevent the duct from sagging again?  Or bacteria entering the duct?  
Can they still do an ERCP after the operation?
What else changes after the operation, digestion, bowel movements,etc?
I don't think I can keep having these ERCPs indefinitely, are there other approaches?

Here's my most immediate question:
My last ultrasound taken before I began my increased hydration routine recommended by the ATMD showed "no change", ei, no increase in dilation or more stones, though stones or sludge are still seen.  My GI dr thinks I should have another ERCP so that we can determine that there is nothing in the bile duct and another ultrasound after I have been on the hydration therapy for some time to see if it is working?????

[slwp2015]

A related discussion, Bile duct blockage. was started.

[surgeon]

Unless you are having documented recurring stones in the duct, there's no value in doing the Roux-en-Y (or any other drainage procedure on the bile duct). "Sag" (which is hardly a described problem, absent persisting dilatation and/or stones) is very hard to evaluate as a condition needing treatment. There are other more mainstream drugs one can take to improve bile flow as well. Given that, as I understand you, you are no longer having stones in the duct, I'd not, as a surgeon, be at all anxious to perform the operation.

[Kevin Pho, MD]

I am not familiar with the Henry Ford system, thus I cannot recommend a GI doc there.  

Regarding the duct sagging - it would depend on what is causing it.  One can consider a stent to keep the duct patent.  I would also consider further evaluating the pancreas - either an MRI or endoscopic ultrasound - to evaluate for any masses that have been missed.

Instead of an ERCP, you can consider a less-invasive MRCP if the physician simply wants to examine whether the ducts are patent.  An MRCP will not have the risk of pancreatitis that the ERCP will have.  

As for the Roux-en-y, I am not a surgeon, and cannot comment on this procedure and its side effects.

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