Biliary Dyskinesia

[palm91]

Hi, I am a 40 year old female. I had an episode of severe pain last May that led me to the ER. I had chest pain that radiated to the back and I thought I was having a heart attack. ER doctor ran heart tests and they came back normal. I was given nexium with some relief but the pain got better after using gas-x. I stayed at the ER for another set of heart tests, which also came back normal. The ER sent me home with omeprazole. I saw my PCP the following week and he put me on Nexium (I am still taking it). He also ordered an abdominal US. US results: limited pancreatic tail visualization. The visualized portions of the pancreas appeared unremarkable. Findings suggesting a tiny gallstone that was not mobile near the neck of the gallbladder with a negative sonographic Murphy sign. This could also potentially represent a sludge concretion. The shadowing was not distinct. A HIDA scan with CCK could be obtained for further assessment as clinically indicated.  I went back to my PCP and I am symptom free at this time, with occasionally bloating, but no more pain. PCP ordered a HIDA scan and referred me to a surgeon for assessment. Today I had my HIDA scan done. The results are: no evidence for cystic or common duct obstruction. Significantly decreased gallbladder ejection fraction of 1% consistent with severe biliary dyskinesia. I had no pain or discomfort with the CCK injection. I have an appt with the surgeon in 2 weeks. My questions are:
- is surgery indicated in this case?
- is there any non-surgical treatment?
- I am basically symptom free at this time, should I do surgery (which I am very relunctant) even if I have no symptoms?

Thank you very much for your help and advice.

[scarletnymph]

I have been sick for over 4 and a half months with constant nausea. I only have minor discomfort by my right cage. Out of the deluge of tests I've had within that time (I have had very efficient doctors at least - my PCP has been amazing) but the only thing that has come up out of the ordinary was an ejection fraction of 30% when given the injection to get it to work. I was refered to a surgeon. One heck of a nice guy but his answer for me was that "No one can tell you it isn't your gallbladder." He wasn unable to given me an answer either way which I understand is impossible as much as we would like to think otherwise. Especially with gallbladder dyskinesia.  My symptoms are nausea, chills(no fever), gas, rumbly stomach and the feeling of a ball sitting in my gut right below my right rib cage.  These are apparently atypical to gallbladder dyskinesia. I am about 90% made up on whether I should have my gallbladder out in the painfully obvious lack of other affirmations through the diagnostic process and out of sheer exhaustion from being sick and tired for so long.  I would love to know how you are doing.

[palm91]

Thanks again for all your help! I really appreciate it!

[CalGal]

Palm, the lack of pain could mean something or nothing. There are people with severe GB dysfunction who have no reaction to CCK injection. Others with near normal ejection fraction are miserable with the injection, so it's hard to say.

GB emptying problems can be due to a muscle defect, such as thickened walls or lack of muscle action, problems with stones in the cystic duct or problems along the length of the common bile duct from what I understand.

To measure whether or not you have 'underlying' SOD, the test that's used is the ERCP with manometry measurement. Like any test, it has risks. Since the instrument used to measure the pressure needs to enter the sphincter to measure the pressures inside the duct(s), that maneuver carries a risk. Post-ERCP pancreatitis is also an issue. Unless you're showing clear signs of SOD, I doubt most docs would say yes to an ERCP before having the GB removed.

If SOD is the underlying cause of problems, it's very likely that the problem would continue. But you have to keep in mind that the reports you're reading on boards such as this is because people are looking for answers to medical issues. There are many, many people who have the GB removed and have no continuing issues.

A big help after GB surgery can be following a low fat diet for many months following GB removal. Since you'd no longer have the 'concentrated bile' the GB provides, the breakdown of fat will not be as it was before surgery. Wouldn't help with SOD if that were present, but can be helpful for those who have issues with fat digestion after the GB is gone.

[palm91]

I have one more question, if you don't mind.  I had no pain with the CCK injection, what would that mean in terms of diagnosis?
I understand that abnormality of gallbladder emptying can be due to a smooth muscle defect of the gallbladder itself or heightened tone in the sphincter of Oddi.
Is there any other test that could be used to rule out sphincter of Oddi dysfunction? If so, what are the risks?
Also, if I undergo cholecystectomy and the real problem is a sphincter of Oddi dysfunction instead of a gallbladder dysfuntion, wouldn't I continue to have problems?
My concerns are that I am pain free at this time, and I am afraid that if I undergo cholecystectomy and the source of my problem is the sphincter of Oddi, I could bring back the pain and worse symptoms than I have now.
Thanks again for all your help. I would like to have more information so I can be prepared for my consultation with the surgeon on Monday.

[palm91]

Thank you very much for your help and for your comment. I will see the surgeon this coming week and see what she says.

[CalGal]

surgery would typically be suggested when the ejection fraction is at 1 percent. The problem with leaving a gallbladder in place with little-to-no ejection is the bile remaining in the gallbladder may further concentrate resulting in a concentrated mass. Or a mass that could result in possible infection or problems in the future.

There are unfortunately no non-surgical treatments at this point in time to restore the muscular contractions to the gallbladder that would allow for expulsion of the bile in the gallbladder.