Repeat stones post Cholecystectomy

[Clairevw]

I have just had an ERCP following acute pain and stones found on ultrasound in the bile duct. My gall bladder was removed laprossopically 12 years ago aged 26. What is the incidence of this? How likely is it to happen again? Is there anything I can do to avoid further stone production? The pain was immense until the stones were removed and I am scared of undergoing this awful ordeal again in the future.
No one seems clear why this has happened for a second time. I am now 38, a physical therapist, slim and very fit. My diet is healthy and I weigh 65kg at height 5'6''. I would be grateful on any view point or references I can follow.

[ellyhound]

My 25 year old daughter has suffered with similar issues.  She began having intermittent abdominal pain attacks at the age 15.  Our doctor did a sonogram and barium swallow follow through test and found no issues.  Put her on meds for indigestion.  Symptoms increased gradually and tests were repeated at age 17 and 19 when he referred her to a general surgeon.  Surgeon said images of her gallbladder showed sludge in the organ and that it seemed to have shrunken and had thickening in the walls.  Her gallbladder was removed in Jan 2009.  Symptoms returned in late 2009 and family doctor put her on omeperazole.  She suffered with intermittent attacks again for a couple years and in a 2010  physical had a slightly elevated ALP.  

In September 2011 she began having multiple moderate pain attacks and then while visiting in Phoenix AZ suffered a massive pain attack that took us to the ER.  All three liver enzymes were in the 200 to 400 ranges, she was admitted to the hospital and an MRI showed gallstones blocking the common bile duct.  An ERCP and spincterotomy (sp) was done to remove stones with the GI specialist stating that he thought they had been left behind when her gallbladder was removed.  

Our family physician checked the surgical notes and found that a dye test to check for stones in the common bile duct had NOT been done after the gallbladder was removed.  In fact, I distinctly remember being concerned as my daughter was only in the outpatient surgical center for about 45 minutes from the time she went back to the time they were rolling her out to my car to discharge her.  The family doctor felt the stones were in fact left behind by the surgeon.  

In December 2011 her pain attacks returned and in February 2012 an MRCP found a 4mm "defect" in some of the images and all three enzymes were moderately elevated.  She saw a GI specialist who reviewed the images and performed another ERCP and spincterotomy removing the stone and sludge.  He said the stone had been hard to find but did finally get it and thought it had been missed by the GI in Arizona as it was difficult to find.  

Within weeks her pain attacks returned and she suffered a major attack in late April that took her to the ER where her white blood count was high and all three liver enzymes were "mildly" elevated.  The same GI did an MRCP that did not show stones but with all symptoms pointing to a blockage he did another ERCP finding thick sludge and multiple small white stones.  At this point he became concerned she was creating new stones and sludge and started our daughter on 600mg Actigall to help prevent sludge and stones.  He also followed monthly checks on a liver panel to check enzymes.  Two enzymes did return to normal but her ALP has remained mildly elevated in the 150 to 190 range.  

November 2012 her pain attacks returned accompanied with dark urine and watery stools.  Now living in Tucson, she was referred to a GI at a teaching hospital there who did an MRCP that found three .5mm stones.  He did an ERCP and removing sludge and small stones.  He increased her Actigall to the maximum dose of 1200mg a day and has now ordered lab tests to screen for multiple cancers and immune diseases.  She continues to suffer from mild pain and loose stool.

I know this has been a long post, but I have learned that information is key to diagnosis.  Definitely keep track of your symptoms and be prepared to share them with your doctor.

[Jaybay]

One other issue is the changing hormones we ladies experience in perimenopause.  Hormone levels have a big impact on how thick the bile is that is produced in the liver.  The thicker the bile, the greater the likelihood that it will form into sludge/ stones.  That is one reason that the "classic" gallbladder patient is Female, Fertile and Forty.  It's not all that uncommon for a woman to develop gallstones during pregancy - particularly nowadays with older women having babies.  

Diet isn't always the culprit in stone formation.  It's more about how each person's body produces bile.  Some people have had good results using statin drugs like questran to keep the bile thinned out and moving properly through the ducts.  You're doing everything right as far as diet and fitness, and it's probably unlikely that you would have to go through this again.  Definitely ask your doctor about actigall or questran as a preventive measure.  The side effects of these meds may not be worth taking them, but the subject is certainly worthy of a discussion with your doctor.

[CalGal]

There are two methods that I know of by which people seem to 'develop' stones after GB surgery - even many years afterward. One is that some small stones escape during the surgery  and however they're able to do so, they manage to lodge themselves in areas of the common bile duct until something disturbs them and they begin causing trouble.

The other theory is that due to changes in the structure of the common bile duct following GB surgery in some, small pockets or outpocketings forms and the flow of bile over or through these 'formations' cause eddying - and eddying result in the depositing of small 'nuclei' that starts the formation of a stone. It's analogous to the eddying that occurs in blood vessels that purportedly caused obstructions in the circulatory system.

I'm not sure if anyone knows how to prevent this from happening, I'm sorry to say. But if the formation is due to deposition of cholesterol (do you know if the stones were cholesterol based?), supposedly if your cholesterol levels remain low and you remain well-hydrated, cholesterol may not be able to precipitate as quickly or as well out of solution.

You might also want to ask your doc about possibly using a medication such as Actigall. It may or may not be a preventative measure, but check with your doc.