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Gastroenterology  (Expert Forum)
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Decision re: gallbladder surgery
Answered by
Kevin Pho, MD - Internal Medicine
Kevin, M.D. Boston - MA
This forum is for questions regarding Gastroenterology issues such as Acid Reflux (GERD), Barretts Esophagus, Colitis, Colon/Bowel Disorders, Crohn's Disease, Diverticulitis/Diverticulosis, Digestive Disorders, IBS, Stomach Pain.
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MedHelp Member's Question

Decision re: gallbladder surgery

by meg4535, May 16, 2003 12:00AM
Over the past 1 1/2 years, I have had a 70 lb wt. loss.  Not really trying, but overall decreased appetite and nausea.  I have been treated for IBS, but colonoscopy ok.  I also have known adhesions following hysterectomy and postop infection. Over the past month, nausea has been really bad. Earlier this week I had a strange painful periumbilical pulsation, had CT which was ngt for aneurysm.  Next day, abdominal pain was more generalized, and started having severe chest and mid back pain.  Went to ER and had ngt cardiac workup.  SGOT and SGPT were elevated.  Gallbladder workup (ultrasound and HIDA with CCK) were ngt (78% ej. fr.), however the cck reproduced the symptoms exactly and severely.  I have also had a low-grade fever (99.8).  Since the HIDA, pain has continued and in general, I just plain feel sick.  I'm very nauseous and have not had any appetite.  GI doc said that positive cck is enough to remove GB.  She said they could also check adhesions, etc while doing it.  Your opinion please?  If the tests were normal, why would a cck reproduce symptoms so intensely?  Are elevated SGOT and SGPT markers for gallbladder problems, or could they be indicative of other problems?  Are there other tests I should consider first?  Thanks.
Doctor's Answer

by Kevin Pho, MD, May 16, 2003 12:00AM
Hello - thanks for asking your question.



This was certainly an interesting question - I had to do some research on this.  Perhaps our surgical colleague on the forum can comment on this.  



Your HIDA scan was normal with a 78% percent ejection fraction.  Ultrasound negative for stones.  From what I am reading a positive pain provocation from CCK stimulation does not predict symptomatic benefit from cholecystectomy:

"The cholecystokinin (CCK)-provocation test can cause pain in some normal individuals, depending on the rate of CCK infusion. It does not, however, predict a symptomatic benefit from cholecystectomy and should be abandoned when evaluating acalculous biliary pain."

http://www.pulsus.com/Gastro/15_06/shaf_ed.htm



Another article from the GI journal "Gut", comes to the same conclusion:

"Stimulation tests with CCK to duplicate biliary pain have been used historically as a diagnostic evaluation.  Such tests have low sensitivity and specificity in selecting patients with gall bladder dysfunction who respond to surgery."

http://www.romecriteria.org/documents/GUTII/ibs998.pdf



So, it seems like it is not guaranteed that a cholecystectomy will relieve your symptoms.  It may or may not - there are no guarantees.  



As for the elevated SGOT and SGPT, it may also be indicative of liver problems as well.  A thorough medication review, and tests for hepatitis and hemochromatosis may be considered.  If the gall bladder and biliary system is completely normal, you may want to consider further liver tests to evaluate the liver enzymes (with a possible biopsy).  



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.



Thanks,

Kevin, M.D.

Member Comments (7)

by shaelynn, May 16, 2003 12:00AM
I had 20 years of that pain BEFORE a stone FINALLY showed up on the scan.  They were SURE it was Gallbladder but no proof but an elevated sgot/pt and my symptons. FINALLY they were able to do surgery.  Be firm about this and don't wait any longer to get this removed.  Good luck

by surgeon, May 17, 2003 12:00AM
elevated liver enzymes can certainly occur during some gallbladder attacks; but can also be due to many other things. As to the HIDA scan: in my experience, when both the ejection fraction (the percent thing you referred to) is abnormally low, AND the cck reproduces the pain, the chance of symptom relief from removing the gallbladder is pretty good. But not so much if only one is true. It's highly unusual to lose so much weight just because of a gallbladder problem, but not unheard of. So, unfortunately, you are in a gray zone at best. If everything else seems to have been ruled out, and if you are willing to undergo surgery with the understanding that the result is not really predictable, it could be justified to do so. If I were the surgeon you were seeing, and your gastroenterologist told me he/she feels sure that other issues were pretty well ruled out (inflamatory bowel disease, in particular) and that he/she agrees it's worth a shot to remove the gallbladder, I'd be willing to do it -- the point being that it would have to be looked at as a possible benefit, but with no way of being very sure....

by krisg, May 17, 2003 12:00AM
To: meg
Please don't rush into having your gallbladder out.   Like the doc says,  Without evidence of gallbladder stones, etc, you would not likely get any relief from pain and sickness.  I had my gallbladder out because of stones 5 years ago.  I ended up with biliary pain following my gallbladder surgery.  I've had it for 5 years now and it is no picnic.  I know what you are going through!  I too have elavated liver enzymes when I have these attacks of pain.  I had a biliary sphincterotomy done in Feb. 2003.  I only have 50% relief, but it's better than it was.  I would definetly have your liver checked out and the biliary tract checked too.  The problem probably rests in one of those two places.  Good Luck.  Hope you find answers.

by meg4535, May 24, 2003 12:00AM
I wanted to follow up on what happened with my situation.  I met with a surgeon and after reviewing everything, he said that he believes in treating the patient, not the x-ray.  So, after discussing the risks and benefits, I decided have it removed.  Once he was in there, he found that the gallbladder was surrounded by scar tissue and felt this was definitely the problem.  Although I am QUITE sore and think the recovery will be a bit slower than I thought, the symptoms of chest pain, nausea, back pain, etc. were gone immediately following surgery.  He said that adhesions generally will not appear on imaging studies and laparoscopy is really the only way to diagnose this condition.  I have many more adhesions from previous surgeries in the pelvic area, but we will leave those alone for now since they are relatively asymptomatic.

by angelgal, Jun 02, 2003 12:00AM
My story is quite similar.  I had attacks since April 1, 2003.  The ultrasound revealed no stones.  My HIDA ejection rate was 43%.  My symptoms were immediately reproduced with the CCK.  My surgeon highly suggested removal of the gallbladder