Questions for the doc

[Guest guest]

Hi all,

I have an appointment coming up and was wondering if there were some

questions that you folks could give me that I should be asking my

doctor. Thanks for your input.

A little background on my case:

I had my first attack of pancreatitis on June 17th of last year. For

the next month or so I would have similar attacks that lasted about 2

hours 3 times a week on average. My first hospitalization came after

I had the pain for nearly a day and had been vomiting for what seems

like just as long. I was only in the hospital for 4 or 5 days. It

was believed that it had been caused by gallstones. After I was

released I continued to have the attacks in similar fashion and it

was decided that I should have my gallbladder removed. A few days

before that happened I was admitted again and my visit was similar to

before, culminating in my gallbladder surgery being done as scheduled

on October 7th. From what my wife tells me they did find some small

stones in the gallbladder and there was a cyst at the entrance to the

gallbladder, which is why the gallbladder didn't show up on the HIDA

Scan. Since then I don't think I have had any pain, but seem to have

some discomfort every so often in the area where the gallbladder

was. I am also still experiencing the nausea and what I suppose I

would call nervous bowels. Some times I can eat something and have

no problem but other times it sends me running for the bathroom.

I am concerned about what kind of damage was actually done during the

attacks. Also, I have some phenergan that I occasionally take if the

nausea gets to be too much. Is there a medicine that would do a

similar job but make a person less sleepy?

Thanks in advance for your suggestions,

Jerrel

[Guest guest]

Hi Jerrel,

I guess the most important thing at this visit is to figure out what

exactly the attacks are that you are describing. You need to

figure out if they are more like biliary colic attacks or are

pancreatitis flares. You may want to become familiar with the

syndrome called " post-cholecystectomy syndrome " . There is a

good article on the e-medicine website. Basically this is the

syndrome which occurs after gallbladder removal. The pain and

other symptoms are similar to what the patient felt prior to having

the gallbladder removed. A colic attack is a common symptom

of this, as well as pancreas abnormalities. Another diagnosis

that pertains to this is sphincter of Oddi dysfunction (SOD) and a

good article can be found about this on the Journal of the

Pancreas website. It is written by Stuart Sherman and Glen

Lehman. SOD can also occur after gallbladder surgery - either

as a result of the surgery or as secondary problem coming to

light after gallbladder issues have been addressed.

Usually a single attack of acute pancreatitis does not damage

the pancreas so much that you become chronic. So the question

of how much damage may have occured prior to your surgery is

hard to answer. If your attacks were caused solely by your

gallbladder the odds are that you do not have permanent

damage. But....if the gallbladder was just one component of the

injury to the pancreas then you may have damage there to such

an extent that it has become chronic . Sometimes removing the

gallbladder is just the first step to peeling away the layers of

pancreas disease. There is the possibility that SOD was there

completely independent from the diseased gallbladder, or there

is a chance that you have pancreas disease that is not related to

the gallbladder, like hereditary pancreatitis, congenital,

idiopathic, etc....If so, sometimes this doesn't come to light until

after the gallbladder is gone. However, if you want to base your

thoughts strictly on statistics then you can find some comfort in

the fact that gallbladder pancreatitis is one of the commonest

causes of acute pancreatitis and that it rarely converts to chronic

pancreatitis if the diseased gallbladder is removed. But there are

always exceptions. If you are still having symptoms consistent

with pancretitis, I would question your doctor on getting to the

bottom of this aggressively as the longer you wait, the least likely

you will be able to limit the damage to your pancreas. The

sooner you discover the problem, the higher the probability that

you can slow down the progression of the disease.

So my thinking is that you need to ask questions to figure out if

your pain is biliary in origin or pancreatic or both. Ask if there is a

chance that the stones or sludge may still be there in the

common bile duct or the pancreas duct. Ask if it is time to look

into having a MRCP or ERCP done to investigate the pain. Ask

about having labs drawn within 24 hours of an acute flare of your

pain episodes (if it is a biliary problem your liver function tests

may elevate within hours of having an colic attack, if it is

pancreas, your amylase and lipase MAY be elevated - but if you

wait more than 24 to 48 hours the levels may have already

returned to normal - this is what happened with me...the liver

enzyme levels would elevate quickly and return to normal just as

quickly, which is typical of intermittent obstruction to the common

bile duct). If an ERCP is in the picture you may want to inquire

about having manometry performed as this will help determine a

diagnosis of SOD. Also an endoscopic ultrasound may be

indicated if the physician is going to look at your pancreas. You

will want to make clear that the ERCP will be the whole ERCP,

which looks at both the pancreas and bile ducts, or just the ERC,

which just looks at the biliary tree (many, if not all physicians will

use the term ERCP even when they mean ERC so you need to

clarify exactly what your physician is going to do). I know that

many people think I am splitting hairs, but this difference had big

ramifications for me. I was told that my doctor was going to do

the whole ERCP but instead he just did the ERC. So my

pancreas problem was missed and I had to go through the

entire procedure again three weeks later. I would have rather

had it all done at once as I thought it was suppose to have

happened rather than being hospitalized twice in three weeks

with all the hassles and expense that this involves. If the ERCP

is scheduled, you will want to know if he will do a sphincterotomy

if indicated and / or stents. What type of sedation will be used?

(general anesthesia or conscious sedation). Hospital

admission or day surgery? All of this type of stuff......But this may

be jumping the gun at this point......

So I guess the general approach would be to first to try to figure

out what the pain is related to, symptom wise. Then to discuss

what procedures and examinations will be done to get to the

bottom of things. Or if you opt to do a " wait and see " approach,

ask what kind of diet and life style changes you could make,

what kind of medications may help, and what symptoms you

should be on the lookout for that means you need help urgently.

I would also try to objectify your pain prior to seeing this doctor. If

you can tell him specifically what makes it worse, what better,

how often it gets to high levels, how it interferes with your daily

life (including work and social activities), where it is located, if it

is sudden and severe or builds up over time....all things like that

help the doctor get a better idea of what may be causing it.

I am thinking that because you had a relatively recent gallbladder

surgery, his first step may be to look for retained stones or

sludge. This is usually one of the first things that they do. Then

they go on to look at pancreatic problems. Of course this will all

depend on your complaints and history.

As far as your nervous bowel....this is very common after

gallbladder surgery and it can take up to a year for your system to

adjust to not having a gallbladder. But it is also a symptom of

pancreas problems too so this may not be diagnostic. Your GI

doc though may try to convince you that it is " just IBS " , so don't be

surprised if you hear this. It may help to watch your fat intake not

only for that meal itself but on previous days too. Sometimes it is

the cumulative effect of fat that makes one day ok and the next

not. Also, the size of the meal itself may influence how the food

is digested. I noticed though that when I had my biliary colic

attacks it was almost always followed by diarrhea. So it could be

because bile and other digestive enzymes are not able to flow

out of the ducts when it is temporarily obstructed.

As far as other anti-nausea drugs.....I use zofran and this does

not make me drowsy. The only thing with this is that it is not a

rescue drug. That is, it is more a preventive than a medicine that

will stop nausea once it takes hold on you. I was advised to take

it at the very, very first signs of quesiness, or to use it

automatically before I eat, that if I wait until full blown nausea

hits, the drug will not be too effective.

Hope this helps a little...... Some of this stuff I was smart enough

to do, and other of this advice is what I wished I would have done

or would do if I had the chance to go back and do it all over again

the right way.

Laurie