From: "Howard McCollister" <hmacXX@XXcharter.net>
Newsgroups: sci.med
Subject: Re: Acid after Gallbladder removal
Date: 1 Oct 2003 06:53:07 -0500
Message-ID: <3f7abf6e$0$543$45beb828@newscene.com>

"Kathy Burke" <leavemealone> wrote in message
news:1064989840.54022.0@despina.uk.clara.net...
> Thanks Emma (and Howard et al), appreciate it.
>
> What's confusing me is that the possibilities being suggested seem not to
> consider the possibility that if when the gallbladder is removed then the
> bile constantly drips into the intestine, even when no food is
> present. and that in this concentrated form, the bile acids are very
> irritating to
> the linings of the intestine - then why isn't this the more obvious cause of
> the discomfort?
>

The purpose of the gallbladder is to store and concentrate bile that is
normally always flowing from the liver to the intestine. When you eat
something, particularly something with a high fat content, the gallbladder
gets a signal to contract and empty an extra load of bile into the intesting
to help digest that meal. Since the liver is always making bile, it
constantly drip into the intestine anyway if the gallbladder is already
full, whether you have food in the intestine or not. The gallbladder can
only hold so much bile, then the excess that is being made just keeps on
flowing.

The bile that flows isn't irritating to the small intestine, but the change
in flow pattern after gallbladder removal can result in irritation to the
colon, which is the reason some people get a (usually transient) diarrhea
after their gallbladder is removed.

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Gall Bladder Question
Date: 4 Dec 2004 21:31:21 -0600
Message-ID: <41b28059$0$3795$45beb828@newscene.com>

"DHess" <dhess31IHateSpam@comcast.net.invalid> wrote in message
news:pan.2004.12.05.00.03.35.11457@comcast.net.invalid...

>> I agree that gallbladder symptoms can be mistaken for reflux symptoms and
>> vice versa. I interpreted the OP's original point and question based on
>> the
>> part where he said: "A friend of mine recently had her Gall Bladder out
>> because of "serious reflux".  She had no pain.  My question is, is how
>> exactly does the gallbladder cause heartburn or acid reflux?"
>>
>> HMc
>
> This is correct.  She has said that it is too soon to know whether it has
> had any affect on her reflux yet.  I was wanting to know whether the two
> were related, because I know a bit about this sort of thing and thought it
> was odd.
>

There are a number of GI problems that can manifest themselves with similar
symptoms, and these include gallbladder disease, GERD, peptic ulcer disease,
irritable bowel syndrome. Nailing down the diagnosis can be difficult, but
it would be hard (not impossible) to justify removing the gallbladder in the
absence of any defineable pathology. If I were conducting a workup for upper
abdominal pain and the gallbladder was normal, removing it would likely have
to wait until other causes of the symptoms had been excluded to the extent
possible. There is a more ready tendency to remove the gallbladder for
indications that would have been well outside the standards of care 15 years
ago when it required a major right upper quadrant incision. I'm not saying
that's necessarily a bad thing, but the OP's scenario of removing the
gallbladder for reflux symptoms sounds pretty far off the mark.

HMc

From: David Rind <drind@caregroup.harvard.edu>
Newsgroups: sci.med
Subject: Re: Gall Bladder Question
Date: Sat, 04 Dec 2004 23:28:20 -0500
Message-ID: <cou2lg$ht0$1@reader1.panix.com>

Howard McCollister wrote:
> There are a number of GI problems that can manifest themselves with similar
> symptoms, and these include gallbladder disease, GERD, peptic ulcer disease,
> irritable bowel syndrome. Nailing down the diagnosis can be difficult, but
> it would be hard (not impossible) to justify removing the gallbladder in the
> absence of any defineable pathology. If I were conducting a workup for upper
> abdominal pain and the gallbladder was normal, removing it would likely have
> to wait until other causes of the symptoms had been excluded to the extent
> possible. There is a more ready tendency to remove the gallbladder for
> indications that would have been well outside the standards of care15 years
> ago when it required a major right upper quadrant incision. I'm not saying
> that's necessarily a bad thing, but the OP's scenario of removing the
> gallbladder for reflux symptoms sounds pretty far off the mark.
>
> HMc

Agreed. I'm guessing that the woman who had her gallbladder out at least
had gallstones. If there really were not even gallstones, and they took
her gallbladder out just to see if that might help with reflux-type
symptoms, that would be a pretty unusual decision.

--
David Rind
drind@caregroup.harvard.edu

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Gall Bladder Question
Date: 5 Dec 2004 06:58:10 -0600
Message-ID: <41b3054b$0$88450$45beb828@newscene.com>

"David Rind" <drind@caregroup.harvard.edu> wrote in message
news:cou2lg$ht0$1@reader1.panix.com...

>
> Agreed. I'm guessing that the woman who had her gallbladder out at least
> had gallstones. If there really were not even gallstones, and they took
> her gallbladder out just to see if that might help with reflux-type
> symptoms, that would be a pretty unusual decision.

Actually, cholecystectomy in the absence of gallstones is becoming quite a
bit more common than in the past. The diagnosis of biliary dyskinesia is
seen with increasing frequency. That diagnosis is made by HIDA scan with
volumetric gallbladder emptying in response to IV administration of CCK. An
ejection fraction of less than 30% is considered a positive test, as well as
duplication or exacerbation of the pain with the injection. Personally, I
like to also see some supporting factors, such as strong family history or
classic pain presentation (fatty food->RUQ pain->radiate to back...etc).

A typical workup might be ultrasound of the GB. If negative, then probably
an EGD for ulcer or esophagitis. If negative then perhaps empiric trial of a
PPI, or maybe ambulatory pH testing and esophageal manometry *or*  HIDA/CCK
.. . Maybe a gastroenterology consult in there somewhere for irritable bowel
syndrome workup.

There is an entity called hypertensive Sphincter of Oddi. This can be
painful, and can cause RUQ pain that can be troublesome. The diagnosis is
made by manometry of the sphincter and common duct and treatment is
sphincterotomy. There's only one place in this state that has that equipment
(Mayo Clinic doesn't have it), and the gastroenterologist that runs the
program won't even do the testing unless the patient continues to have that
pain after cholecystectomy. I've actually seen a few patients with this -
one of those situations where the diagnosis is elusive, and this GI
consultant recommended empiric cholecystectomy. Interestingly, it eliminates
the problem in most of the situations I've done this, even in the absence of
in the absence of ANY of the usual indications. The 2 patients whom it
didn't help turned out to have hypertensive sphincter of Oddi and
sphincterotomy fixed it.

So much of what I learned in my residency has turned out to be wrong....

HMc

From: "Howard McCollister" <nospam@nospam.net>
Newsgroups: sci.med
Subject: Re: Gall Bladder Question
Date: 5 Dec 2004 11:09:04 -0600
Message-ID: <41b34027$0$31863$45beb828@newscene.com>

"David Rind" <drind@caregroup.harvard.edu> wrote in message
news:covd28$sbi$1@reader1.panix.com...

> I, too, have seen more people being diagnosed with sphincter of Oddi
> dysfunction. I have been underwhelmed at the accuracy of HIDA scans in
> diagnosing biliary dyskinesia (or much of anything) in a primary care
> setting where prevalence of disease is low. Your mileage may vary.
>
> However, my above point remains: at least around here, it would be pretty
> unusual to remove the gallbladder in someone without gallstones who had
> symptoms that were atypical for biliary colic. If you are seeing that
> being done a lot, I'd love to see a randomized trial of cholecystectomy
> for dyspepsia or GERD symptoms in people with only HIDA/CCK evidence of a
> gallbladder problem.

No, it's certainly not being done a lot, and I agree that we still like to
see some semblance of indications before doing a cholecystectomy, and I'm
generally opposed to the concept of empiric cholecystectomy. The only
circumstances where I've done that have been on the recommendation at
consultation from a gastroenterologist.

A recent anecdotal example: 36 year old female with persistent
mid-epigastric and RUQ pain. Fatty food intolerance and family history of
gallstones. U/S negative, HIDA/CCK negative. PMH bilateral mastectomy for
unilateral breast cancer with adjuvant chemo 3 years previously. I sent her
to the GI guy for sphincter manometry, but he instead did an EUS and
diagnosed chronic pancreatitis, probably from the chemo. Aha! I thought, but
in the next paragraph he recommended cholecystectomy anyway. I did that, and
her pain disappeared. Crappy anecdote, but it's all I've got.

HMc

From: Steve Harris <sbharris@ix.netcom.com>
Newsgroups: sci.med
Subject: Re: Frequent biliary colic (severe pain without fever or vomit)
Date: 31 May 2005 17:42:28 -0700
Message-ID: <1117586548.541662.258950@f14g2000cwb.googlegroups.com>

>>She refuses surgery (removal of colecystis): first of all because we
have a relative who died of colon cancer (and constant leaking of gall
in the intestin slightly increase colon cancer probability) at a
relatively young age,<<

COMMENT:

I know of no evidence for that.  Who says so?

People who have gall bladders out have a slightly increased risk of
colon cancer and other GI cancers diagnosed around the time they have
it out, but that's no doubt either because either the cancer was found
incidently at the time of surgery (less likely in these modern days of
laparoscopic procedures, ironically), or else because the symptoms that
caused the gall bladder to be removed were actually being caused by
cancer, which is shortly diagnosed after it's discovered that the gall
bladder isn't the problem.

If you go out 2 years after cholecystectory, you find it doesn't
contribute to colon cancer risk significantly after that.  Which it
would continue to do, if there was some big causal connection.

SBH

=========

Br J Cancer. 2005 Apr 11;92(7):1307-9.

Cancer after cholecystectomy: record-linkage cohort study.

Goldacre MJ, Abisgold JD, Seagroatt V, Yeates D.

Unit of Health-Care Epidemiology, Department of Public Health, University
of Oxford Old Road Campus, Old Road, Oxford OX3 7LF, UK.
michael.goldacre@dphpc.ox.ac.uk

We investigated whether cholecystectomy is associated with subsequent
cancer and, if so, whether the association is likely to be causal, by
undertaking a retrospective cohort study using linked medical statistics,
comprising a cholecystectomy group (n=39 254) and a reference cohort
admitted for a range of other medical and surgical conditions (n=334
813). We found a short-term significant elevation of rates of cancers of
the colon, pancreas, liver, and stomach after cholecystectomy, but no
long-term elevation. Excluding colon cancers within 2 years of admission
to hospital, the rate ratio for colon cancer after cholecystectomy,
compared with the reference cohort, was 1.01 (95% confidence interval
0.90-1.12) and after 10 years or more follow-up it was 0.94 (0.79-1.10).
It is highly improbable that the short-term associations between
cholecystectomy and gastrointestinal cancers are causal, and we conclude
that cholecystectomy does not cause cancer.

PMID: 15770220 [PubMed - indexed for MEDLINE]