Biliary Colic, No Stones
I recently saw a 36 year old woman who has a 7 month history of “classic” biliary colic: recurrent post-prandial right upper quadrant pain radiating through to the back, associated with nausea but no vomiting, exacerbated by fatty foods and lasting for one to two hours.
Laboratory and diagnostic studies of Biliary Colic
She has had 2 normal ultrasound exams and a normal HIDA scan with an 88% gallbladder ejection fraction. She has seen two gastroenterologists, undergone a CT scan, ERCP, small bowel series, lactose breath test and colonoscopy, with the only finding being a small ulcer in the sigmoid colon, biopsies of which showed “nonspecific” colitis. She has been treated with proton-pump inhibiters, H2 blockers, tranquilizers, Asacol and Rowesa enemas, all without improvement. Physical exam shows only some mild right upper quadrant tenderness, below the costal margin.
The patient is s/p hysterectomy at age 29 for adenomyosis. Two years ago she developed recurrent pelvic pain and underwent laparoscopic lysis of adhesions and incidental appendectomy with relief of her symptoms. She is otherwise healthy.
Now that the GI guys have run out of ways to finance their BMWs, they have referred her to me for cholecystectomy. Although her symptoms are highly suggestive of biliary colic, I am concerned by the complete lack of any objective data, including a normal GB ejection fraction and the failure of cholecystokinin to reproduce her pain, expecially since most published series in the past few years cite a reduced GB EF as a critereon for elective cholecystectomy in these patients.
How many of you would proceed with laparoscopic cholecystectomy based solely upon her symptoms?
I know that you will have a fit – but I would operate on this poor lady IF she seems like a reasonable person and understands she may not get well! I personally have had at least half a dozen people like this in the last ten years – all having had the mega dollar workup – and all but one got remarkably better after the surgery.
Obviously, this is one of the accusations (?rightfully) against us “knife-happy” surgeons for doing unnecessary surgery. Especially now that “Lap Chole’s are so easy.”
How many of you out there have done surgery like this before?
3 anecdotes only:
45 year old obese male with similar work-up for recurrent RUQ pain, HIDA scan with CCK abnormal so I did lap chole and then discovered his real problem (after his BiPAP treatments caused marked bowel distention)–he had a malrotation of the intestines with the cecum under the gallbladder and a constricting band across the transverse portion of the colon–this was causing intermittent recurrent obstruction of this abnormally positioned cecum.
29 approx marginally mentally retarded bipolar female with long-standing abdominal pain, mega-work-up, finally found gallstones and removed gallbladder with some improvement but then returned within year with pseudo-obstruction of colon colonoscopically decompressed and then returned a few months later and found to really have sigmoid volvulus, fine now since emergency sigmoid colectomy (actually I wonder if your patient’s solitary sigmoid ulcer might have this type of etiology).
62 year old thin healthy RN at our clinic with at least 1 year hx of RUQ and R pelvic pain, mega-work-up all completely normal including HIDA with CCK and duodenal drainage (no bile crystals). Her son is a hematologist oncologist. I was finally talked into lap chole, incidental lap appy and lap right salpingo-oophorectomy. (This one was obviously a set-up for failure in a patient I would have to face every day.) The Pathologist did give me a chronic cholecystitis on her gallbladder. She had a fibroma of her ovary. Her appendix was normal. Most surprisingly, all the pain went away.
We never do HIDA scan for biliary tract problems,but,with or without ,the only symptoms can not validate a laparoscopic or open cholecystectomy.
>How many of you would proceed with laparoscopic cholecystectomy based solely upon her symptoms?
I would. Classic symptoms are the best predictor of relief of pain by cholecystectomy in patients without gallstones.
Based on what you have presented, I would be leary of cholecystectomy in this patient. I guess I am always a little leary of those who have relief of pain after adhesiolysis, since in my experience they always come back with something a little different like she has.
Not me, by no means, unless you’d demonstrate that in duodenal drainage there are cholesterol crystals in abundant quantity. Otherwise, very likely that your patient will continue to present symptoms after lap chole… This I say being we chilean surgeons inclined to take out all gallbladders that, even not symptomatic, present some kind of objective pathology. Don’t op this patient unless you find something in her GB or at least in her duodenal content.
I feel badly making any comment here since I am a gastroenterologist. However, this case is one that should have biliary manometry. High pressures will respond to sphincterotomy. This has been proven by Dr. Geenean and Dr. Hogan and Dr. Lehman. The latter is a surgeon (by the way).
I did operate on such patients before (2 or 3). I told them that the chance of the operation to succeed is less than 50 %. This case however appears problematic. I do not like the successful placebo effect of the laparoscopic adhesionolysis which is a B-S procedure.
I had an identical case a year ago. She was 38 yrs old, and went through extensive workup. I finally referred her to the University of Michigan gastroenterology clinic. They did an endoscopic transduodenal ultrasound and identified tiny gall stones. I removed her gall bladder and she did fine.
Not too long ago I had a patient who had what appeared to be biliary colics, but no stones, negative hida scan, negative CT scan, negative ERCP, negative endoscopic ultrasound, normal liver enzymes and so on and so on. The patient insisted on having her gallbladder removed to the point that when I finally agreed to proceed with the surgery and her insurance plan denied authorization for the procedure, she hired a lawyer and obliged the carrier to authorize a cholecystectomy. The results were wonderful and she got cured. Should you operate? If the patient really wants it, yes, otherwise stay away.
If the patient is aware that surgery probably wouldn’t help and still wants to proceed because she is sick of being in pain then I don’t think it would be unreasonable to offer the procedure. Also, consider the fact that a lap chole on this patient would likely be diagnostic, positive or negative you still have the answer.
Apparently you are not aware of an extensive literature on this subject–biliary colic alone predicts relief of symptoms with cholecystectomy 80% to 100% of the time in this setting of chronic acalculous gallbladder disease, and no other modality at all improves this result–CCK stimulation is no more accurate than flipping a coin in predicting success according to the data–as opposed to the conclusions–of virtually all studies of it, including the only prospective blinded study of it published in 1974! CCK is used and has become entrenched in this role only because we surgeons are so insistent on having some positive test first–any test–much to the delight of the radiologists’ bank accounts. Read the literature, then have the professional security to make your decision on the basis of the patient’s presentation–as long as it is truly biliary colic, and not any nonspecific discomfort–and you’ll save these poor patients a big useless bill, and get them treated much earlier. So–please tell us where you picked up this “fact” that surgery “probably” won’t help this patient, because that is clearly against the evidence? See the following study and its references: Chronic acalculous gallbladder disease:a clinical variant South Med J.
Yes I knew of that reference and others. I didn’t say it wouldn’t help the patient. I said I would tell the patient that it “probably wouldn’t help” (actually to be more specific, I tell the patients that it “may not” help and usually quote them a 75% success rate based on
Results of Surgical Therapy for Biliary Dyskinesia. ArchSurg
which found a 75% response rate in people with classic symptoms who have pathologically normal gallbladders. [I know this isn’t Level 1 evidence but, like you say, there is plenty of literature out there supporting this claim])
If they still want surgery knowing that 1 in 4 don’t get better then I know it is “worth it” to them. And if I am underestimating their chance of success, then they’ll be even happier when it works 😉
That sounds reasonable–but another twist on this that many of us are not aware of is that in the presence of gallstones, there is about a 90% success rate of cholecystectomy in the setting of biliary colic–that is, a 10% chance that cholecystectomy will not relieve symptoms, and thus giving rise to the “post-cholecystectomy” syndrome. I wonder how often you rtell your patients this, as well?
The really tough part is convincing the insurance company to pre-certify the procedure.
I always do. It is part of the informed consent.
Do you always do gastroscopy precholecystectomy to help make sure that the abdominal pain is really biliary in origin?
I use to say to the patient and his or her relatives that the cholecistectomy is planned to solve the gallbladder problem, not all the digestive problems that the patient is supposed to have, such as peptic ulcer, functional colopathy, or others. When the patient ask me if I can assure that the problem will be solved, I use to answer with this question: “Where do you live?, he says where he lives, then I ask: Are you sure you are going to arrive home safe?, most probable you’ll do and in surgery, most probable your problem will be solved”. I emphasize in the words “most probable”.
100% of the time. It’s on my list of risks I discuss with my patients.
Usually not, especially if the symptoms fit. The reason for this is mainly financial. It would break our health care system to perform other (usually unnecessary, and very expensive) tests on these people unless the symptoms warrant. And even if you did, where would it stop? Should they get a BE to rule out hepatic flexure tumor, CT to r/o pancreatic tumor, CXR to r/o RLL infiltrate, MRI of the spine to r/o pinched nerve, etc.? Any or all of these tests may be warranted after surgery if the symptoms continue, but I have a hard time justifying them before unless I am suspicious of something else going on.