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What Is The Cause And Treatment For Biliary Dyskinesia?
Question: I am writing back for follow up on my previous work up. 55 yo male with chronic history of gerd IBS s/p cholecystectomy for biliary dyskinesia 2005. Diagnosed with sod type 3 nov 2012 had manometry during ercp cbd pressures elevated sphincterotomy was done. Temporary Stent was placed in pancreatic duct to protect against pancreatitis. Symptoms resolved after 2 wks. 5 wks ago recuurrence of severe burning and shearing pain just below my xiphoid process with anorexia increased belching and malaise were prominent. All labs mrcp and ct scan of abd and pelvis with IV contrast and large bolus of water were normal. Egd revealed hyperplastic polyp 2 cm on body of stomach and same on duodenal papilla were unchanged. Ercp was repeated cbd was scarred over and stenosed balloon was inserted and sphincterotomy was performed up to 8 mm. Pancreatic duct was not touched. No complications virtually no pain for first 10 days on liquid and soft diet. As diet was advanced burning shearing pain returned. Also increased bowel movements 20 mins after eating and some pain with swallowing of solids. Creon was of no value. Elavil was started and relieved burning pain but difficult for me to tolerate increased sedation and some muscle cramps. I guess at this time my biggest concern is the possibility of chronic pancreatitis. I guess i need to know since these specific symptoms the unremitting burning pain and 10 pound weight loss have now occurred on 3 different occasions all approx 2 years apart have significantly affected my functionality. Im also wanting to know how sensitive the negative radiologic studies are for ruling out ch pancreatitis. And if this is negative what actually is/are my diagnoses and can i get some relief. Thank you for reviewing my case- XXXXXXX
Brief Answer:
Might be pancreatic duct SOD, please get evaluated
Detailed Answer:
Hello,
I understand your concern , as you are already diagnosed with Biliary dyskinesia, most of them get relieved after cholecystectomy, and even after 4- 5 years post cholecystectomy status patients might still experience some pain.
As you have crossed that phase , and in your case manometry of biliary duct was done and sphincterotomy as well as balloon dilatation was done , and still you have persistence of symptoms , then please check firstly if you have pancreatitis.
Check your serum amylase, serum lipase levels, serum lipid profile , stool routine and stool for fat, sugars - these will tell you if your pancreas are good or if there is any insufficiency, which usually should be seen on imaging like MRCP OR CT, but since they are normal , please go ahead with these tests.
Additionally, if these tests say you have pancreatitis , and other causes of pancreatitis are ruled out in you, then it might be pancreatic duct sphincter of oddi dysfunction.
In such cases please consult your surgical Gastroenterologist and the ideal thing will be division of both your biliary and pancreatic duct sphincters, this might cause relief in 70- 80% of the patients.
Please consult your Gastroenterologist as he/ she would direct you better after your thorough examination. Hope I could help you.
Thank you.
Might be pancreatic duct SOD, please get evaluated
Detailed Answer:
Hello,
I understand your concern , as you are already diagnosed with Biliary dyskinesia, most of them get relieved after cholecystectomy, and even after 4- 5 years post cholecystectomy status patients might still experience some pain.
As you have crossed that phase , and in your case manometry of biliary duct was done and sphincterotomy as well as balloon dilatation was done , and still you have persistence of symptoms , then please check firstly if you have pancreatitis.
Check your serum amylase, serum lipase levels, serum lipid profile , stool routine and stool for fat, sugars - these will tell you if your pancreas are good or if there is any insufficiency, which usually should be seen on imaging like MRCP OR CT, but since they are normal , please go ahead with these tests.
Additionally, if these tests say you have pancreatitis , and other causes of pancreatitis are ruled out in you, then it might be pancreatic duct sphincter of oddi dysfunction.
In such cases please consult your surgical Gastroenterologist and the ideal thing will be division of both your biliary and pancreatic duct sphincters, this might cause relief in 70- 80% of the patients.
Please consult your Gastroenterologist as he/ she would direct you better after your thorough examination. Hope I could help you.
Thank you.
Above answer was peer-reviewed by :
Dr. Shanthi.E
Labs were all normal and f/u ercp was negative for any pancreatic duct abnormalities. GI doc considered visceral hypersensitivity or gastroparesis as cause of pain. Not sure what to think anymore.thx- XXXXXXX
Brief Answer:
Gastroparesis should be evaluated .
Detailed Answer:
Hello,
Thanks for getting back and providing more insight, yes viseral hypersensitivity in IBS can cause symptoms as mentioned by you, but do you have urgency of stools?( as it one of the prerequisite) .
If it is visceral hypersentivity than there are four modalities that can be tried for your chronic pain.
1) To reduce acid over production in the stomach by giving a PPI.
2) To reduce nerve pain by giving anti convulsants ( by calming the nervous system)
3) Tricyclic analgesic s to reduce the nervous system sensitivity to pain.
4) lastly opiods are also an option but long term use of opiods can cause hyperalgesia (more pain).
But all these can only be started by your doctor as they have to monitored.
These medications can cause some amount of relief to you.
Secondly Gastroparesis should be confirmed by radionuclide studies and xrays and other studies.
If Gastroparesis is confirmed , the reason for gastroparesis should be evaluated as treatment can be given on those bases, more than 50% of cases of gastroparesis is because of Diabetes, long standing,please check your sugars again.
Hope I could help you.
Thank you.
Gastroparesis should be evaluated .
Detailed Answer:
Hello,
Thanks for getting back and providing more insight, yes viseral hypersensitivity in IBS can cause symptoms as mentioned by you, but do you have urgency of stools?( as it one of the prerequisite) .
If it is visceral hypersentivity than there are four modalities that can be tried for your chronic pain.
1) To reduce acid over production in the stomach by giving a PPI.
2) To reduce nerve pain by giving anti convulsants ( by calming the nervous system)
3) Tricyclic analgesic s to reduce the nervous system sensitivity to pain.
4) lastly opiods are also an option but long term use of opiods can cause hyperalgesia (more pain).
But all these can only be started by your doctor as they have to monitored.
These medications can cause some amount of relief to you.
Secondly Gastroparesis should be confirmed by radionuclide studies and xrays and other studies.
If Gastroparesis is confirmed , the reason for gastroparesis should be evaluated as treatment can be given on those bases, more than 50% of cases of gastroparesis is because of Diabetes, long standing,please check your sugars again.
Hope I could help you.
Thank you.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Thank you much yes i do have urgency- also whats intersting is when im having this pain which occurs for approx 4-6 wks every 2 years i have many large bowel movements thru the day and after 2-3 the pain in my upper abdomen jist below my sternum gets accentuated but pain in lower abdomen subsides. Elavil did help with this upper abdominal pain. Am seeing GI doc again on tuesday. Im wondering the cause of the upper abd pain after repeated b.m.'s thx again youve been very helpful
Brief Answer:
Thank you so much.
Detailed Answer:
Hello again,
Thanks to you too for getting back and letting me know. Then as per your summary it might be visceral hypersentivity as mentioned above.
Yes please do consult your doctor and you can discuss with him the treatment options and hope you get relief. Do get back to me for any queries you have, would be happy to help.
Thank you.
Thank you so much.
Detailed Answer:
Hello again,
Thanks to you too for getting back and letting me know. Then as per your summary it might be visceral hypersentivity as mentioned above.
Yes please do consult your doctor and you can discuss with him the treatment options and hope you get relief. Do get back to me for any queries you have, would be happy to help.
Thank you.
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Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
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