Brief Answer: Recommended course of action is penned below Detailed Answer: Hi Ma'am, Thanks for your query. I fully understand the agony that you are passing through. I have gone through your problems very carefully and also taken full note of the test-reports given by you. However, there are still some more information required. Hence, in order to PINPOINT the exact cause of your problems; give you a SOUND professional advice; and, TRUE VALUE FOR YOUR MONEY, may I request you to kindly provide additional information as follows :- # Have you been having episodes of watery diarrhea in the past? # Apart from egg allergy, have you ever noticed that you get abdominal upsets and discomfort, pain, diarrhea after having wheat, barley or rye products; sugar, milk, cheese or yoghurt? # Though it is evident that you are passing through tremendous mental stress due to your health problems, have you ever passed through chronic anxiety/mental stress PRIOR to the onset of present problems? Nevertheless, pending receipt of the requested additional information, the possible causes of your problems- based on the information provided- are :- * H.pylori infection of the esophagus, stomach and intestine with consequent GERD: ALL your symptoms fit into this possibility, apart from Post-Cholecystectomy Dumping Syndrome (a complication of gall-bladder removal) as given below. * Post-Cholecystectomy Dumping Syndrome : occurs due to unregulated spilling of bile into the stomach, duodenum and early part of intestine. This condition manifests as all symptoms that you have been undergoing since long. * Achalasia cardia : a condition in which the propulsive movements of the esophagus wall is abnormal. This can be due to functional abnormality of nerves responsible for coordinating esophageal movement; or, as a complication of Chaga’s disease, contacted in the past. However, I presume that this condition was EXCLUDED through barium swallow study. * Mental stress/persistent anxiety-related hyperacidity. If I were your treating physician, my course and sequence of action would have been as follows:- (a) A regular, short-term course of a combination of anti-depressant + anti-anxiety drug to curb your mental stress/persistent anxiety and thereby, eliminate one of the aggravating factors of your abdominal problems. (b) Simultaneously, I would have empirically started a 14 days’ course of anti-H.pylori therapy + a Pro-kinetic drug, such as, metoclopamide or domperidone; followed- with effect from Day 15- by 3-6 months’ regular course of an anti-acid drug, such as, lansoprazole or rabeprazole along with prokinetic drug as above. (c) Simultaneous supplementation of Probiotics, such as, Lactobacilli and pancreatic enzymes for at least 4 weeks or more, as required. (d) Further advice : small frequent meals 5-6 times/day; eat slowly and chew properly; high fiber, high protein, low fat diet; sleep in 30 degrees propped up position. Consult your doctor and apprise him of my opinion. I am certain that he will agree with my opinion/course of action and prescribe the recommended treatment in appropriate doses. Hope I have addressed to your concerns to your complete satisfaction and you find my response helpful and informative. I will be happy to answer further queries, if any. In any case, I SHALL BE LOOKING FORWARD TO HEARING FROM YOU ALONG WITH THE REQUESTED ADDITIONAL INFORMATION. Fond regards and have a nice day, Dr. Rakesh Karanwal

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Brief Answer: Problems suggestive of gall-bladder removal effect Detailed Answer: Hi Ma'am, Having gone through the entire information, I am firmly of the opinion that you have a combination of inter-related conditions (Irritable Bowel syndrome + GERD + highly possible H.pylori infection + irritable tightening of Lower esophageal Sphincter, esophagitis due to reflux of acid and bile in esophagus), FOLLOWING gall bladder removal. Hence, my recommended course of action REMAINS THE SAME, along with addition of empirical medication on experimental basis. Additional Treatment recommended ( in addition to the treatment recommended earlier) :- * Add Nitrates (Isosorbide dinitrate or Mononitrates) or Calcium channel blockers, (such as amlodipine, diltiazem) to relax XXXXXXX and duodenal sphincter/narrowing. * Cholestyramine to neutralize the effects of bile on stomach and duodenum. It is also suggested that Pancreatic function tests, liver function tests and, if your surgeon feels appropriate, ERCP may be conducted to see for an impacted stone in the bile duct. It is possible that gradually progressive increase in size of an old silent stone in bile duct, might have produced abrupt obstruction of the Common Bile Duct. I am highly confident that you will gradually BUT steadily, exhibit tremendous response to the RECOMMENDED TREATMENT. You may therefore discuss in great detail, my opinion and recommendations with your doctor. I am sure he will agree with me and act on my advice. Take care, Dr. Rakesh Karanwal

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Brief Answer: You have IBS-Constipation Predominant type. Detailed Answer: Well ma'am, Firstly, there are 3 subtypes of Irritable Bowel Syndrome (IBS) : 1. diarrhea predominant, 2. constipation predominant and, 3. diarrhea alternating with constipation. You are suffering from IBS - Constipation Predominant type. Further, as already mentioned, possibility of a dormant gall stone in the common bile duct(CBD) may have-over the years- increased in size, big enough to cause sudden obstruction of CBD. This can account for the sudden onset of your symptoms 11 months back. that's why, I have recommended ERCP. Quite often, acid and bile cause reflex, tight constriction of XXXXXXX which relaxes intermittently and cause reflux of acid and/or bile. It is possible that the XXXXXXX was tightly constricted at the time probe was put in to your esophagus. H.pylori infection can occur any time. It could have occurred AFTER biopsies were taken and found negative for it. In my clinical practice, I routinely come across several patients who were tested negative for H.pylori, but showed miraculous response to anti-H.pylori therapy! All symptoms described by you just now, point towards the diagnosis of GERD. The pain/discomfort under left rib cage in the spleen area is called "Splenic Flexure Syndrome", characterized by trapping of intestinal gas in the part of colon which overlies the spleen and under the left rib cage. I once again assure you that you will certainly show remarkable improvement with the treatment advised by me. Lastly, you may also discuss possibility of D.difficele infection of the intestine, with your gastroenterologist tomorrow. PLEASE DO NOT HESITATE IN SEEKING FURTHER CLARIFICATIONS, IF ANY. I will be happy to answer your queries. Dr. Rakesh Karanwal

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