43 yo woman: Must she have her gallbladder out?

43 yo woman: Must she have her gallbladder out?
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Dr. Daniel Smith
Message 1 of 8 , Jun 8 2:05 PM
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43 yo woman presented to my office six week ago.
In early March she awoke with exquisite abdominal pain generally localized to her URQ.  Vomiting and nausea ensued.  She went to the ER.
CT, MRI (cholangiopancreatography) and U/S were negative.
Lipase was elevated at 320.
Amylase and all other standard panels were normal

Two days later even the lipase was normal.  It has been checked three times since then and has been consistently normal.

She was released from the hospital on 3/7/16.  The doctors effectively punted her (with a diagnosis of pancreatitis) as her abdominal pain -while no longer 10/10 and constant- still presented daily at regular interval.

Prior to this episode she was taking minocycline for acne.  Minocycline IS associated with pancreatitis (rarely), but upon stopping taking the drug, the pattern of her RUQ pain has not changed.

She currently is eating simple: few to no meats, well cooked veggies or soups, fruit, bone broth, very low carbs, low fats and only quality fats if present at all.  Her pains are worse about an hour after eating and last for about 1-2 hours.  If she eats "badly" she is a trainwreck.  The pain escalates and lasts in some cases up to a week.  Her stool has a tendency to be soft/diarrhea.  Nausea without vomiting is a common issue for her.

My testing included
SIBO - negative for methane and hydrogen production
CDSA- high in commensal bacteria otherwise unremarkable
CCK-stimulated cholescintigraphy - gall bladder ejection fraction LOW 19% (normal >35%)

I have put her on a strict diet (see above).  She is compliant.

Supported her detox pathways, specifically with fiber to bind bile
Ox bile seemed to help but only according to her "it helps me to predict when the pains will hit.  Without the ox bile, they could hit just about anytime"

Supported her with probiotics, PC, HCl, homeopathics, Rowachol (when I was considering the possibility of bile sludge/stones), bile supportive supplements with an eye toward cautious use of cholegogues.

Her PCP put her on Creol.  I am not sure how much, but it is not uncommon in pancreatic insufficiency to use 50,000 - 70,000 units of lipase with this medication.

Ultimately I have been able to reduce to frequency of her pain but not eliminate it.  I am clearly missing something.  The results of the CCK-stimulated cholescintigraphy indicate that she is definitely a candidate for cholecystectomy.

http://www.uptodate.com/contents/functional-gallbladder-disorder-in-adults

This article suggests a clear diagnosis of functional gallbladder disorder.

Shee-it, am I missing something here?  Are there any other tests?  Any suggestions?  I would LOVE to help her to keep her gall bladder, but she is very worn out by the regular episodes of pain and nausea.  She is ready to pull the trigger and have that ding dang organ cut out, and the above article offers support to that route.

Your thoughts are welcome.

Daniel Smith, ND
Medford, OR





Emily Kane
Message 2 of 8 , Jun 8 2:21 PM
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Despite low function she had no gallstones or sludge. Right?  I don't think that would cause pain though the timing with food suggests GB. Could also be peptic ulcer. Either endoscopy or trial of aloe juice before meals and DGL right after might elucidate.
Emily Kane ND
Juneau AK





flanagan.laura
Message 3 of 8 , Jun 8 7:33 PM
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Hi Daniel. I agree with Emily's comment. Also want to mention that I have seen Heron Botanicals formula Temper the Bear work wonders for similarly sluggish gall bladders. One patient with before and after testing went from about 13% to mid 50s. I generally keep my folks on it about 6 months then they no longer need it.
Laura Flanagan ND
Spokane, WA





drtjacobs93101
Message 4 of 8 , Jun 9 6:53 AM
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In addition to other excellent responses, consider allergy/sensitivity removal. High sulfur foods like garlic, onions, eggs, can contribute to some cases, but try IgA/IgG testing (I still use US Biotek). Eliminate high sulfur foods in the interim.
Thad Jacobs, ND, LAc. SLC/Park City, UT





Mona Morstein
Message 5 of 8 , Jun 9 6:54 AM
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Is homeopathic chelidonium indicated?  I’ve cured quite a few RUQ gallbladder problems with that remedy.

Mona Morstein, ND, DHANP
Tempe, AZ





tesstrickland
Message 6 of 8 , Jun 9 7:02 AM
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Hi Daniel,
I had a similar patient a few years back.
She had a toddler and baby at home and was very motivated to not go in for surgery. She was on a light, vegan diet which helped and I put her on high doses of malic acid and magnesium for a month, which helped her pain (I think sphincter spasm was a main cause of pain).
 Then on her own, she did the infamous liver flush over a weekend. Despite the U/S reporting no stones, she reports that she flushed over 200 small stones (she said they looked just like the pictures in the book). She was in pain all night before the morning flush occurred. She smoked marijuana, took an Epsom salt bath and layed on a biomat all night for pain relief.
After the flush her pain and nausea went away for over a week.
She did another flush a few weeks later and this time not much came out and she said she couldn't ever swallow those concoctions again.
Still the pain, though much better and much more local persisted.
Then she went on a wacky website's " pico-magnesium". No loose stools and the pain went away completely. No nausea. Completely. She stayed on this magnesium and it never came back.
So, did I miss something? I don't think so. But the remedy for her would have been a supervised, even hospitalized flush with pain meds. And the final answer to a persistent sphincter spasm was a magnesium that absorbed better. Sometimes, you are just a helpful stepping stone but the determination of the patient is where the ultimate answer lies. This patient was one of the most determined I'd ever seen.
TESS



J. Claire Green, ND
Message 7 of 8 , Jun 9 7:05 AM
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What about some phosphatidylcholine?
I had a case of a 65 yo female with similar presenting picture with negative GI workup who was scheduled to have her gb removed.

I had her follow a gluten free diet as attacks seemed to be triggered by wheat, plus lecithin, and integrative therapeutics super milk thistle X.  She continues to do well, with her gallbladder intact.  You need lecithin to keep your bile from sludging up.




J. Claire Green ND
Santa Rosa, CA




tesstrickland
Message 8 of 8 , Jun 9 7:35 AM
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I should specify that my goal was to Rx high dose Mg but she was intolerant of very small doses. She just couldn't absorb it. On low dose she had nausea and loose stools. On the "pico magnesium" that she orders she got pain relief on very high doses without these effects.
And I agree with the others that Ulcer should be ruled out.
TESS