gastroparesis and biliary dyskinesia

[dpmd]

If you have a pt with both how do you decide what to do, especially when the symptoms are difficult to decipher (in this case main sx are intractable nausea and vomiting with epigastric pain which worsened during the stimulus portion of the hida).

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[balaguru]

I'd probably do a cholangiogram and remove the gallbladder unless there was some prohibitive risk.

 

[dpmd]

Well...if they are a relatively low risk operative candidate and the story is good for biliary dyskinesia...one option is just to take the gallbladder out of the equation (literally).

But you have to have a very realistic and grounded conversation with the patient about the low odds of this leading to symptom resolution/improvement. Which can be really difficult as these patients are often a handful.

Very true. This pt actually attempted suicide a few weeks ago (not sure if due to the symptoms, or just because of depression and being in jail)

 

[SLUser11]

If you have a pt with both how do you decide what to do, especially when the symptoms are difficult to decipher (in this case main sx are intractable nausea and vomiting with epigastric pain which worsened during the stimulus portion of the hida).

If the symptoms are exacerbated by the CCK injection, I think it's reasonable to put the GB in a bucket. Of course, we all know the long-term success rate of cholecystectomy for biliary dyskinesia is bad...and probably worse when there are vague, atypical symptoms that could be attributed to another problem....

That being said, this doesn't sound like the correct time to do a potentially non-therapeutic elective surgery on this patient, as he/she is mentally unstable and actively suicidal....and incarcerated....

 

[dpmd]

If the symptoms are exacerbated by the CCK injection, I think it's reasonable to put the GB in a bucket. Of course, we all know the long-term success rate of cholecystectomy for biliary dyskinesia is bad...and probably worse when there are vague, atypical symptoms that could be attributed to another problem....

That being said, this doesn't sound like the correct time to do a potentially non-therapeutic elective surgery on this patient, as he/she is mentally unstable and actively suicidal....and incarcerated....

Yeah, this is along the lines of what I was thinking. He has been admitted for the past week due to the intractable nausea and I don't see a single note from psych (he went back to jail after the attempt, and hasn't tried anything on this admit, but he has two guards in his room at all times though). GI found a bunch of food in the stomach on EGD, hence the gastroparesis dx but their last few notes have just said "awaiting cholecystectomy" but I was just consulted yesterday evening. I guess they don't have CCK because they gave ensure to check the EF. I am not really sure how to interpret the fact he had pain and nausea with that, since it could be due to the gastroparesis as well, but the EF was 8%. I talked a little with the patient about chole and he isn't super enthused about the idea of an operation anyway, so that is good for me. However, I know the hospitalist and GI guy are going to press me for an inpatient chole so I figured I would poll the crowd to see if I was being too negative about the situation.

 

[balaguru]

Yeah, this is along the lines of what I was thinking. He has been admitted for the past week due to the intractable nausea and I don't see a single note from psych (he went back to jail after the attempt, and hasn't tried anything on this admit, but he has two guards in his room at all times though). GI found a bunch of food in the stomach on EGD, hence the gastroparesis dx but their last few notes have just said "awaiting cholecystectomy" but I was just consulted yesterday evening. I guess they don't have CCK because they gave ensure to check the EF. I am not really sure how to interpret the fact he had pain and nausea with that, since it could be due to the gastroparesis as well, but the EF was 8%. I talked a little with the patient about chole and he isn't super enthused about the idea of an operation anyway, so that is good for me. However, I know the hospitalist and GI guy are going to press me for an inpatient chole so I figured I would poll the crowd to see if I was being too negative about the situation.

Hahaha. I was going to ask for more details about the diagnoses but figured they were straight forward. There was a shortage of CCK and until only recently we were using ensure too which has the annoying consequence of making a patient no longer NPO. Retained food on EGD is a dubious way to diagnose gastroparesis, especially if he doesn't have some co-morbid condition like diabetes. If he truly has gastroparesis then this would make it difficult to interpret the stimulation portion of the HIDA if they used ensure. I would also look closely at his meds. One of his psych meds may be responsible for all this.

 

[SLUser11]

Yeah, this is along the lines of what I was thinking. He has been admitted for the past week due to the intractable nausea and I don't see a single note from psych (he went back to jail after the attempt, and hasn't tried anything on this admit, but he has two guards in his room at all times though). GI found a bunch of food in the stomach on EGD, hence the gastroparesis dx but their last few notes have just said "awaiting cholecystectomy" but I was just consulted yesterday evening. I guess they don't have CCK because they gave ensure to check the EF. I am not really sure how to interpret the fact he had pain and nausea with that, since it could be due to the gastroparesis as well, but the EF was 8%. I talked a little with the patient about chole and he isn't super enthused about the idea of an operation anyway, so that is good for me. However, I know the hospitalist and GI guy are going to press me for an inpatient chole so I figured I would poll the crowd to see if I was being too negative about the situation.

He certainly needs a more extensive workup prior to proceeding. "Gastroparesis" diagnosed due to food in the stomach on EGD is pretty weak. A more fitting diagnosis may be non-compliance with NPO status, plus or minus some malingering.

I also know very little about how to interpret biliary EF based on enteral protein shakes. Maybe this is well-established, but I'm not familiar.

I would start running away from that patient immediately. Do not take out the gallbladder.....

 

[dpmd]

The egd was after 4 days of observed npo and vomiting in house, but I was wondering why they hadn't done anything else to eval it especially since he isn't diabetic. Good point about the psych meds. I am feeling better about wanting to back away from this.

 

[Gastrapathy]

This patient has functional dyspepsia. The placebo effect from a chole should keep her away for 6 months but she'll be baaaack.


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