58 year old woman, Level 10 pain that Cholecystectomy didn't cure.

Posted by davosmarsh @davosmarsh, Feb 13, 2022

The wife has had the following PAIN events & SURGERY to remediate:

* 5 level 10 pain episodes lasting on average 30-45 minutes
* Pain is in the sternum and just below it, it radiates to the back, it is unbearable
* Dates of pain:
* 8.27.21 < level 10
* 8.28.21 < level 10
* 8.30.21 Level 10 – "worse than childbirth"
* 8.31.21 < level 10
* 9.13.21 Level 10 (ER visit details below)
* 9.15.21 < level 10
* 9.17.21 < Level 10
* 10.31.21 Level 10 "worse than childbirth"
* 11.1.21 Level 10 "worse than childbirth"
* 11.4.21 gallbladder removed / cholecystectomy
* 2.9.22 Level 10 "worse than childbirth"

TESTING:

* 11 blood-work tests from 9.13.21 – 02.10.22
* 9.13.21 XR Chest single vw – no acute cardiopulmonary process
* 9.13.21 EKG normal
* 9.13.21 ED US Aorta – Aortic Ultrasound, no evidence of abdominal aortic aneurysm
* ED US Biliary – gallbladder without any signs of cholelithiasis or cholecystitis

Second ER visit, different hospital
* 11.4.21 CT ABD Pelvice-iv only – Moderate extrahepatic biliary ductal dilation without visualized obstructing mass lesion no intrahepatic biliary ductal dilation, differential of which includes stricture, spasm, and non visualized ampullary stone. Correlation which cholestatic enzymes may be useful. Mild gallbladder distinction with mild to moderate gallbladder wall thickening without visualizing gallstones, differential of which includes mild cholecystitis. Moderate prominence of the extrahepatic bile ducts with maximal diameter of the common hepatic duct of 11mm and maximal diameter intrapancreatic portion of common bile duct of 11.55mm…without visualized obstruction calculus or mass lesion. No intrahepatic biliary ductal dilation.
*11.4.21 MR MRCP Details – There are 203 small hepatic cysts (largest in the posterior segment – 17,, with o suspicious hepatic mass or concerning lessons, stomach and spleen, and pancreas are unremarkable – not sure what organ cysts are on but later ultrasound indicates there are cysts on liver… Mild GB wall thickening, mild CBD prominence (10 mm series 5,) which tapers smoothly to the level of the ampulla, MRCP imaging demonstrates no filling defects to suggest choledocholithiasis.
* 11.4.21 – OR Cholangiogram intaop rad details, nine-spot images under fluoroscopy were reviewed, no fillings defects are noted in the common bile duct, dilation of the common bile duct is noted
* 11.4.21 Gallbladder removed
* 02.09.21 Level 10 pain event – same symptoms / pain as before gallbladder was removed

BLOODWORK:

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Any thoughts that would lead her to a path to green? Are we even looking under the correct rocks (digestive related)?

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@davosmarsh

Any thoughts that would lead her to a path to green? Are we even looking under the correct rocks (digestive related)?

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Look into Median Arcuate Ligament Syndrome. It has very similar symptoms to a gallbladder attack. Pain in the same area and it can be quite severe. It's not picked up with conventional testing so it's easily missed. If the symptoms seem to fit, ask a GI doc about it and get them to order a mesenteric artery duplex ultrasound.

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I think she should have some repeat imaging done, looking for blockage of bile ducts.
I also agree that testing for MALS should be done.

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@jhmontrose & @astaingegerdm Thank you! She has an appointment scheduled with a GI doctor on March 2, 2022, and we will ask for the mesenteric artery duplex ultrasound /MALS scan as well as more imaging focusing on blockage of the bile ducts. This information is greatly appreciated, thank you again for your time and insight!!

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