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Ask Dr. D. Love Your Own Question

Dr. D. Love
Dr. D. Love, Doctor
Category: Medical
Satisfied Customers: 17509
Experience:  Family Physician for 10 years; Hospital Medical Director for 10 years.
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Right sided chest pain radiating to back shoulder blade, nausea,

Customer Question

Right sided chest pain radiating to back shoulder blade, nausea, sometimes right sided mid back pain. Abdominal area beneath right rib cage tender when pressed.
Lifts showed slightly raised alp
Ultrasound x 2 1st one showed gallbladder sludge, second one normal
MRI of bile ducts, gallbladder, liver pancreas all normal
Hida scan normal.
I have done quite a few gallbladder flushes which I find resolved my pain and discomfort for about 8 weeks then my symptoms return.
I find chocolate and cheese dairy worsen symptoms
Please help
Submitted: 2 years ago.
Category: Medical
Expert:  Dr. D. Love replied 2 years ago.
Hello from JustAnswer.
It will help if you could provide some further information,
Have you had an upper GI endoscopy (or esophagogastroduodenoscopy/EGD)?
Do you have the ejection fraction of the gallbladder on the HIDA scan?
Are you taking any chronic medicines? Were you taking these medicines when the HIDA scan was done?
Customer: replied 2 years ago.
I've had an upper gi and it was normal.
I'm not sure an ejection fraction was given. The consultant just said it was contracting normal. I was only given the injection for the tracer,I don't think I was given cck
Expert:  Dr. D. Love replied 2 years ago.
Since you know that an injection of CCK is sometimes given, you already know more about HIDA scans than most people.

With your history, it is worrisome for dyskinesia of the gallbladder. Dyskinesia is the medical term for abnormal motion, which in the gallbladder means abnormal muscular activity. One of the most sensitive tests to detect dyskinesia is the HIDA scan, and the ejection fraction of the gallbladder in response to the injection of CCK is one of the more sensitive aspects of the HIDA scan. The other factor that can be assessed with a CCK injection is whether it precipitates the typical pain, which is also a sign that the gallbladder is the source of the pain.

I also ask about medicines because there are certain medicines that can interfere with the HIDA scan, and the HIDA scan/ejection fraction would be more accurate if these medicines are stopped and out of the system before doing the HIDA scan.

If an endoscopy had not been done, then that clearly should be done, but since you had an endoscopy is not an issue.

It is also worth noting that it would be OK to perform a gallbladder flush every 2 months, if it helps to control symptoms.

But the next test that I would typically consider to ascertain the cause of your symptoms would be a HIDA scan with CCK injection and ejection fraction determination.

If I can provide any further information, please let me know.
Customer: replied 2 years ago.
So my hida scan went like this:
I went in, the nurse injected something into my arm, I them had to stand In front of a machine while pictures were taken for 2 minutes, this was repeated every ten mins maybe 3 times. I was then asked to eat a chocolate bar, cme back in 20 mins and stood in front of machine for another 2 minutes, then went home.
Does this sound to you that cck wax involved?
What is dyskinesia?
Do you think this could be liver related with the raised Alp?
Expert:  Dr. D. Love replied 2 years ago.
If you only had one injection, that would be the tracer, which is a nuclear medicine dye that is taken up by the liver and then passes into the gallbladder and ultimately into the small intestine, and they were timing how long it took to be taken up by the liver and then the gallbladder. They used the chocolate intake as a way to cause the bile to enter the small intestine to show that it passed into the small intestine. However, the response to chocolate is not a standardized as the response to a CCK injection.

A CCK injection would have involved a second injection, which you obviously did not have. There are a couple of ways that the CCK injection can be done, but in this country, the current recommendation is to perform an infusion of CCK over an hour.

Dyskinesia only means what I said above. It comes from the Greek, dys- = abnormal and kinesis = movement. The term can be applied to many different body parts, although when used alone, it typically refers to skeletal muscles. However, when applied to the gallbladder, it refers to abnormal muscular activity of the gallbladder.

The alkaline phosphatase is a liver enzyme, but it is elevated in situations in which there is a problem with bile drainage of the liver, so can be elevated from gallbladder disease or from conditions that press on the bile duct before it enters the small intestine, such as from pancreatic swelling, or a tightness at the entry into the small intestine, such as a stricture or spasm of the sphincter.
Customer: replied 2 years ago.
So you think this is gallbladder related?
Why would I have relief after the flush only for the symptoms to come back again after an average if 8-10 weeks?
Would this be because I am emptying the gallbladder if sludge etc then it gradually fills up again?
When I do the flush I pass a lot of green coloured pebbles ranging in sizes. What are these?
Expert:  Dr. D. Love replied 2 years ago.
Yes, as I said above, with your history, it is worrisome for dyskinesia of the gallbladder.

Relief may be transient because it is cleaning out the gallbladder, but the gallbladder will return to the prior condition over time. Whether it is sludge cannot be determined. It is possible that there could be a small amount of sludge that cannot be detected by the ultrasound, but it also could be inflammation or low level infection of the gallbladder that eases with cleaning, but slowly recurs.

The green coloured pebbles are likely bile that has coalesced into pebbles as they pass through the gut. Bile is naturally green in colour, and the colon reabsorbs water, so can make the bile form what appears as pebbles. It does not mean that there are similar pebbles in the gallbladder, which we would call stones, since stones would typically be detected by an ultrasound.
Customer: replied 2 years ago.
Would anything detect inflammation or low level infection? Inflammation is what I suspect but obviously I am not a doctor!
Expert:  Dr. D. Love replied 2 years ago.
The current evidence is that the inflammation or low level infection is what causes the dyskinesia. There is no test for the inflammation or low level infection, per se, or at least not until the gallbladder can be looked at under the microscope after surgical removal. Instead, we test for the signs that are related to the inflammation or low level infection.

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