Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Sunday, April 01, 2007

Marble Dinosaur Egg: Biliary Symptoms

"Clinical Pearl", "Marble Dinosaur Egg"; all the same.


In the wake of Sid Schwab's most recent post about the surgical aspect of the gall bladder, I'd like to toss in something about how you can tell that your patient could benefit from Sid's tender ministrations instead of a few weeks of some wonder drug.

Biliary symptoms are by definition things that are caused by some malfunction of the gallbladder, by stones, bile duct obstruction (stones or tumors) and/or that mysterious entity to which Sid alluded, sphincter of Oddi dysfunction. Those symptoms, though, can include nausea, vomiting, pain in assorted locations and other more unusual kinds of gastrointestinal-type distress. How is one to know that a given patient's queasiness and right shoulder pain is in fact related to the gall bladder and not to the seafood salad and pick-up football game at Sunday's picnic?

When symptoms are "typical" -- nausea, vomiting, right upper quadrant pain 2-3 hours after a fatty meal in a fat, fortyish, fertile, flatulent female -- well, the janitor on Scrubs could make that diagnosis. The problem is that biliary symptoms often present atypically.

(An aside in the context of Zebra diagnoses: as a general rule, common things present uncommonly more than uncommon things present at all. What this means is that weird symptoms are more likely an atypical presentation of something ordinary than a zebra.)

There's an old, probably apochryphal, story of the GP who diagnosed his 45-year-old male patient with left shoulder blade pain with gall stones. How did you know it was gall stones, asks the incredulous housestaff. Simple, replied the old-timer. That's how his father's gallstones presented, and his grandfather's gallstones and his uncle's gallstones.

Here's the key: while symptoms may be atypical (epigastric pain instead of right upper quadrant is common) it's the timing -- post-prandially (after eating) -- that usually indicates the biliary tract as the source of symptoms. Whenever you have a patient with any kind of gastrointestinal symptoms about 2-3 hours after eating (if it's a fatty meal, it's a gimme) think gall bladder early. Ultrasounds are cheap, usually easy to get and generally very reliable for this diagnosis.


At Sun Apr 01, 10:31:00 PM, Blogger Sid Schwab said...

Gallbladder should certainly come to mind, allright. As should the fact that a great many people have their biliary-originating pain unrelated to fat or to meals at all. Awaking at one or two a.m. with biliary colic is a very frequent presentation. And I can't count the number of consults I've had on patients in the CCU, admitted to r/o MI, cleared, and found to have gallstones. The good news is we have surgeons to clear up the confusion...

At Sun Apr 01, 10:48:00 PM, Blogger Sid Schwab said...

I should have added this: the nature of the pain is at least as important as the timing: true colicky pain is a pretty good cohort. Also, at least in my experience, biliary pain is typically closer to a meal than 2 or 3 hours, when it's in fact related to eating. More like half an hour or hour. By the time two or three hours goes by, you're thinking partial SBO, gastric ulcer, etc. But as you rightly said: typical presentations aren't all that typical.

At Mon Apr 02, 06:39:00 AM, Blogger #1 Dinosaur said...

Actually, Sid, my point is that it's the nature of the pain that is often atypical. That's the idea behind "anything post-prandial, at least look at the gall bladder early."

At Mon Apr 02, 11:48:00 AM, Blogger Sid Schwab said...

Fair enough!

At Tue May 08, 01:39:00 PM, Anonymous Anonymous said...

Quite a few years ago I went on a fat-free diet, and it was truly fat-free. After a couple of weeks, I woke in the middle of one night with such stomach pain I couldn't move. I was alone, my youngest child having gone off to college 6 months before. I reconciled myself to death (a huge first for me), but eventually it eased enough for me to fall asleep. Next day, I was fine and did not consult a doctor. I decided the fat-free diet caused it, and began to include fats in my eating again. I've never had a repeat of that experience, not in two decades. My docs say I'm one of the healthiest people they know. This has always been true. Could it really have been the totally fat-free diet that caused the 'attack'? This is the first time I've ever mentioned it to anyone.

At Fri Aug 17, 07:43:00 PM, Blogger BillyBob said...

But what if your 'gallbladder pain' turns out to be an atypical bout of say... end stage liver disease, like mine?

At Fri Aug 24, 12:25:00 AM, Anonymous Anonymous said...

yeah, re the FFF (fat, female, forty) canard (i'll leave out flatulent since, in my 51 years of living, you XY types carry the flag on that one) vis-a-vis gallstones: i dieted my whole life, extremely, w/o being able to avoid my fat destiny (for which i compensate with exercise and good nutrition). about 10 years ago i had a series of gallbladder attacks (i have had them since the beginning of my crazy dieting in my 20s), during which i prayed for death. my PCP told me to cut fats in my diet to 20%, then 10%, then 0% (NOT fun!). during the latter phase i had the worst attack of my life. i would have begged Death for the sickle and done myself in. the surgeon i consulted (about age 60) said that the % of fat in the diet is NOT a reliable means of predicting or controlling gallstone and GB attack behavior. he said, "if they're going to move, they're going to move, no matter what you eat." 10 years later, i still have them (they are calcific and fill the lumen, even though fluid is present as a sonographer i like to "visit" them now and then), but have learned to eat so as not to piss them off. Internal Detente, i call it. ---timbre440, BA, RDMS

At Wed Dec 26, 03:06:00 PM, Anonymous Anonymous said...

I don't really like fat-free dieting!


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