Time Bomb No.2, please

Monday – 13th March 2017 – off to see my GP to get a prescription for Colesevelam, a bile acid sequestrant. He greeted me with “bloody hell, you look well!”  I didn’t understand the reason for his comment until later. We agreed on the new drug and he also reviewed my existing medications. So far so good.

He had been reading my medical record, the last entry of which was a trip to A&E with jaundice.  He had assumed that I was back to see him with a recurrence of the  problem, hence his comment. He asked me what the plan was following discharge back at the beginning of February. As far as I was concerned I had undergone a follow-up ultrasound scan and it was now matter closed. Clearly he thought there should have been some follow-up. He was rather miffed that I had heard nothing and said that he would chase it up.

We then had a fairly lengthy discussion on gallstones and surgery to have my gallbladder removed. That was a bit of a shock. I had gone in to get a prescription and come away with a referral to see a surgeon. Not what I was expecting. I managed to book the referral for 3 weeks time

Wednesday 5th April 2017 – East Surrey Hospital

This was going to be another one of those “interesting” appointments. I hadn’t been to see a surgeon since 2011. It would be with someone I hadn’t met before and I knew from experience that much of a first appointment would be taken up with the new doctor rapidly trying to assimilate my medical history. I thought I might help this process by producing the diagram below.

Unfortunately the doctor had already read my notes before he called us in so my diagram did not have its intended benefit.

My wife accompanied me as surgery and recuperation obviously affects all the family, not just the patient.  We were greeted by the new consultant who turned out to be a professor. I had produced a list of questions based on the BARN principle – Benefits, Alternatives, Risk or do Nothing (or what’s Next?). Our discussion  covered many aspects of gallbladders and the biliary system. I’ll use my list to organise them into subjects.

BENEFITS

What would be the advantage of having galbladder removed? No more gallstones and therefore no more risks associated with them.

Would the operation be laparoscopic cholecystectomy (keyhole) or open surgery? What are the deciding factors? Due to my previous surgery and the likelihood of extensive adhesions it might not be possible to use keyhole techniques. The only way of seeing what adhesions are present would be by inserting a camera into the abdominal cavity.

What are hospital and recovery period for open surgery? Usually two days in hospital and two weeks recuperation.

BAM currently well controlled by 2 capsules of Loperamide/day, would losing my gallbladder mean starting on Colosevelam? No. It should not affect the current situation

ALTERNATIVES

Is there an alternative to surgery ie. ERCP? ERCP only suitable for removing stones from ducts once they have left the gallbladder.

We could do nothing – see below

RISKS

Any risks specific to gallbladder removal? There would be the usual risks of surgery but given my other conditions :

Portal Vein Thrombosis
Cirrhosis
Crohn’s DIsease
Bile Acid Malabsorption
Thrombocytopenia

They could cause additional complications. He was specifically concerned about thrombocytopenia (low platelets) and the chance of losing a large amount of blood during the procedure. He was also concerned about potential liver damage and noted that I already had the start of cirrhosis.

(As an aside – BAM could actually be helping my condition as there is less bile for recycling)

Given my past experience could surgery lead to post operative ileus? With keyhole surgery it is unlikely but there is a possibility with open surgery.

do NOTHING

What happens if we do nothing? It was finely balanced as to which course of action would be best. As I was asympytomatic and feeling well then maybe this was the option to choose. Ultimately it would be a joint decision between the consultant and myself.

Can “do nothing” cause long term damage to other organs? If another gallstone escaped from the gallbladder then the amount of potential damage  would depend where it came to rest. He drew a simple diagram to illustrate his point. If the stone lodged just below the gallbladder then it could cause it to expand. If it lodged further down the system at the sphincter where the stomach joins the duodenum then it could cause cholangitis (inflammation of the biliary ducts) and/or pancreatitis (inflammation of the pancreas). Both are very serious conditions.

What would the warning signs be? Pain in the right side, maybe stretching up to the shoulder. Skin and whites of eyes turning yellow. Usually the pain would be severe which is why it was strange that I felt nothing during my recent episode of jaundice.

NEXT steps

He put in a request for a further ultrasound scan (locally) but would be recommending that I was referred to a hospital with a dedicated, specialist liver unit due to his concerns about the potential risks of an operation ie.  needing a liver transplant if things went badly wrong!!!! I asked him to discuss this with my gastro consultant at St. Thomas’ Hospital.

In future I must try and avoid fatty or spicy foods as these could cause the gallbladder to contract which might, in turn, expel a stone into the ducts.

When I returned home I emailed my consultant at St. Thomas’ to give him an update on my situation and explain about being referred to a dedicated liver unit. I also asked if the results of the recent biopsies (taken during a colonoscopy) were available and whether my liver stiffness should be the subject of ongoing monitoring.

Time Bomb No.2

Maybe it’s being slightly over dramatic but it does seem that I am now carrying another time bomb around with me. No.1 – the esophageal varices – have now been joined by No.2 – gallstones. If the varices burst, again, or another gallstone gets stuck then they will needing emergency hospital admission…. but the sun has been shining all day so let’s not get too hung up about it.