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Julia Kizhner
Julia Kizhner, Physician Assistant
Category: Health
Satisfied Customers: 1126
Experience:  7 years experience working in Primary Care as well as Gastroenterology, Sleep Medicine & Weight Loss
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Hi Julia, Ive returned to give an update regarding my ongoing

Resolved Question:

Hi Julia,

I've returned to give an update regarding my ongoing GI issues, and to get your advice.

As you may recall, I had a colonoscopy and EGD a little more than two months ago. The colonoscopy was clear, but the EGD showed a small hiatal hernia, gastric ulcer and several areas of erosion. I was placed on 20 mg daily of Prilosec, and told to return for a follow-up EGD.

Since then, I have continued to have bouts of diarrhea and constipation, often with tan/yellowish stools. In addition, the gnawing pain in my stomach seemed to get progressively better. However, I continued to have dull URQ pain that would radiate to my back and flank. I had asked both my PCP and GI doc about the possibility of a gallbladder issue. Both reassured me that past ultrasounds showed no stones.

Because the stool issues and URQ pain didn't subside, I called and spoke to my GI doc's nurse about what to do. She said she would talk to the doc and get back to me. The next day, she called to tell me that my GI doc wasn't sure what to do with me, because the ultrasounds were clear. She said they would refer me to another practice that could do some testing they couldn't. Puzzled about this strategy, I asked about having a HIDA scan first. The nurse said she would consult the doc and get back to me. Apparently the doc had a change of heart and agreed to the HIDA scan. Lo and behold, my ejection fraction was only 14%!

My GI doc then referred me to a surgeon, to discuss the prospect of having my GB removed. I trust this doc, because he removed my appendix and is highly regarded. Thus, I'm scheduled to have it done on 8/11. Putting the pieces of the puzzle together, it now makes some sense, why I was having the diarrhea and URQ pain.

I just had the follow-up EGD last Tuesday, to look at the healing progress of the ulcer, and the GI doc said it is completely healed. However, this seems weired because the gnawing stomach pain has come back. Along with it, seems to be some reflux, which I had experienced many times in the past. But, I'm left to wonder how this can be, if the ulcer is healed? Is it possible to have these symptoms, following a normal EGD?

The EGD report didn't mention anything about whether the erosions healed, or anything else for that matter. However, I would assume if there was anything else noteworthy, it would have appeared on the report.

I'm concerned that if everything in my stomach is okay, that the pain is due to something else. Maybe my small bowel, or something related to my pancreas due to my GB issues. No stones were found in my GB.

Like when this whole odyssey started back in mid May, the gurgling and stomach pain has recently returned. I have a stomach ache nearly all the time. The problem with my stools seems to be better, in that I'm not having regular diarrhea.

I'm so confused, and don't have a ton of faith in the GI doc. In fact, I'm afraid to call her back and tell her about the recurrence of stomach pain, because she will think I'm crazy.
Submitted: 3 years ago.
Category: Health
Expert:  Julia Kizhner replied 3 years ago.

Hi there,

Sorry for not getting back to you sooner. We moved this weekend and I had no internet connection at home.

I am glad you pursued the issue with HIDA scan, it is often an under diagnosed and ignored condition. 14% is a very low gallbladder function and definitely explains your RUQ pains.

 

My question is this...are you still taking Prilosec? Are the pains that you have now located all over your abdomen or more concentrated in the area of upper abdomen (epigastric)? Are these pains separate from reflux you are having? Do you feel bloated?

 

 

Customer: replied 3 years ago.
Between getting married and moving, it sounds like you've got your hands full! So thanks for getting back to me.

This pain is a gnawing type of pain that seems to be slightly left and a little above my navel. It waxes and wanes a bit. As I mentioned, I think that I'm having some reflux as well. Lately, I have what feels a little like a lump in my throat and a little heartburn. I had similar symptoms back in 2006, and was told by my ENT after a scope of my throat, that it was reflux. The only other symptom that I've noticed is an increase in saliva. But, it's not horrible.

I'm still taking 20 mg of Prilosec before both breakfast and dinner. I've also added some Mylanta once in awhile. On top of this, I'm still eating really bland. The only benefit, is that I continue to lose weight. I'm 5'8 and weigh about 215, so I've still got a ways to go.

I've been much better about obsessing about my health over the last month or so. But, it's tough because I still have these issues, and feel like without my persistance and cyber-sleuthing, I wouldn't have figured out I have a GB problem. Thus, I feel compelled to try and solve this gnawing stomach ache. On the other hand, having two EGD's and a colonoscopy recently makes me feel like either something has been missed, I haven't had the right tests or it's simply something I have to live with. I just don't get why I'm still having this pain while taking Prilosec for two months? Apparently it must be working somewhat if the ulcer healed.

I know it's impossible for you to diagnose someone remotely. But, hopefully I'm providing you with enough of the story to get a sense of hat is going on. So far, I have more trust in your opinion than my GI doc.

Should I be asking for some other tests or meds? Should I continue to live with it and see if it goes away? Should I find another GI doc? What is your experience with the success of GB removal? I'm not really nervous about it, but concerned because I've read that as many as 20% of people don't get a resolution to their symptoms.
Expert:  Julia Kizhner replied 3 years ago.

Thanks for the additional information. Yes, my life has been crazy, on top of getting married and buying a house and moving, I am also 7-months pregnant :) I cannot keep up with all the things happening :) Now, to more serious things.

 

Knowing that you had a normal follow-up endoscopy and colonoscopy is very reassuring. However, just because you had a normal endoscopy (showing healed ulcer and no erosions), it doesn't mean that you cannot have reflux. Reflux is independent factor from ulcers/erosions. It is possible that Prilosec is not very effective to reduce your reflux so you might need to be switched to a different medication such as Nexium or Protonix (both are available by prescription only) or you can try adding Pepcid AC instead of Mylanta.

 

When you had an ultrasound of your gallbladder, it also looked at your liver and pancreas (it usually always does). If there is no report of any abnormalities, I highly doubt there is something wrong. Usually pain which is secondary to pancreas problems is up higher (epigastric area) and can radiate to your back. I dont think there is a problem with your pancreas, however, to be certain, CT scan of abdomen is not a bad idea. Sometimes on the ultrasound, pancreas is obscured by gas and is not fully visible.

 

Given the fact that most of your dull pain is around your navel points more in the direction of IBS (since besides small intestines, there is nothing else there).

 

You are correct about not 100% success rate following GB removal, however, its a guessing gain into which percentage you are going to fall. Since you are symptomatic with RUQ pain, I would definitely recommend removing GB. At least that should solve a part of your abdominal pain.

 

It sounds that you have 3 things going on - 1. Reflux, 2. Gallbladder, 3. IBS. Each one needs to be treated independently of the other. Following GB removal, if your pain continues, you might consider treatment for IBS. There are so many different options available now-a-days. You can even consider treatment for IBS even prior to GB surgery. For reflux. I think you should either have your prescription changed or try Pepcid instead of Mylanta.

 

Let me know if you have any other questions. I do have to step away from the computer for about an hour but will be back after 1:00.

 

Julia

Customer: replied 3 years ago.
WOW! Congrats on the baby! Like you, my wife and I moved when she was pregnant. She gets mad at me over that, and it was more than two years agoLaughing

We have a little boy that just turned two this past Saturday. In fact, he and I share a birthday...except mine is 40 years before his. Our son had colic for the first year, and didn't sleep through the night until he was about 11 months. So, it was really difficut for my wife and me. Many mornings I would come downstairs to leave for work, and the two of them were on the couch crying.

He was born with Torticollis, which was eventually fixed with PT. Between the colic, Torticollis and him not sleeping or latching, I thought we were going insane. On top of it, my poor wife was pumping like crazy, all hours day and night. She finally got to a point where she said the sound of the Medela pump was almost taunting her.

The upside is now we have a healthy two year old that is into everything and learning something everyday. If you've had other kids, you may have been through some of this already. If not, it's going to be the most rewarding thing you've ever done.

Sadly, my health issues are what's standing in the way of Chace getting a sibling. My wife is 40 and just has a few ticks left on the clock. Of course, I feel immense pressure about letting both of them down, due to my poor health. Last year, I had to have sinus surgery and then developed Epstein-Barr. So, between my health and our son, my wife was about ready to go on a permanent vacation.

Aside from the stomach pain, perhaps the biggest struggle is actually related to my diet. The GI doc gave me a list of foods to stay away form because they could exacerbate the stomach issues. At the same time, I have to be really careful about what upsets my GB. As I mentioned, I'm losing weight, which is awesome. But, chicken and white rice can only be cooked so many ways!

I noticed that you have experience with weight loss, and wonder given your GI experience, if you have any suggestions? Right now, my diet consists of the following: rice (mainly white, cuz too much whole grain seems to make things worse), chicken, rice & chicken soup, white bread, bananas, eggs (mainly whites), graham crackers, plain salad with a tiny amount of vinagrette and Dasani water. I stopped taking my Centrum multivitamin, cuz it seemed to upset my stomach. I don't even dare take my wife out to dinner, because there isn't anything I confident about eating. Straying from this narrow list, definitely has its pifalls!

I should also mention that my URQ pain has never been nearly as severe as others I have talked to or read about. This makes me wonder if removing the GB is necessary. Don't get me wrong, it does give me some nagging pain, gas and bloating. But, I wonder if that's enough to warrant having it removed. I read horror stories about people that end up with chronic diarrhea after having their GB removed. Yet, I also read about folks that describe how much better they feel since having it removed. At this point I'm still planning to go through with it, but would welcome your thoughts.
Expert:  Julia Kizhner replied 3 years ago.

We are having a boy as well. Its a first one for me so it is kind of scary but exciting at the same time. Any illnesses in such little people are scary so I completely understand how your wife felt when he didn't feel well).

 

I really dont think that your health should be stopping you from having another baby. You do have some resolvable issues, thankfully nothing permanent or disabling so having another addition into the family will bring everyone joy.

 

In terms of diet: I dont think you need to be on such restricted diet. For gallbladder, you need to avoid all greasy/fried foods, otherwise there are really no certain recommendations. For acid reflux the foods that you need to avoid are such: any tomato based products (especially meat/marinara sauces), pizza, spicy, citrus, chocolate, coffee, and mint. I dont really think you need to keep your diet so "blah". You can have fish, shrimp, turkey, lean red meat. Just make sure it is broiled or grilled or sautéed. You can have vegetables (other then tomatoes) as well as fruits. You can have regular eggs, oatmeal, cereal (fiber preferred). There are plenty of things you can eat. If you have more specific food questions, let me know, there is so much information available that I am just giving a generalized answer but would be happy to go into detail if you wish.

 

In terms of removing your GB: There is definitely no urgency in having it done. Maybe first you can concentrate on getting your reflux under better control and treating IBS. There are many medications available for IBS. Most of the IBS drugs are also used to treat anxiety and because IBS is considered a "nervous gut", these medications are quite helpful. However, some of them may have some sexual downfalls, such as decreased libido, inability to have an orgasm and others. These effects are transient, once you stop the medication, side effects go away as well and it is not guaranteed that you will get these side effects so if you think that your health right now is more important, you might give it a shot. One of my favorite medications for IBS is Lexapro. It is a 10 mg once daily pill, can also be taken at 5 mg. It is associated with least amount of overall side effects. Another medication which can work well but has more side effects is Amitriptyline. This medication needs to be started at a low dose (at bedtime) and titrated up).

If getting reflux and IBS under control satisfies you and your RUQ pain is not very bothersome, you might not need to or want to go through gallbladder removal. I still think you should have a consultation with the surgeon though. Chronic diarrhea is not common following GB removal although does exist.

 

I will not have access to internet until tomorrow again so if I dont get back to you right away, please excuse me. Our home internet will not be ready till August 5th.

 

Julia

 

 

Customer: replied 3 years ago.
As always, thanks for the help!!!!

My wife cried during the ultrasound when told we were having a boy, because as she put it "I don't know what to do with a penis" and "I can't believe there is something growing inside me that has a penis." Of course, now she can't imagine life without her little momma's boy. If we were to have another, I would secretly want a girl, but would be thrilled with a healthy baby regardless of sex.

Since our last exchange, I got a follow-up call from my GI docs nurse, and I explained the symptoms of pain. After consulting with the doc, she called back and said they would like to do a capsule endoscopy. Apparently, there can be something in the small bowel that causes similar symptoms. However, she didn't elaborate on what those things might be.

She said they would do it this week, which makes me wonder about whether I should postpone the surgery, currently scheduled for next Wednesday. In case they found something in the small bowel that needed surgery, I wouldn't want to have two procedures, if it could all be done at the same time. Does this make sense, or is it unlikely that a general surgeon would work on the GB and SB at the same time?

If this test comes back normal, I would think that there is not much more that could be tested for?!

I may have forgotten to mention that I did meet with the surgeon, and he is the same guy that removed my appendix in 2005. When I met with him, he said that he wasn't going to push me one way or the other, as to whether I should have my GB removed. Essentially, he told me that I could call him when I've gotten tired of dealing with the symptoms. I asked if he has ever had any patients that had any surgical complications, and he said only one in the 15 years he has been doing them. And that was a woman that had a very complicated anatomy. He also said that GB removal is the one procedure that causes him the most anxiety, because there are so many critical structures in that area. But, he went on to tell me that he is very meticulous and does 150+ a year. In fact, he said in the last year he has only had to do one open procedure.

The laproscopic procedures are done on a same day basis at this hospital. I do trust the surgeon and the hospital. I just don't know if I should wait until after the capsule test, or move forward and get the GB done now, and hope that alone helps some of the problems????
Expert:  Julia Kizhner replied 3 years ago.

I dont think small bowel capsule study will show anything, however, since you are getting it done this week, you can postpone surgery. If there is something wrong with small intestine (which, again, I dont think there will be), the same surgeon will take care of both things and can do it at the same time.

 

You might also want to postpone surgery if you would like to see if different therapy for reflux and new therapy for IBS will take care of most of your symptoms. There is no urgency in getting your GB removed, I do agree with the surgeon.

 

GB removal (called cholecystectomy) is one of the most common procedures done by the surgeons now-a-days. You will be in the hospital for a 23-hour observation following laparascopic procedure, you will not go home the same day. I also dont know of anyone who had cholecystectomy to have any kind of complications with the surgery.

 

I would love to know what small capsule endoscopy shows, if anything. Let me know know.

 

 

Customer: replied 3 years ago.
Thanks Julia!

When the surgeon said it was done on a smae day basis, I was a little shocked. He said that as long as ther are no surgical complications, you come in the morning and leave in the late afternoon. After doing some checking with other hospitals here in the Twin Cities, it appears that many are the same way.

Is this not good? Of course, no one wants to be in the hospital if they can help it (excluding those that work there). But, maybe I should reconsider using this doctor or hospital??
Expert:  Julia Kizhner replied 3 years ago.

I dont think you should reconsider. Maybe surgical procedures changed since I was doing my surgical practice but in the past it was that you stayed in the hospital for a 23-hour observation. The only reason for it was to make sure there arent any complications that develop following surgery and also because they put a tiny draining tube and take it out before you leave. But maybe it has changed especially if other hospitals are now doing it the same way.

 

I would still wait for, at least, results of your small bowel capsule study. Usually that takes 48 hours after getting it done so you might even get the results before your scheduled surgery.

Julia Kizhner, Physician Assistant
Category: Health
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Experience: 7 years experience working in Primary Care as well as Gastroenterology, Sleep Medicine & Weight Loss
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