Gallbladder Polyps

[Guest ABMWannabe]

Hey Flight docs,

I'm an active duty cross-trainee with a class III medical, currently awaiting ABM training. A few months ago, I started experiencing some pretty intense GI issues to include constant indigestion/ & reflux w/associated chest pain (stress test ruled out cardiac), nausea, stomach pain, and back pain (right shoulder and between the shoulder blades). I was placed on medical hold after I arrived to Tyndall. Of primary concern was the reflux, which has been resistant to every medication in the book (I'm currently on protonix), and which was discovered to have caused some moderate gastritis and esophagitis upon endoscopy (although the esophagitis has cleared up as indicated by a second scope). Flight medicine sent me to a GI specialist in an attempt to discover the root cause of all this stuff, and the specialist put me in for a bunch of tests to include esophageal pH monitoring (which verified pretty severe reflux), an abdominal ultrasound, and a HIDA scan w/ CCK injection. I got word today that the gallbladder tests found that I have "gallbladder disease" (nurses words on the phone) as indicated by multiple gallbladder polyps. The nurse didn't say how many there are exactly or how large they are , but they have referred me to a surgeon for gallbladder removal. With all that said, here are my questions:

1. My flight doc already told me that I will require a waiver for the history of esophagitis/gastritis/reflux, but said that they should be pretty easy waivers to get as long as another scope shows they have cleared and if the reflux symptoms are under control. Assuming that these gallbladder issues are the root cause of everything (I never had reflux issues before all of this started), and that all of my symptoms/issues go away with gallbladder removal (which the specialist seems to think will be the case), how long do you think I will be down before I'll be cleared to start training? Obviously, there is time needed for waiver processing and what not, and I know they will have to do another scope to see if the gastritis is gone (so said my flight doc ), but I guess the real question is how long do they usually ground flyers after uncomplicated gallbladder removal? Also, am I correct in assuming that gallbladder removal is a waiverable issue? I'm assuming that from reading other posts I found in the forum.

2. I read that gallbladder polyps can sometimes be pre-cancerous or cancerous, and that the only way to tell is via a biopsy. Do you think flight medicine will require a biopsy to determine if the polyps were malignant or had malignant potential, and do you foresee any additional DQ issues if the polyps turned out to be cancerous or pre-cancerous? I would assume that removing the gallbladder would make it a mute point, but would a history of cancerous or pre-cancerous polyps be an issue?

Thanks in advance for your insight.

[Guest F16PilotMD]

Cholecystitis (gall bladder disease) and gastroesophageal reflux disease (GERD) are both extremely common. That said, they occur together a lot. They have some similar symptoms but a gall bladder attach is a no brainer. Your symptoms are from your gall bladder, I'll bet. You may have reflux as well. Some reflux is not symptomatic. Having your gall bladder out is pretty easy and not a flying problem. Reflux requires a waiver. I wouldn't worry about the polyps being cancer. The polyp-cancer association is a carry-over from colon polyps leading to cancer. Much less is known about GB polyps. Many times they end up being simple gall stones at the time of surgery.

Things I would want to know:

Did the HIDA scan cause you any symptoms? If it caused your symptoms to occur....diagnosis is made.

What was your "ejection fraction" on the HIDA? If it was below about 30%, you GB is bad. If it's <30% AND you had symptoms, case closed.

Was your GB wall thickened? >3mm thick = chronic inflammation....probably needs to come out.

Did Protonix stop your symptoms? If NOT....it's likely NOT reflux. If it did work, likely it IS reflux.

[Guest ABMWannabe]

Cholecystitis (gall bladder disease) and gastroesophageal reflux disease (GERD) are both extremely common. That said, they occur together a lot. They have some similar symptoms but a gall bladder attach is a no brainer. Your symptoms are from your gall bladder, I'll bet. You may have reflux as well. Some reflux is not symptomatic. Having your gall bladder out is pretty easy and not a flying problem. Reflux requires a waiver. I wouldn't worry about the polyps being cancer. The polyp-cancer association is a carry-over from colon polyps leading to cancer. Much less is known about GB polyps. Many times they end up being simple gall stones at the time of surgery.

Things I would want to know:

Did the HIDA scan cause you any symptoms? If it caused your symptoms to occur....diagnosis is made.

What was your "ejection fraction" on the HIDA? If it was below about 30%, you GB is bad. If it's <30% AND you had symptoms, case closed.

Was your GB wall thickened? >3mm thick = chronic inflammation....probably needs to come out.

Did Protonix stop your symptoms? If NOT....it's likely NOT reflux. If it did work, likely it IS reflux.

Did the HIDA scan cause you any symptoms?

I was having pretty bad symptoms when they did the test, so I can't really say for sure. However, I can definitely say that the CCK injection made the stomach cramping (especially in the GB area) much worse...so bad I was kind of groaning for 2 or 3 minutes

What was your "ejection fraction" on the HIDA?

Havn't gotten the official results yet, just a preliminary "your being scheduled for a surgery consult ASAP due to GB disease" from the specialist's nurse. I meet with him on Friday, so I should get my ejection fraction then.

Was your GB wall thickened?

Still nothing offical until Friday, but during the ultrasound I overheard the techs mention something about thickening when they were looking at the GB ; they spent some extra time measuring the wall thickness. I would bet something along those lines was occuring.

Did Protonix stop your symptoms?

That's a big no. This has been going on for months now (I was seeing family practice before I left, hence the slow time to diagnose :), and they have tried me on everything from zantac to aciphex to protonix. Nothing has worked. I'm currently on 40mg of protonix twice a day (have been for a month and a half) and still get reflux/chest pain constantly. Before this started, I had never once had heartburn or reflux (or at least that I noticed), and then in the course of a weekend I started getting reflux all day, everyday (chest pain so bad that I went to the ER when it first started). OTC antacids do nothing either.

Also, I have major gallbladdr issues in my family (mom's side); my mom, grandmother, grandfather, and aunt all had to have their gallbladder removed for gallstones. I'm no doctor, but I think I can agree with you that the specialist is on the right track. I'll post my offical test results on Friday (if you're interested).

The one thing that still concerns me is the gastritis; my flight doc says it has to go away with resolution confirmed by endoscopy before proceding with waiver. From your experience, would you say the gastritis has a pretty good chance of getting better after the GB removal? (If this is, in fact, my GB). I'm also on carafate to help with that issue.

Thanks, Doc!

[jcj]

ABMWannabe -

I am not a flight surgeon or AME. I am a pilot and a general surgeon (I do gall bladder surgery regularly). Although GERD (reflux) symptoms and gallbladder symptoms overlap as noted by F16PilotMD, what you have posted sounds to me to very likely to be from your gallbladder - the medical term is biliary colic or chronic cholecystitis - and based on what you've written I agree completely with the recomendation for cholecystectomy (gallbladder removal). The fact that you still had symptoms after endoscopy showed healing of the gastritis points strongly to gall bladder disease as the cause of the symptoms. The test results you mentioned also suggest gallbladder trouble rather than reflux.

Most surgeons can get the gall blader out with the laparoscope >90% of the time. If you are one of the few that has to have an open operation (usually because the gall bladder is too inflamed to safely remove with a laparoscope) you will have a bigger scar and a slightly longer recovery, but you'll still get over it fine (assuming surgery goes well and no complications - the complication rate with the surgery is very low but not zero). I can't speak about the military side, but in the civilian world you're good to go after complete recovery from successful surgery, laparoscopic or open. I don't know any reason why the military would be different.

Gallbladder "polyps" do exist, but usually things that are thought to be gallbladder polyps on ultrasound are actually gallstones. Gallbladder cancer also does occur, but is very rare (I've seen two cases in 11 years of practice as a general surgeon). The gallbladder and it's contents will be completely removed during your surgery. After the surgery, your gallbladder will be carefully checked by a pathologist - including looking at it under a microscope - to be sure there's no cancer. Gallbladder cancer is a big deal but it's so uncommon that I tell my patients not to worry about it - but we check every time to be sure.

Laparoscopic cholecystectomy is usually an outpatient operation (or overnight stay) and about 2 weeks until you are pretty much back to full speed. If you have to have an open cholecystectomy, expect to be in the hospital 3-4 days and about a month before you are close to completely recovered. These are expected times to get back to "normal" activity. I don't know how long you might be DNIF.

good luck

[Guest ABMWannabe]

Forgot to add - laparoscopic cholecystectomy is usually an outpatient operation (or overnight stay) and about 2 weeks until you are pretty much back to full speed. If you have to have an open cholecystectomy, expect to be in the hospital 3-4 days and about a month before you are close to completely recovered. These are expected times to get back to "normal" activity. I don't know how long you might be DNIF.

Outstanding information all around....much thanks to all!

[Herk Driver]

Forgot to add - laparoscopic cholecystectomy is usually an outpatient operation (or overnight stay) and about 2 weeks until you are pretty much back to full speed. If you have to have an open cholecystectomy, expect to be in the hospital 3-4 days and about a month before you are close to completely recovered. These are expected times to get back to "normal" activity. I don't know how long you might be DNIF.

I'm no doctor, but I did stay at a Holiday Inn Express last night.

The symptoms that you relayed are the same symptoms that a friend of mine had. It was misdiagnosed as GERD. A later IBS diagnosis was added. This friend had three different reflux meds to treat the GERD and none of them ever helped at all. Finally, this friend got a proper diagnosis and did the same Nuke test that you had. The ef was 10. Luckily, this person was able to have the gallbladder removed the next day. It was an open operation and was an outpatient procedure. This particular doctor uses a self-perfected open procedure on all his gallbladder patients. My friend went in that morning at 0800 and was at home by 2 pm. Within 4 days this friend was up and about and within about two weeks was in no discomfort whatsoever. I realize that this is not common, but even an open operation is not that big of a deal.

There do not have to be stones to have a diseased gallbladder. There can be fine crystalline-like particles or "sludge" in the gallbladder that will elongate the tubes of the gallbladder making it more and more difficult to accomplish its' mission. That is what happened here and from talking to several other people that have had this same problem, it happens more often than you might realize.

All the GERD and IBS symptoms have sense gone away. It seems to me that gallbladder disease is a very misdiagnosed problem as there are many symptoms that are common to other ailments. Just my uneducated $.02.

Good luck. Hopefully your other symptoms will go away and someone will decide that your reflux and other symptoms were simply misdiagnosed.

[Guest ABMWannabe]

I'm no doctor, but I did stay at a Holiday Inn Express last night.

The symptoms that you relayed are the same symptoms that a friend of mine had. It was misdiagnosed as GERD. A later IBS diagnosis was added. This friend had three different reflux meds to treat the GERD and none of them ever helped at all. Finally, this friend got a proper diagnosis and did the same Nuke test that you had. The ef was 10. Luckily, this person was able to have the gallbladder removed the next day. It was an open operation and was an outpatient procedure. This particular doctor uses a self-perfected open procedure on all his gallbladder patients. My friend went in that morning at 0800 and was at home by 2 pm. Within 4 days this friend was up and about and within about two weeks was in no discomfort whatsoever. I realize that this is not common, but even an open operation is not that big of a deal.

There do not have to be stones to have a diseased gallbladder. There can be fine crystalline-like particles or "sludge" in the gallbladder that will elongate the tubes of the gallbladder making it more and more difficult to accomplish its' mission. That is what happened here and from talking to several other people that have had this same problem, it happens more often than you might realize.

All the GERD and IBS symptoms have sense gone away. It seems to me that gallbladder disease is a very misdiagnosed problem as there are many symptoms that are common to other ailments. Just my uneducated $.02.

Good luck. Hopefully your other symptoms will go away and someone will decide that your reflux and other symptoms were simply misdiagnosed.

Thanks for the reply. To follow up, I met with the specialist yesterday and got my official results. Apparently, my ejections fraction was a big fat ZERO! In other words, my gallbladder isn't working at all. No wall thickening, but the specialist is pretty sure that the polyps are actually gallstones attached to the wall of the gallbladder. He is also pretty sure that my symptoms will go away when they remove the little bastard....two weeks from now.

I'll post in a few weeks to let everyone know what happened.

[jcj]

Thanks for the reply. To follow up, I met with the specialist yesterday and got my official results. Apparently, my ejections fraction was a big fat ZERO! In other words, my gallbladder isn't working at all. No wall thickening, but the specialist is pretty sure that the polyps are actually gallstones attached to the wall of the gallbladder. He is also pretty sure that my symptoms will go away when they remove the little bastard....two weeks from now.

I'll post in a few weeks to let everyone know what happened.

Normal GB Ejection fraction is > 45%, and usually it's in 70% range. As pointed out, you can have a nonfunctioning gall bladdder with or without stones. Either way, if it causes symptoms it needs to come out. You have a couple of absolute indications for cholecystectomy, and I suspect your symptoms will be gone completely as soon as you're over your surgery.

I would not expect GB wall thickening. That indicates acute colecystitis, which you do not have.

Edited June 3, 2007 by jcj

[jcj]

I'm no doctor, but I did stay at a Holiday Inn Express last night.

The symptoms that you relayed are the same symptoms that a friend of mine had. It was misdiagnosed as GERD. A later IBS diagnosis was added. This friend had three different reflux meds to treat the GERD and none of them ever helped at all. Finally, this friend got a proper diagnosis and did the same Nuke test that you had. The ef was 10. Luckily, this person was able to have the gallbladder removed the next day. It was an open operation and was an outpatient procedure. This particular doctor uses a self-perfected open procedure on all his gallbladder patients. My friend went in that morning at 0800 and was at home by 2 pm. Within 4 days this friend was up and about and within about two weeks was in no discomfort whatsoever. I realize that this is not common, but even an open operation is not that big of a deal.

There do not have to be stones to have a diseased gallbladder. There can be fine crystalline-like particles or "sludge" in the gallbladder that will elongate the tubes of the gallbladder making it more and more difficult to accomplish its' mission. That is what happened here and from talking to several other people that have had this same problem, it happens more often than you might realize.

All the GERD and IBS symptoms have sense gone away. It seems to me that gallbladder disease is a very misdiagnosed problem as there are many symptoms that are common to other ailments. Just my uneducated $.02.

Good luck. Hopefully your other symptoms will go away and someone will decide that your reflux and other symptoms were simply misdiagnosed.

It's called symptomatic biliary dyskinesia. I've had several women patients with this. They have classic GB symptoms, see a doc and get an ultrasound. The ultrasound is normal, and then their doc starts down the "how's your marriage honey, here's some prozac" pathway. By the time they get to see someone who makes the correct diagnosis, they are pretty pi$$ed. Take the GB out and they're fine.

Edited June 3, 2007 by jcj

[KWings06j]

Curious on the latest data on gastroesophageal reflux as far as waiver/DNIF goes.

I've been told unofficially that I may have it by a well qualified family friend. I started having what I call really painfull hiccups, generally starting at the beginning of eating dinner, that would last for several minutes. A few times they've caused vomiting. Immediately after vomiting I feel completely fine. Symptoms are well controlled with Nexium. 

Before I go bring a concern to my flight doc I want to know what path I may be starting down. Thanks.