Tuesday, August 13, 2013

MEDICAL | I'm a stoner (Part 2)

(Continued from Part 1)

The culprit for my vomiting, abdominal and back pains has been identified: I had stones in my common bile duct (CBD). These stones constrict the normal flow of bile from the gallbladder to the duodenum, resulting in dilation of the bile ducts and inflammation of the liver. Jaundice is also often observed in patients. Because of the dilation, this obstruction also puts pressure on adjacent internal organs, hence, the sharp pain and vomiting. If left unattended, this could cause infection and can even be life-threatening. This presence of stones in the CBD is known as choledocholithiasis.

While stones that end up in the CBD are often gallstones, mine was not the case as my gallbladder was clear, meaning, the stones weren't formed there. What x-ray and ultrasound imagery found, however, was that I also had multiple stones all throughout the intrahepatic ducts of my liver. This other condition is known as hepatolithiasis.

01to illustrate position of hepatolithiasis and cholodecholithiasis1
An x-ray shot of an ERCP procedure. Notice where the intrahepatic ducts and the CBD are. The presence of stones in the former is referred to as hepatolithiasis and choledocholithiasis if in the latter. [Photo source: summitgastro.com; with labels added]

Contrary to choledocholithiasis, where the stones are in the CBD outside the liver, with hepatolithiasis, the stones are in the bile ducts that are within the liver. More so, mine weren't confined to a specific area of the liver only. Instead, they were widespread, scattered across my liver's biliary network. Now this doesn't sound good at all, does it? What's the prognosis? How do we treat this thing? These were, of course, my next questions.

ERCP
One thing was certain: the stones had to be removed because unless the obstruction is cleared, the infection will persist despite the antibiotics being administered on me. Much to my relief, Dr Galang did not offer surgery as a first option. He proposed ERCP.

ERCP, or endoscopic retrograde cholangiopancreatography, is a non-invasive procedure that uses endoscopy and fluoroscopy for both diagnostic and therapeutic purposes in relation to certain biliary and pancreatic duct problems. Not all GIs perform ERCP because of special training and certification requirements, and I was referred to another gastroenterologist, Dr Benjamin Benitez. Despite the assurance that the procedure was safe, I was still unreasonably anxious. I wasn't used to medical procedures. Heck, I wasn't used to hospitalizations to begin with!

In ERCP, the patient is sedated or anesthetized. It is absolutely necessary because I couldn't imagine being wide awake while an endoscope is being inserted down my throat without me gagging. From what I remember, I lay flat on the table with an overhead x-ray machine hovering over me.

The residents and nurses were all abuzz prepping me for the procedure. They hooked me up to machines that would monitor my blood pressure and blood oxygen level, linked me to an external oxygen supply, attached a metal contraption to the front of my right leg, and fastened a protective apron against x-ray radiation around my groin area. Then I was made to drink this liquid that I really hated, but which was supposed to help in the x-ray imagery.

A mouth guard was taped in place before I was made to assume a position where I was half-lying on my belly and half on my side. Before I knew it the sedative had kicked in.

In this procedure, the endoscope is inserted through the mouth, down the esophagus, into the stomach, and up the duodenum. Both the endoscope's camera and the fluoroscopy serve as the doctor's eyes into the patient's innards.

02to illustrate ercp
An x-ray shot of an ERCP procedure. The endoscope itself cannot fit into the duodenum, so a much smaller contraption is released. [Collaged images from gehealthcare.com and medgadget.com]

To remove the stones, the doctor may opt for either sphincterotomy, which involves making an incision to enlarge the opening of the ampulla (the opening of the CBD and pancreatic duct) and allow removal of the stones, or balloon or basket sphincteroplasty, which does not involve any incision and instead uses a balloon or basket in removing the stones. If my memory serves me right, I think Dr Benitez employed the first method with me.

Because there is a slight risk of bleeding, the doctors had to make sure my blood clotting time was okay before the procedure. To help achieve the desired level, I was repeatedly given Vitamin K in the days leading up to the procedure. A patient, by the way, is also required to fast at least a few hours before the ERCP.

The procedure went well but instead of stones, they found biliary sludge in my CBD. Nonetheless, they were enough to constrict my normal bile flow. The stones in my intrahepatic ducts, however, were another story because no endoscope can reach them. Removing the obstruction in my CBD was the primary concern at that moment. I was discharged in the next day or two.

Ascending cholangitis
Luck must have eluded me because just a few days after my discharge, I was back at the ER for fever and chills. We were, however, warned beforehand that some patients--however small the percentage--may suffer from complications following an ERCP, especially if sphincterotomy was employed. Apart from bleeding, perforation, or even pancreatitis, among these possible complications is ascending cholangitis.

2007 08 30_2nd confinement (post-ercp)
So lucky to have My Bibe. Taken on Aug. 30, 2007, this was during my second confinement, shortly before I was discharged I think.

Ascending cholangitis, or simply cholangitis, is basically an infection of the bile duct caused by bacteria ascending from the duodenum area. While in this case the ERCP did it, ascending cholangitis is primarily caused by obstruction in the bile ducts. If left untreated, ascending cholangitis can be life-threatening, as I would experience just a few months later.

(To be continued.)

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