| Ask A Doctor |
The Ask A Doctor message board provided a medium for sufferers of Heartburn and Gerd to ask questions about medical and surgical options for heartburn and receive answers directly from experienced Gastroesophageal surgeons.
Please Note!!! The Ask A Doctor message board is now a read only message board. Since May 1, 2000 the Doctors have answered over 1500 questions that have been posted to the board. We join you in thanking the doctors for performing this excellent service.
Additional Ask A Doctor message boards can be viewed at Message Board
[ Contents | Search | Next | Previous | Up ]
From: David Cloyd MD
Date: 05/15/00
Time: 01:49:39
I would like to try to separate bile problems form gallbladder problems. They are two pretty distinct items. Bile problems may not have anything to do with the gallbladder itself, and can occur whether it is present or absent. Bile reflux, in particular, occurs when bile that is supposed to go downstream after emptying into the duodenum instead flows backwards into the stomach, and then sometimes all the way up into the esophagus. To me this implies a problem with the motility of the lower stomach and proximal duodenum, since normally the pylorus (outlet of the stomach) serves as an effective barrier to the retrograde flow of bile.
A gallbladder problem, on the other hand, has more to do with gallstones and emptying of the gallbladder itself. A typical attack occurs when a stone tries to pass out of the gallbladder and gets stuck in the cystic duct, which is the outlet of the gallbladder. This can produce severe pain when the stone gets impacted, which can also disappear rapidly if the stone gets dislodged. But there are also a myriad of less easily described gallbladder symptoms that occur when the gallbladder is functioning less than perfectly. Inadequate or incomplete emptying can cause the formation of sludge and tiny stones which may not block the gallbladder completely, but can still cause irritation, leading to symptoms of bloating, fullness, gas, indigestion etc.
With this as background, I would answer your question by saying, yes, absolutely, there are probably a large number of patients with "failed" anti-reflux procudures who are having trouble with either bile or their gallbladder. Between the two, I would say the gallbladder problem is both more common, and easier to evaluate. So I keep a pretty high index of suspicion for the gallbladder, and anytime someone has either atypical symptoms preoperatively, or is a failure post operatively, I would be quick to get at least a gallbladder sonogram.
I am wondering exactly what symptoms you are having post-op. Is there heartburn or acid regurgitation, or are the main symptoms the burping and bloating? The reason I ask has to do with a problem I don't think has been discussed yet on the board - gas bloat syndrome. This occurs when a Nissen is the equivalent of too tight, and doesn't allow ordinary burps to escape readily. The stomach can distend with gas, and cause bloating. This problem is exacerbated by carbonated beverages and gas forming vegetables. It is also aggravated by a behavior problem called aerophagia - an interesting but little documented habit that almost all chronic refluxers acquire during the course of trying to (unconsciously) self treat their symptoms. It is my belief that in trying to relieve the pressure, pain and burning that typify GERD most patients at one time or another try to belch, just to see if it will ease the pressure. With time, they learn to swallow air in order to belch more repetitively. Unfortunately, this really doesn't help much, and actually the net result of swallowing and belching is to pump ever more air into the stomach (this has been studied under fluoroscopy). In the end, the stomach just gets even more distended by this cycle of swallowing air and inducing burps. It doesn't cause harm in the preop setting, because eventually a spontaneous (normal) burp comes along and releases the pressure. But a postop patient with a tight wrap may NOT be able to release the air. It therefore becomes particularly important in this setting to unlearn the habit of aerophagia, which is present in so many patients with GERD.