I’ll be Glowing!

Not really, but that was my first thought when a nuclear medicine (NM) test was ordered for me. It required radioactive material to be injected into my veins. The test is called NM Hepatobiliary Scan with Pharmacologic Intervention.

Let’s get a definition of hepatobiliary before we do anything else. Thank you MedicineNet at https://www.medicinenet.com/script/main/art.asp?articlekey=19515 for this one:

“Hepatobiliary: Having to do with the liver plus the gallbladder, bile ducts, or bile. For example, MRI (magnetic resonance imaging) can be applied to the hepatobiliary system. Hepatobiliary makes sense since “hepato-” refers to the liver and “-biliary” refers to the gallbladder, bile ducts, or bile.”

That’s my kind of definition. Clear and easy for those of us who are not doctors to understand. It makes sense, too, since we were exploring what I called discomfort and my PCP called pain just under the lowest rib on my right side… very close to the gall bladder. The more than occasional nausea helped her to decide this test was necessary.

According to the test report, this is how it works:

“TECHNIQUE:

Frontal standing images of the abdomen and pelvis were obtained immediately and 30 minutes following the intravenous administration of Tc99m IDA. Pharmacologic intervention with CCK (or equivalent) and/or morphine with additional dynamic imaging was also performed.”

I didn’t know what Tc99mIDA or CCK was, so I’m guessing you don’t either.  Wikipedia at

https://en.wikipedia.org/wiki/Technetium_(99mTc)_mebrofenin  tells us,

“Technetium (99mTc) mebrofenin is a diagnostic radiopharmaceutical used for imaging of the liver and the gallbladder.”

Hmmm, we could have figured that out from the way the term is used in the context of the technique.

Let’s try CCK. This is also from Wikipedia but this time at https://en.wikipedia.org/wiki/Cholecystokinin.

“Cholecystokinin (CCK or CCK-PZ; from Greek chole, “bile”; cysto, “sac”; kinin, “move”; hence, move the bile-sac (gallbladder)) is a peptide hormone of the gastrointestinal system responsible for stimulating the digestion of fat and protein. Cholecystokinin, officially called pancreozymin, is synthesized and secreted by enteroendocrine cells in the duodenum, the first segment of the small intestine.” 

Well, that’s fairly explanatory, but keep in mind that Wikipedia entries can be edited by anyone.

I know, now you want to know the results. Back to the test report:

“HIDA scan:

Gallbladder clearly visualized. Gallbladder ejection fraction calculated at 37% at 30 minutes. Greater than 35% is normal.

Study Result Impression:

Gallbladder clearly visualized. Borderline abnormal gallbladder response to cholecystokinin challenge.”

Here’s where I got lost. If my gall bladder ejection fraction is normal, how can I have a borderline abnormal gall bladder response to cholecystokinin challenge? Yep, it’s time to make an appointment with my family doctor since she ordered these tests and, being who she is, can probably explain that in terms I can understand.  More on that after next week’s liver MRI and an appointment with her to discuss the findings of both tests.

While this is all interesting, what does it have to do with the kidneys? I went back to SlowItDownCKD 2013 to find out what I’d written about that after my New York daughter’s gall bladder was removed.

“After speaking with my daughter, I still wondered what gallstones have to do with Chronic Kidney Disease.  Searching the web only garnered this one article from January, 2009 … and the study only covered Taiwan. Of course, I found it at the National Institutes of Health at https://www.ncbi.nlm.nih.gov/pubmed/19352299.

‘The prevalence of gallbladder stones in patients with Chronic Kidney Disease is significantly higher than in those without Chronic Kidney Disease. Our findings suggest that increasing age, Chronic Kidney Disease, body mass index > or =27 kg/m {greater than 59 pounds}, metabolic syndrome, and cirrhosis are the related factors for gallbladder stone formation.’

Now think about it another way: you already have a compromised immune system because you have CKD.  Gallstones can cause infection of the gallbladder. As in Nima’s experience, infection causes white blood cell elevation. So you know you have an infection, you might even realize it could be in the bile ducts, too.  But did you check to see if there’s infection in other areas of your body? That would mean you can read your own test results or have the kind of relationship with your doctors – especially your nephrologist – to freely ask questions.

As for what this organ does, this is what MedlinePlus at https://vsearch.nlm.nih.gov/vivisimo/cgi-bin/query-meta?v%3Aproject=medlineplus&v%3Asources=medlineplus-bundle&query=gall+bladder&_ga=2.56082859.126205281.1548540376-1108406265.1544652518 had to say.

‘Your gallbladder is a pear-shaped organ under your liver. It stores bile, a fluid made by your liver to digest fat. As your stomach and intestines digest food, your gallbladder releases bile through a tube called the common bile duct. The duct connects your gallbladder and liver to your small intestine.’

Keep in mind that your liver, the largest organ in your body {The skin is actually the largest organ, but it’s external.} is the other organ that filters your blood.  Since your CKD has been diagnosed, your liver is already working harder. Add losing your gallbladder and you’ve got one very hard working – possibly overworked – liver.”

Needless to say, while I was taking this in stride, especially since my kidney function is the best it’s been in the over a decade since I’ve been diagnosed with CKD, I am now eager to have the liver MRI and get back to my primary care doctor (PCP) so she can explain what a lay person can’t understand from reading the results-  even with further researching.

A few announcements, if you please:

Our friends at @antidote_me are hosting the first of their new free monthly patient focused webinars. This one is about how medical research really works and is this Wednesday, January 30th. It’s a 15 minute webinar.  Register now: https://hubs.ly/H0gc_KV0.

Also, I write the blogs from a U.S. angle since that’s where I live. There is a new Facebook CKD support group which is from the British angle. It’s Chronic Kidney Disease Support Group for UK! Another is CKD Support UK. These are only two of several from across the sea. If you’d like to find the others, go to Facebook and in the search bar on top, enter CKD Support in UK. That little word “in” is what makes it searchable.

Until next week,

Keep living your life!

Oh, The Gall!

I thought I’d write about macular degeneration this week since that’s the newest diagnose in my life.  But my daughter’s  Cholecystectomy is taking precedence in my mind, so we can postpone the macular degeneration.  Her what, you ask?  That, my friends, is what the procedure to remove your gall bladder is called. By the way, I asked what it was, too.       photo

This is Nima’s description of how it all started and what the procedure was like:

“At one point or another we’ve all that had that midnight snack of a slice of cold pizza and maybe some juice to wash it down. So when I woke up with severe sharp pain on my right side I didn’t think much of it, except I shouldn’t have eaten that pizza, and where is the Tums?  After two Tums and a hot shower, the sharp pain continued all around the middle of my back to the middle of my front right side. I finally thought to myself, ‘Don’t be stupid. You have a family history of CKD, and one family member who passed stones a few years back. Better to be safe than sorry, get it checked.’

Off to the ER I went. After I described my symptoms to the first year resident, she picked up very quickly on the fact it could be gallstone/gallbladder related due to the side of the pain (right) and asked for a urine sample, as well as ordering blood work, and a sonogram of that area. I was also given an IV, morphine drip for pain (which honestly did nothing – too much pain- all I wanted to do was rock back and forth or keep walking in circles to help me be in motion so I didn’t have to think about the pain), and eventually antibiotics.

The doctor came back with the results of the blood work to tell me that my white blood count was elevated to 12, an indication the gallbladder was infected. I was finally taken to sonogram. A bariatric first year resident explained I had an impassable 2.7 in. diameter gallstone that was causing blockage in the duct in the front and a bunch of pain. There’d be no way to take it out other than surgery. After meeting with the attending physician, he concurred. He also mentioned that, because the gallbladder was infected, it’d be smart to remove it.

So, I did. I’ll now have to learn an entirely new way to eat (low-fat) as the gallbladder is what processes fat. I’ve learned quickly if I consume the slightest bit of fat, my body’s response is “Um, what the hell are we supposed to do with that?!” and to reject it in a not so nice way. I’ll have to play it smart and step up the exercise and water intake as well to make up for the missing organ and amount of bile that could now possibly be floating in my body because it has nowhere to go. As for pizza at midnight? Well unless, I want another episode like the one I just had, those days are now in my rearview mirror.”

But what do gall stones have to do with chronic kidney disease?  Searching the web only garnered this one article from January, 2009 – that’s four and a half years ago – http://www.ncbi.nlm.nih.gov/pubmed/19352299. The relevant quote is this:

“The prevalence of gallbladder stones in patients with chronic kidney disease is significantly higher than in those without chronic kidney disease. Our findings suggest that increasing age, chronic kidney disease, body mass index > or =27 kg/m {greater than 59 pounds}, metabolic syndrome, and cirrhosis are the related factors for gallbladder stone formation.”

Now think about it another way: you already have a compromised immune system because you have ckd.  Gall stones can cause infection of the gall bladder. As in Nima’s experience, infection causes white blood cell elevation. So you know you have an infection, you might even realize it could be in the bile ducts, too.  But did you check to see if there’s infection in other areas of your body? That would mean you can read your own test results or have the kind of relationship with your doctors – especially your nephrologist – to freely ask questions.

Let’s back track a little since I’m so good at that.  Here’s a picture of the location of the gall bladder. gall_bladder

As for what it does, I went to http://www.nlm.nih.gov/medlineplus/gallbladderdiseases.html.

“The gallbladder is a pear-shaped organ under your liver. It stores bile, a fluid made by your liver to digest fat. As your stomach and intestines digest food, your gallbladder releases bile through a tube called the common bile duct. The duct connects your gallbladder and liver to your small intestine.”

Keep in mind that your liver, the largest organ in your body {the skin is actually the largest organ, but it’s external} is the other organ that filters your blood.  Since your ckd has been diagnosed, your liver is already working harder. Add losing your gall bladder and you’ve got one very hard working – possibly overworked? – liver.

What about the surgery, you ask?  There are two kinds: open which is surgery as we understood it before laparoscopic surgery and laparoscopic surgery.  In the latter kind:

image-07Under general anesthesia, so the patient is asleep throughout the procedure.

  • Using  a cannula (a narrow tube-like instrument), the surgeon enters the abdomen in the area of the belly-button.
  • A  laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient’s internal organs on a television screen.
  • Other  cannulas are inserted which allow your surgeon to delicately separate the gallbladder from its attachments and then remove it through one of the openings.
  • Many  surgeons perform an X-ray, called a cholangiogram, to identify stones, which may be located in the bile channels, or to insure that structures  have been identified.
  • If the surgeon finds one or more stones in the common bile duct, (s)he may remove them with a special scope, may choose to have them removed later through a second minimally invasive procedure, or may convert to an open operation in order to remove all the stones during the operation.

After the surgeon removes the gallbladder, the small incisions are closed with a stitch or two or with surgical tape.

Thank you for this information Society of American Gastrointestinal and Endoscopic Surgeons at: http://www.sages.org/publications/patient-information/patient-information-for-laparoscopic-gallbladder-removal-cholecystectomy-from-sages/

And that, ladies and gentlemen, is all I know about the gall bladder and gall stones.

Until next week,

Keep living your life!