Gastroenterology

PCP submission

89 year old female patient with chronic c/o abdominal discomfort and bloating. Abdominal ultrasound was positive for limited visualization of the gallbladder due to underdistention. This is an abnormal finding if patient was truly nothing by mouth for 6 hours.

What do you think about this finding and how should I optimize her care?

Specialist response

Thank you for this consult on an 86 yo woman with anemia and chronic c/o abdominal discomfort and bloating. Her abdominal US revealed under distension of gallbladder. Lack of gallbladder distention, with a width less than 2.2 cm, is potentially a highly sensitive sign for exclusion of acute cholecystitis, which is unlikely based on her chronic abdominal pain . The gallbladder is usually physiologically contracted after eating, if this patient fasted for at least 6 hour, the underdistended GB is an abnormal finding warranting consideration of further evaluation with a HIDA scan if, in fact, this elderly woman’s goals of care are aligned with further testing and treatment. A HIDA takes about an hour to perform and it’s typically not painful, but some patients are not able to lay still for that long and may become anxious in the scanner. The most common conditions causing a poorly visualized gallbladder, are chronic cholecystitis due to cholelithiasis or choledocholithiasis, and rarely dueto GB cancer. There there is no evidence of stones in the gallbladder or biliary tree on US, however, this does not exclude chronic cholecystitis. In the interim, to address the symptoms of bloating and abdominal discomfort, particularly if there’s suspicion of a functional gastrointestinal disorder such as IBS, a trial of the low FODMAP diet could be considered. This diet helps identify food intolerances that may contribute to these symptoms. Probiotics and antispasmodic medications such as hyoscine butylbromide (Buscopan) 10 mg up to three times daily or dicyclomine (Bentyl) 10-20 mg four times daily can also be beneficial. PPIs or H2 blockers may be used if dyspeptic symptoms are prominent, following appropriate dosing guidelines based on the specific medication chosen. Lastly, ensure that the patient is counseled on adequate hydration and fiber intake if no contraindications exist, as these can affect gastrointestinal motility and symptomatology. Again, I would ask the pt how aggressive she wants to be with testing and treatment. I would also keep in mind that a healthy 86-year-old, on average, has a life expectancy of about 6.5 more years; if she has multi morbidity, life expectancy is less. The time to benefit from a HIDA scan, and potentially treatment of the findings, needs to be taken into consideration in light of life expectancy.