You experience periodic boutsof abdominal pain. You’ve been to the ER. Ultrasounds and CAT scans can’t verify the presenceof stones – in the gallbladder, or in the bile ducts. Frustration mounts! What is wrong with me, you ask?

According to Dr. Rakesh Gupta, many patients experience theseuncomfortable and elusive symptoms. Using procedures developed at major universitymedical centers, Dr. Gupta hasalleviated the suffering of many.

Recently, he sat down with Emerging Scene to discuss how we are flushing out the causesand winning the war on non-stone biliary disease.
Explain how the CAT scan and ultrasound are negative, but the patient is still hurting?

“It is due to the mechanics of this pain. The gall bladder and bile ducts outside the liver carry bile juices. This juice helps with digestion. The biliary fluid normally moves through the duct system at a relatively low pressure.”

“When an obstruction occurs, the result is similar to four lanes of traffic squeezing into two lanes of the road. The pressure at which the bile flows is raised and this creates pain,” Dr. Gupta says.
So if there are no stones, what kind of disease can cause this
blocking?
There  are  two  groups  of
causes.  The  first  is
malignancy. malignancy,  the  Withpatient  a will

usually have yellowing of the skin due to jaundice. The

ultrasound and CT scan usually will show some evidence to suspect cancer. For purposes of our discussion, we will have ruled out this situation.

“The second group would be those with non-cancerous partial obstructions. These individuals may suffer on and off for long periods of time, or live with constant pain. Chronic abdominal pain due to partial blockages is very common, but the causes are difficult to diagnose.”

High pressure in the bile duct is the primary cause of non-stone pain.
Can you give examples of medical conditions that cause

narrowing of the sphincter
non  -  cancerous  partial
obstructions?  
“Papillary  stenosis  is  a

at the lower end of the bile duct, mostly due to scar tissue. The papilla functions as a valve. When this valve is damaged or narrowed due to scar

 

tissue in the surrounding area pressing against it.”

“This scar tissue may have been caused by previous abdominal injury due to appendicitis, pancreatitis, cholecystitis, pelvic inflammatory disease, endometriosis, or ectopic pregnancy. If we find kinking, a surgeon, through laparoscopy, can treat it.
1. Papilloma Stenosis

Cut open through endoscope
2. Kinking of the cystic duct

Laparoscopic cholcystectomy
3. Cholecysto paresis(paralysis of the gall bladder)

Laparoscopic cholcystectomy
4. Common Bile Duct Stricture

Dilate stricture through endoscope
5. X-ray negative (stones not previously detected)

Stones pulled through endoscope with basket/balloon
6. Lab / X-Ray Negative Chronic Pancreatitis

Medical / Endoscopic / Surgical Treatment

“Chronic abdominal pain due to partial blockages isvery common, but difficult to diagnose.”
How is kinking diagnosed?

“By the use of a CCK-HIDA Scan. This is a nuclear medicine technique in which a radioactive isotope is injected

into the vein. The isotope is picked up in the liver and excreted in the bile. The computer collects data and tracks the isotope as it travels throughout the system.”

“It is just like sending police helicopters over suspected blocked highways confirming suspicion of traffic jams.”

“Then we follow with ERCP. ERCP is a technologically complex technique combining endoscope with x-ray. A very fine plastic cannula is inserted through an endoscope into the common bile duct and or pancreatic duct. Then we inject a dye, which helps us to see the blockage, or in some cases, stones that have not been previously detected or pancreatic disease if any.”

Choosing the right doctoris essential. Dr. Gupta has 15 years experience with ERCP procedures.
What is your ERCP experience?

“Expertise in ERCP is usually available primarily in major university centers. However, our clinic has been performing ERCP procedures for over 15 years.”

“And we have taken advantage of some recent developments which have lessened the risk and added significantly to the success rate of this procedure.”
Can you give us some details?

“Two things occurred. The first was a refinement of the catheter we use through the

duodenoscope. When performing ERCP, the physician has to maneuver the catheter to get from the pancreatic duct into the common bile duct. It used to be that the tips of the catheter were harder than the wall of the pancreatic pipe, and there was a risk of the catheter puncturing the wall. This used to lead to inflammation of the pancreas, or pancreatitis.”

“Today, we use what is called a 5-4-3-soft tip catheter. The risk of puncture is minimized.”

“The second refinement relates to our use of power for the cutting knife. This sphincterostome is used to cut scar tissue. We now use what is called a 25-25 setting oflaser current. This is a lower current that minimizes the risk of excessive cutting. Conversely, the risk of undercutting is eliminated by the technique of incremental cutting, which is now made possible by achieving deep cannulation of common bile duct with 5-4-3-soft tip catheter. This refinement is used in treating papillary stenosis, which is the most common cause of biliary pain.”

If Dr. Gupta is not listed as a PPO provider, he does try to accept reduced benefit as much as possible.
How do you first learn these refinements of technique?

“These refinements came from a conference I attended at Northwestern University. I personally attend national and


international conferences to learn from worldwide experts.”

“In effect, I shop on behalf of my patients. I am their representative - an advocate for their care – looking for technology and techniques that they can benefit from,” Dr. Gupta says.

“When attendingconferences, Dr. Gupta acts as a representative ofhis patients. “I shop for new techniques on their behalf,” he says.”
Does my health plan cover ERCP?

“Most private health plans do. However, individual situations may vary. Each individual should check with their health plan.”

Appendicitis
Pancreatitis
Cholecystitis
Pelvic Inflammatory Disease
Endometriosis
Ovarian Cyst
Ectopic Pregnancy
 

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