Burt had his gallbladder out twenty years ago. But he had these recurring attacks of pain in his right upper quadrant that built up slowly and lasted for hours and then gradually disappeared.
Other doctors had checked him out and an ultrasound showed nothing unusual, such as an abnormal diameter of his common bile duct. He had even had a normal HIDA scan. Both were done fasting, the usual way.
As I listened to his story, I felt sure this was biliary, but what? It came and went and he was fine between. One time he remembered it happened the night after a high fat meal.
I’ve had patients who needed an ERCP to remove small gallstones at the sphincter of Oddi or to dilate or stent sphincters damaged by inflammation or tumors. But his symptoms were not chronic and he couldn’t very well have a stenosis present that way.
“Sphincter of Oddi dysfunction”, I thought to myself and logged in to UpToDate. “I pay $500 per year for this database”, I started. “I think you can have a bad valve, that lets the bile through some of the time and not others. Let me check something.”
And there, on my laptop screen in front of us, I had the classic symptoms, the Rome criteria which he checked off one by one. We scrolled down to the diagnostic testing. Ultrasound or HIDA scan after a fatty meal (of course!!!), invasive manometry (ugh!). Further down, the answer I was looking for: Antispasmodics may work. (I am linking to two different, free, articles here and here.)
So Burt is sticking to his low fat diet with a new prescription for PRN hyoscyamine.
We shall see…
P.S. Am I the only family doc who didn’t have this diagnosis right at my fingertips?
A Country Doctor Writes: 
Had a patient, only one patient, who had no gallstones anywhere in the hepatobiliary -pancreatic tree of ducts yet had an abnormal HIDA scan. He failed to find relief through dietary manipulation nor from medication.
He had his slowly emptying Gallbladder removed and voila, all better.
Walt,
You are a true physician and educator. You listen to the patient and do the research. Congratulations!
With greatest respect,
Paul
Can you diagnose my “viral syndrome” that I endured. I thought I was going to die. I tested, I forget how many times for HIV, all negative. I tested now, for COVID negative repeatedly, but I feel like sometimes increased pressure in my head, not a headache, like something is growing inside my head. I want closure, a correct diagnosis, to explain what has tortured me for years, for what I have survived. Please help.
I’m sorryp
Definitely not. I found this case report to be interesting and informative. I’ve had patients with similar symptoms that also had a normal ultrasound and HIDA scan. Thanks for sharing!
In retrospect, I think a colleague suffered from this, but not a diagnosis I ever made. Thank you for pulling that from the depths of time for possible application!