Case Study: Persistent Nausea and Weight Loss Following Cholecystectomy for Biliary Hyperkinesia

Case at a Glance

A 33-year-old female with a history of chronic gastritis and biliary hyperkinesia underwent a cholecystectomy, which was complicated by a post-operative bile leak requiring a second surgery. Despite the successful surgical repair, her presenting symptoms of severe nausea, epigastric pain, and reflux persisted and worsened, leading to significant weight loss and raising concerns for post-cholecystectomy gastroduodenal (bile) reflux.

Patient's Story

A 33-year-old female, with a medical history of cerebral palsy, presented with a 2.5-year history of debilitating gastrointestinal symptoms. She described episodes of persistent nausea, dry heaving, and severe upper epigastric pain, which occasionally radiated to the left. These symptoms were often accompanied by reflux, heartburn, and excessive burping, typically worsening within 30 minutes of eating. The patient experienced severe flares 1-2 times per month, resulting in an inability to tolerate oral intake for several days and requiring hospitalization. The chronic nature of her condition led to a significant weight loss of 31 lbs (from 118 lbs to 87 lbs), leaving her severely underweight for her height of 4'11".

Initial Assessment

Initial workup included an esophagogastroduodenoscopy (EGD) which revealed mild chronic inactive gastritis. The patient was trialed on multiple medications for her symptoms, including proton pump inhibitors, with minimal to no relief. The only medication that provided some benefit was sucralfate. Her physical examination was notable for a low body mass index (BMI) of approximately 17.8 kg/m².

The Diagnostic Journey

After extensive negative testing, a hepatobiliary iminodiacetic acid (HIDA) scan was performed, which demonstrated a gallbladder ejection fraction of 95%. This led to a diagnosis of biliary hyperkinesia. The clinical hypothesis was that the hyperkinetic gallbladder was causing gastroduodenal reflux, which in turn was responsible for her chronic gastritis and associated symptoms. Consequently, the patient was scheduled for a laparoscopic cholecystectomy. The procedure was complicated by post-operative hypotension and bradycardia requiring extended observation. Two days later, she developed a bile leak, necessitating an emergency second laparoscopic surgery for washout and drain placement. A follow-up HIDA scan confirmed the absence of any further leak or active bleeding but incidentally noted the presence of gastroduodenal reflux early in the study, which decreased over time. Pathological examination of the gallbladder confirmed mild chronic cholecystitis without cholelithiasis.

Final Diagnosis

1. Status post-laparoscopic cholecystectomy with repair of bile leak.
2. Suspected severe gastroduodenal (bile) reflux, persistent and possibly exacerbated post-cholecystectomy.
3. Chronic gastritis.
4. Severe malnutrition with significant unintended weight loss.

Treatment Plan

The patient's persistent, severe symptoms post-operatively, coupled with the HIDA scan evidence of gastroduodenal reflux, suggest her gallbladder was not the sole etiology. The immediate surgical follow-up was unsatisfactory, with the patient being advised that her primary issue was likely not her gallbladder. Given the lack of improvement, a new therapeutic strategy is required. The patient was referred to a gastroenterologist for further evaluation. The plan includes:

1. Nutritional Support: Aggressive nutritional intervention to address severe malnutrition and promote weight gain.
2. Medical Management: A trial of bile acid sequestrants (e.g., cholestyramine or colestipol) or ursodiol to specifically target suspected bile reflux.
3. Continued Symptom Control: Continued use of antiemetics and sucralfate as needed for symptom management.
4. Re-evaluation: If medical and dietary management fails to provide relief, further investigation into the severity of the bile reflux may be warranted before considering more invasive options such as surgical diversion.

Outcome and Follow-up

Following a one-week hospitalization for her surgical complication, the patient's surgical incisions healed well. However, her core symptoms of nausea, dry heaving, pain, and reflux did not resolve and may have worsened. She remains on a highly restricted, low-fat diet and requires anti-nausea medication to maintain minimal oral intake. The patient is profoundly underweight and distressed by the lack of improvement. The current focus is on managing her symptoms medically through a gastroenterology specialist, with a low threshold to re-evaluate for surgical intervention if conservative measures fail to improve her nutritional status and quality of life.