text:
Wherein a surgeon tells some stories, shares some thoughts, and occasionally shoots off his mouth. Like a surgeon.
Wednesday, March 28, 2007
Slippery Stones: more about the gallbladder
"If you don't have a pretty good idea what's going on with your patient after a thorough history and physical," I was told in medical school, "you probably never will." It's a wise -- if a little dated -- statement. Most of the time, diagnosis isn't all that hard. Rare things are rare. Common things are common: another med-school pearl of wisdom. Figuring out the problem in those outlier situations can be frustrating on each side of the white coat and, in the case of surgery, can lead to errors in both directions: doing operations that don't help, or deferring ones that otherwise might. The gallbladder has been the source of more than its share of such scenarii.
Delicate and robin's-egg blue, the normal gallbladder is startlingly beautiful. Out of place among the muted earthiness of the rest of the abdominal anatomy, it peeks above the lower edge of the right lobe of the liver, demure, nearly luminous; typically you see only the top of it, the rest hidden by the colon and omentum. It's as if the body is shy about revealing such surprising and incongruous loveliness. Aiming to remove it, seeing that color signals a likely easy time; hoping to help a person with grey symptoms, finding a blue bag makes you wonder what you're doing. With significant chronic gallbladder disease, the organ generally is thick and reddened, although in between attacks it can resume its avian amiability.
"Well, doc, whenever I eat freedom fries, few minutes later I get this horrible pain right here [pointing just below the right rib cage]. Goes right through me into my shoulder blade. Hurts like hell. I get to writhing around, puking my guts out, can't stand up, can't sit down. After twenty minutes it starts to go away, and I'll feel fine again. Oh, and my doc asked me to bring you these [shows me ultrasound images of his gallbladder, full of stones.]" No brainer. Textbook stuff. That man is going to love me for liberating him from the clutches of his gallbladder. The preceding, by the way, is a classic description of "biliary colic," resulting from a stone plugging up the outlet of the gallbladder when it's trying to empty itself of bile. It differs from "acute cholecystitis," which is a more severe situation, resulting from the stone lodging in the outlet and not letting go. Instead of just hurting like hell for a few minutes, the gallbladder gets inflamed, swollen, sometimes infected. It's potentially more dangerous than colic. The distinction, I'd have to say, is often lost on non-surgical medical doctors. But I digress.
"Well, doc, whenever I eat french fries..... [repeats the above story including handing me the ultrasound, which is entirely normal.] That's a diagnostic problem. Or this: "I get heartburn a lot. Sometimes I'm nauseated for no reason. [Shows me repeat of the first ultrasound, stones aplenty.] I've heard variations on those themes countless times, and it's a dilemma. Many tests follow, but explanations remain elusive. Operations may or may not ensue. The sad saga of one of my patients is illuminating. Since it's complicated, maybe I'll just tell the story straight through, and consider the implications later.
I'd operated on her for another reason in the past. Now under the care of docs at a hoidy-toidy medical center, she came back to me when surgery was recommended. She'd been through an extensive workup for abdominal pain, not typical of gallbladder origin, but conceivably so; her gallbladder was, by all measures, normal. At the mecca of medical mastery she'd undergone a test on the basis of which it was decided she had problems with the valve at the end of the bile duct (sphincter of Oddi dysfunction -- more about that little gem, later) and she'd been advised to have her gallbladder removed. I called her gastroenterologist: why, I asked him, had he not cut the valve (the usual treatment) when he was there with his scope? Wasn't taking out her gallbladder attending to the wrong end of the stick? Removal of the gallbladder, he said, was curative sometimes (for unknown reasons); and it was their protocol not to cut the valve (papillotomy) in people who hadn't had cholecystectomy (official and impressive term for gallbladder removal). OK, I said. You're the professor.
The operation went fine. (I've always said unnecessary surgery gets a bad rap: it's easy, and people recover faster than when they're actually sick.) Her pain persisted. From her Meccanized professor, she then got her papillotomy, after which she in fact felt better for a while. When her symptoms recurred, a scope showed the sphincter had scarred down, so it was re-cut, after which she was better again, but for a shorter time, after which it was again scarred small. At that point her gastroenterologist recommended surgically cutting the sphincter; that made sense to me, because it seemed the "medical" cutting had helped, and I knew the surgical approach was more definitive and permanent, if a bigger deal. So I did it, a major procedure involving opening the duodenum and carefully (so you don't cause a leak) slicing the end of the bile duct and tacking it open with sutures. Once again she seemed to have been improved, for a while. When her pain returned, her umpteenth scope Xray showed my operation to be wide open, but her doc had her see Supersurgeon at the mecca. He recommended going back in and cutting her pancreatic duct where it joined the bile duct, figuring that in some way I'd compromised its drainage with my operation. I hadn't. (Below is a diagram that shows the relationships. Ignore the stone, in this case.)
Had I somehow interfered with drainage from the pancreas, and were that a cause of her problem (which didn't make sense, since her symptoms were the same as those before any of these procedures were done), that duct would be seen to be dilated on Xrays. It wasn't. My patient wanted me to do the operation if it was do be done, but that's where I drew the line: for one thing, it made no anatomic sense to me in her situation, and for another, I'd never done it -- at least not that way. I told her both reasons. So Supersurgeon did it, finding no operative evidence of a problem, but soldiering on.
When there was no improvement at all, so my patient later told me, and when she had another scope-Xray to check it out, the surgeon entered the exam room, walked past her to the Xray, looked it over, said "Well, my operation isn't the problem," turned on the heel of his bootie-covered shoe, and walked out without ever having said hello.
I tried everything remaining: wound injections and scanning for hernias, pain clinic referral, obtaining opinions from all sorts. The best I could do, at some point, was to assure her that whatever else was true, it was possible to be sure there was nothing going on that was dangerous to her. She continued to visit the clinic, and finally found some sort of equilibrium with her pain. In my next post, I'll try to deal with some of the issues raised. (The assholery of the surgeon will have to stand on its own, addressed no further...)
41 comments:
- Lynn Price said...
""Well, my operation isn't the problem," turned on the heel of his bootie-covered shoe, and walked out without ever having said hello."
Ah, he must be a relation to the unfeeling, rude buttwipe of a doctor who told my mother her time was up and turned on her bootie-covered shoe and walked out. My mother ended having to go to the Urgent Care clinic because the medication Buttwipe tossed at her made her sicker. - 3/28/2007 8:34 AM
Well, I have been through the same mess your patient has and now 10 years later I still have the pain in my right side and under my right shoulder blade. Nobody can figure it out. The only way I am able to work is to live on pain medicine. It's not what I want to do but I can't go on disability and I'm not going to pay for any more useless tests and surgeries. I wish I had known the outcome before I paid for $500,000 + in surgeries and tests. I guess it had to be done though. I could not get any doctor to treat me with pain medication until I went through all the other B.S. first. I guess the dopeheads have doctors thinking that everyone who complains of pain is just trying to get pain pills out of them.
assrot, Sorry about your pain. Have you done ERCP, EUS, HIDA & MRCP? any nuclear medicine??? What tests and surgeries have you done? Were you seeing at doc at the university level? I highly encourage you to find the source of your pain. When you know what you are fighting, it's easier, At least then you can learn about it and knowledge is power. Don't give up or give in. We have a joke in our family, I have a million dollar body, you can't tell by looking at me..I seriously considered getting a night shirt that read "Body by Baylor". You have to laugh..I know, at some point you have to think about the money aside of the fact of the toll it takes on you. Hang in there. Kat
Thanks for your blog, Dr. Sig. I found it the other day after having a HIDA and believing I would be having the GB out shortly. Got my results today with 'normal' return. 17% after onset, 54% after 30 minutes and 54% after 60 minutes. So do you have any direction for me to seek to explain the right shoulderblade pain, yellow stool (mostly diarrhea), terrible bloating, upper abdominal tenderness, and nauaea????? I'm at my wits end living like this and thought I'd found my answer to my problems. Now I feel like it's all in my head, even though my body is insisting it's not. Any suggestions are greatly appreciated. Thanks!!!
- Sid Schwab said...
Marie: much as I'd like to, I really can't make specific recommendations or try to solve problems from this far away, other than to suggest, if you haven't already, that you consult with a gastroenterologist.
I found this blog just prior to having a HIDA last week... great resource and useful information.
So, my HIDA came back as very low output or some such verbiage--he (the gastro-guy) didn't give a percentage (need to ask). He recommended I come back in a month because I didn't have any pain during the test (I guess pain is expected...). No mention was made of gallstones (another question I need to ask)
So, I still have stomach pain before, during, and after eating. My endoscopy came back clean. I've lost 22 pounds... eating is a challenge (other than cottage cheese, chicken and an occasional apple). I'm exhausted most of the time... this is getting old (been going on for three months).
Any recommendations? Do I push to be seen sooner than a month... what questions should I ask?
This is so frustrating and draining... (sorry to grump at everyone -- thanks for listening)! - 10/21/2007 11:45 AM
- Sid Schwab said...
anonymous: I really can't make any meaningful suggestions from so far away. It sounds like you're in that frustrating category of an elusive diagnosis. Those often take time and lots of patience to unravel; I'd assume a CAT scan would be among the future tests you might need. Pain before during and after eating isn't very suggestive of gallbladder source so it's good that your GI doc is dragging the feet for now.
Hello, I had my GB removed in Feb. of 07 (laparoscopically) due to multiple stones. Since then, I have had a feeling of fullness in the epigastric area, and a strange small bulge appears under the top puncture wound, just below my sternum. I was told by my GP during a check up last week that its probably a small hernia from the scope. Is this common? Hard to repair? Thanks for any info.
- Sid Schwab said...
anonymous: not real common, but not real rare. Simple to fix. Check with your surgeon.
My husband has been going through severe right sided pain for the last three weeks. We have been consulting with a specialist in Dothan who has done everything including a Hida,MRI,ERCP,NGSCOPE,CATSCAN,bloodworkd, u name it. They have said that it is possible that it is his gallbladder but not certain and they do not want to operate without being so absolutely certain that it is truely his gallbladder. Any recommendation because we cannot keep going on like this and seem to get no answers from anyone. PLEASE HELP!!!! - 2/04/2008 4:27 PM
- Sid Schwab said...
anonymous: I'm sorry, but I really have no way to provide any meaningful help for a patient I don't know, other than to say to keep with the doctor and let the process go on, as frustrating as it can be. Sometimes it takes an unsatisfactorily long time. The good news is that with the tests he's had, it's unlikely that something really dangerous has been missed.
- pixie said...
I have had terrible urq abdominal pain for over two years now. Had gallbladder removed, diseased and stones. Never have naseau or diarrhea.Seems like pain is not related to food. Always starts late evening and lasts 3 or 4 hours. Have to walk the floor to try to get relief. Take levbid which helps eventually but cannot figure it out. Pain always travels thru to back and up to gums on right side. Any ideas?
- Sid Schwab said...
pixie: It could be many things, related to the surgery or not; colon; cardiac; liver; diaphragm... The list is long and the way to get at it is to work either with your regular doc, your surgeon, or gastroenterologist.
I too have SOD and have been to many specialists. I don't want the surgery because I am in the highest group to get pancreatitis. I am taking levbid long acting and short acting, actigal, and following the Makers Diet, by Rubin. I feel much better and my liver function tests are back to normal. I just hope it lasts.
- i12bbanned said...
I'm wondering if you have an opinion about the laparoscopic cholecystectomy versus open cholecystectomy. Do you think the lap chole is responsible for the exaggerated number of patients who are still suffering post-surgery? If so, why? Is it because the stones and sludge in the ducts is not being cleared out properly?
I'm in my third year of suffering. I've had the lap chole and sphincterotomy. I have constant pain in my RUQ and attack pain post-prandially and with movement. I also have constant nausea and fatigue. Prior to this, I was an extremely healthy, active, happy person. Now, I'm a lump, waiting for the next test to give me a diagnosis so I can get going on treatment and get well.
I thank you for your time and your blog!
All the best,
Sam Alexander - 3/18/2009 5:09 PM
- Sid Schwab said...
Sam: Here's what I wrote about lap chole vs open. As you can tell, I preferred my version of open, which was quicker, safer, and less costly than lap chole, with as quick recovery. I did it mostly as an outpatient operation.
That aside, I think it has nothing to do with long term outcome. The problems you are having, I'd guess, are not related to the type of operation. I say that, of course, with no knowledge of your situation, but as a general comment about the nature of operations. - 3/18/2009 5:26 PM
- i12bbanned said...
Thank you so much for your comment. Your honesty throughout this blog humbles me. I don't envy you, being unable to comment to bloggers who are clearly asking for medical advice.
Thank you for your time and I wish you all the best,
Sam - 3/18/2009 6:50 PM
Dr, I had my gall bladder removed 2 years ago and have been suffering ever since. I was diagnosed with bile reflux as a result. I have a general question for you. What are your thoughts on the roux-en-y surgery for the purpose of mitigating bile reflux? Success probability vs. bad outcomes? TIA
- Sid Schwab said...
John, it can be very effective; there can be side effects as well. I assume you've been tried on medical rx, like questran and/or drugs like prilosec. There's also a question of whether the lower esophageal sphincter is functioning properly. When all else has failed, it's certainly an appropriate consideration. I think it's one of those situations where second opinions are sometimes useful.
- Unknown said...
I just had a lap choly 9.23.09 I had just a constant pain in my URQ and upset stomach very bad about 6 times a day. I would occasionaly have attacks of pain in URQ. Last year in august GB was 88% so they said sorry not sure what your problem is. It got better for about 6 months and came back! This year I moved and it was 22% this august at a different hospital. They advised to remove it. Removed it and it had no stones or sludge but had adhesions from duodenum to gallbladder very bad. Woke up from surgery to a morphine drip screaming in pain. Morphine made it worse. They thought it was gas. I then kept having URQ pain. Took erythromycin for a root canal 3 weeks post op and started having bad attacks again like in recovery. This continued even after I stopped taking it. The pain is now in my epigastric area during attacks and I have constant URQ pain and nausea. I mentioned to my surgeon could it be the erythromycin causing pancreatitis and he said no. It was my bile duct swelling to take the place of my GB and I was probably sensitive. My last attack happened a few weeks ago. I was throwing up yellow liquid. I went to er. they gave me dilaudid which caused another attack so then given ativan which stopped it. I was discharged. I went home and threw up green paste and had bad pain again. Went back my liver levels were elevated. aslt and ast around 350 and tbili around 1.9. My amylase was up to 54 in range but high for me. My normal is 19. Lipase was 14. They admitted me and said I may have sod or microduedcholeastasis sp? My bile duct was not dilated though. Now I have to go to MUSC for ercp and MRCP. I am terrified. I thought my GB removal would fix this but its a lot worse. Now I cannot even have narcotics to help control the pain because they make my sphincter spasm I hurt 10 times more. Does this sound like SOD, pancreatitis or microduedcholeastasis?
- Sid Schwab said...
Karen, I guess all of those are on the list of possibilities. Since, based on your description, it seems you are having the same problems you had before the gallbladder was removed, it's also possible that it has nothing to do with your biliary system. If you read this post, you know I'm a bit of a skeptic on SOD, although I guess it does exist.
It may be a while and a test of your patience and of your doctors' skills to get to the bottom of things. I wish you well. - 11/21/2009 6:13 PM
- Unknown said...
Thanks for writing Sid! I actually am far worse off than when I had the gallbladder. Before I would really only have pain in the URQ and mild attacks since it is out I get severe attacks that feels like the stomach is eating itself about 2 inches down under my breasts in the middle. I cant sit stand or do anything during these aattacks. and since my GB is out morphine and dilaudid causes even more severe pain and attacks so I cant get help that way anymore in the er. I hate this seems to fall under SOD as no one ever really seems cured with the surgery. With SOD it semms you live with pain or with what drugs you can tolerate to manage it. I pray I have something that can be fixed my drs here are not sure and referred me to Dr cotton at musc the SOD expert. Guess I am at his mercy. My Drs here have done colonoscopy that only showed mild- moderate inflammation on biospy, endoscopy that was ok, and CT and ultrasound that is ok. They only know I had very high liver ast/ alt levels during an attack recently that came back down in a few days and an elevated WBC of 15.5- 19 since this started in June. So GI has done all he can do here. I am now referred to MUSC for SOD evaluation and oncologist for the WBC.
I have had stomach issues since I was 15 which have been diagnosed as many things from peptic ulcer to allergy to milk, all of which have not been the case. This week I had the HIDA scan done after the ultrasound revealed no stones. My gastro doc said I have very low output and referred me to a surgeon. I am skeptical after almost 20 years of guesses. My symptoms don't really sound like other people's. My pain is on my left side, carbonated beverages are my worst enemy, the pain is slow coming on but severe once it really gets going, laying on my left side helps, bloated later and weird mucus in my stools the next day and feel like I've been punched in the gut. Any suggestions would be helpful.
- Sid Schwab said...
Well, as you evidently have inferred from this post and from your own experience, you're in a tough category, diagnostically. I wrote another post about that, too. In my experience, if the HIDA scan shows very low output, AND if the injection of CCK (the stuff that makes the gallbladder contract) reproduces the symptoms, there's a pretty good chance (but not certainty) that removing the GB will do the trick.
I don't think I ever took out a gallbladder in these difficult diagnostic situations if the patient hadn't first seen a gastroenterologist who'd investigated all the other possibilities and who concluded the operation was reasonable. It seems you've filled all the squares, so I'd think it's reasonable to see a surgeon. Express your concerns; ask his/her opinion on the chances of resolution by surgery. Ask about possible side effects of the operation.
Ultimately, you have to decide if the discomfort/disabilities you are experiencing are enough that you're willing to have an operation understanding it might not help and that, whereas the chances of adverse effects are low, they're not zero. Absent gallstones, it's highly unlikely that, even if the cause of your troubles is biliary dyskinesia, serious problems would occur if you opt against surgery. Hear what the surgeon has to say, then decide if your symptoms warrant going for it.
It's a heck of a lot easier decision when the symptoms are typical of gallbladder and there are stones present! - 12/05/2009 12:19 PM
Thanks for the blog. I have been reading it off and on for a long time.
It appears I am one of your "just don't know" patients. A year ago I expericed a bout of "biliary colic". No stones were seen on ultrasound and I was released. The pain was a bit atypical in that it lasted days instead of hours, but the location was right.
A couple more episodes led to a HIDA scan with CCK and a GB that looked dead (in the teens EF). GB surgery proceeded and except for a large hematoma/seroma that left my wound draining for 2 months all went well with it...until the pain came back.
In between pain episodes I often have a "dumping syndrome" with the diarrhea minutes after, if not during, a meal. However DURING the pain episodes, which last for days, this stops.
CT scan by the surgeon on the 1st reoccurence of the pain did not show anything. The pain is completely unresponsive to pain medications, so I tend to not accept narcotics. The pain is the same in nature to the pain felt previous to the surgery and my chemistries do not change much (occasional slight liver elevations) during them.
The pain is found in the upper right abdomen, radiating to the back and up into the right shoulder blade. It feels gnawing and caustic and after days leads to a generalized muscle spasm in the area.
I am scheduled for an MRCP, which if all goes as usual, will find nothing.
I have other vagus nerve issues from an illness years ago and think perhaps I have a dysfunction of the SOD or just biliary dyskinesis.
The long preamble was just for catharsis. The base questions are:
Does the bile duct contract in a type of peristalisis moving the bile down its path? In other words, can the dysfunction occur not only at the sphincter but in the smooth muscle contractions down the duct? Would cutting the sphincter be of any use in this case? Can the entire duct be stented open as a trial?
Reading up, it seems like the further we persue the cause of the pain, the more dangerous the tests will get following the MRCP.
Assuming the poor duct motility idea is true, sans stones, does the bile stasis cause any danger? To me it seems like it is causing a good bit of inflammation as this pain is quite long lasting during an episode.
My surgeon is "done with me" and I am back following up with my GP. - 7/25/2010 11:15 AM
- Sid Schwab said...
anonymous: yes, your situation is the nightmare we all hate -- doctors, patients, families. I dragged my feet as long as I could before removing the gallbladder in patients with similar stories. I tried to insist that they had been seen by a gastroenterologist and had all the rocks turned over. It's hard to know to what extent your symptoms were or are related to your biliary system. The pain you describe -- RUQ, radiating to the shoulder blade -- is certainly suggestive.
The bile duct is pretty much an inert tube, without peristalsis. If there are emptying problems, the treatment is some sort of procedure -- endoscopic or surgical -- to open the sphincter. I suppose stenting as a temporary diagnostic procedure would have some merit. You'd have to ask a gastroenterologist about it. I'm not sure there's much advantage to doing it, however, as opposed to a sphincterotomy done endoscopically. With a stent there's more risk of infection.
Bile stasis, in the strict sense that I understand it, is not a good thing. It can cause cirrhosis and other problems. Usually, though, it's a specific diagnosis associated with corroborating evidence which is pretty definitive: certain abnormalities of blood tests, and imaging studies that confirm congestion in the ducts. I infer, without knowing, that such a diagnosis hasn't been made in you.
I assume you've been seeing a gastroenterologist as well as your GP. These are the situations where a good one can be of great help. These are also the situations that try men's (and women's) souls. - 7/25/2010 12:29 PM
I had my gallbladder removed almost 2 years ago. All tests prior were normal. I was experiencing spasmy pain that was constant so the GI dr said my gb could still be a problem so the yanked it out. No stones or sludge was seen, only slight inflammation and some thickened bile and a couple of adhesions. 3 days after the surgery, I experienced a rush of what felt like acid on the URQ that traveled down and across my abdomen and up to my throat. It has been like this ever since. Constant burning pain all over. I've had a HIDA scan that showed bile refluxing into my stomach and I also have bile diarrhea. What the heck happened to cause this? I've tried all the PPI's and they seem to make things worse, Questran, Domperidone, natural stuff, nothing helps. I get pressure in my URQ still and when that is happening, it seems the diarrhea stops. I"m assuming the bile is building up and then when it releases, my intestines are not happy. My last upper Endoscopy showed mild gastritis and bile. Any thoughts or suggestions? I'm petrified of an ERCP so that right now is not an option.
Thanks! - 11/21/2010 9:09 AM
- Sid Schwab said...
Sorry to hear of your trouble. If by "all tests prior were normal" you mean sonogram, HIDA scan and anything else they did to evaluate your GB pre-op, it would have been a tough call to recommend removal.
Assuming your anatomy is otherwise normal, it's hard to imagine in what way or where bile would be "backing up." There are some uncommon anatomical conditions that can partly obstruct the duodenum, Ladd's bands, for example, that could explain the symptoms. So could, perhaps, various malabsorption syndromes.
I suppose it's also possible that something caused surgical changes to the duodeum, although it'd likely be "north" of the place where bile enters, so backup of bile would be an unusual result of a very unusual occurrence.
In general, it's my opinion that post cholecystectomy symptoms often reflect the fact that it was something else going, for which the surgery did no good, than a side-effect of the surgery; especially when the original indications for surgery were not absolutely clear-cut. I'm not suggesting that's the case in your specific situation, because I have no way of knowing. - 11/21/2010 11:48 AM
Sid, Thanks for making your expertise available to patients. After having read information on several different sites regarding gallbladder symptoms, it seems that there is much conflicting advice out there. What is prompting my post here is my situation. I began experiencing mild pain in my lower abdomen and tenderness in my left flank area that lasted for a couple of weeks. I had also been having some acute attacks of pain in my right flank area coming on suddenly and lasting for 30 seconds and then not appearing again for weeks at at time. I decided it was time to get this checked out. I then began having very thin bowel movements and intestinal discomfort which did not go away.(Haven't read that this is really a key symptom of gallbladder problems except under porcelain gallbladder) The next symptom to appear was a burning sensation in my abdomen a while after eating, not the same as heartburn or acid reflux. I feel like I could be a dragon and fire would come out if I exhaled!!! i was also burping a lot. The initial symptoms came on overnight and the rest gradually came on over a period of 3 weeks. Have had a pelvic and vaginal ultrasound, ct scan of abdomen, colonoscopy (found a beign polyp and diveticulosis) and abdominal ultrasound. The abdominal ultrasound confirmed that I do have gallstones and a thickening of the lining of the gallbladder, but no cancer present(Can they really diagnose that from an ultrasound??) From your experience, what are the "typical" symptoms of gallbladder problems. I've also read that sometimes they have found cancer when just doing a surgery to remove the gallbladder due to stones and that having them removed with a lap as opposed to open creates additional problems in this case. By the way, I woke up in the middle of my colonoscopy to intense pain and was told to not move, and obviously they upped my sedation right away as I don't remember anything else. Kind of scary since telling a doped up patient to not move might not guarantee that advice is heeded. One other question...can they detect IBS through a colonoscopy or is that also somewhat elusive. Interesting how after having thin bowels for 3 weeks, cleaning out my colon to prepare for the colonoscopy seems to have eliminated this problem. I understand that you cannot directly comment on my situation, but would appreciate your comments on the questions I have listed, so when I do go back to the doctor, I am an informed patient and can ask the appropriate questions.
- Sid Schwab said...
If you go to the newest post (which is pretty old by now) on this blog, and look at the posts listed in "Sampler" you'll see links to all my ones on the gallbladder, in which most of your questions are answered. Typical symptoms, etc.
IBS is not really associated with any anatomical changes, so it's mostly a diagnosis of exclusion, meaning when they can't come up with anything specific...
I don't think there are symptoms specific to porcelain gallbladder.
Gallbladder cancer is very rare, and even more so in people younger than 60. By what it's removed is less important than if it can be removed entirely. When found incidentally, meaning not expected or seen during surgery but found in a tiny amount when the gallbladder is examined after removal, it may or may not be decided to go back in and remove more of the area around the gallbladder bed. - 2/25/2012 8:33 AM
I have been having abdominal pain for over 3 years now and have had ultrasounds, CT scan, colonoscopy, endoscopy all with normal results. Most recently I had the HIDA scan with an ejection rate of 3.9%. My GI specialist was very confident that having my gallbladder removed would improve my symptoms. (prior to the test he said I had an 80% chance of feeling better if I had my gb removed. After the scan he said my chances increased to 90-95%) I was actually relieved to finally have an answer to my discomfort and was looking forward to being on the road to recovery. My surgeon however, was not as confident and told me my chances of feeling better were only 50% (I haven't seen those figures anywhere else). She was concerned because I have had ULQ pain as well and that is not typical of gb disease. I am currently waiting for a third opinion but was wondering if you could offer any input on patients that have had ULQ pain and had their gb removed with successful results.
- Sid Schwab said...
ULQ pain can certainly originate in the gallbladder; it can present like heart pain, too. The problem is in being sure. It helps a lot when there's undeniable evidence of gallbladder abnormality: stones, swelling, and when other possibilities have been ruled out.
In the situation when no stones or inflammation have been demonstrated, and when the only evidence is a HIDA scan, it's hard to be confident.
As I've said many times here, I was most confident in recommending surgery to a patient without stones when they had typical symptoms, when the HIDA was definitely abnormal, and when the injection of CCK, the drug that makes the gallbladder contract during the study, reproduces the pain. Even then, it's not a slam dunk.
I never considered a HIDA scan that shows poor emptying definitive evidence on its own, absent other corroborating symptoms. On the other hand, there's no way to say surgery won't help. I've had patients whose symptoms were ULQ pain and who were relieved by surgery. Generally, though, they had typical findings on ultrasound.
I always considered the opinion of a consulting GI doc to be important; when they'd ruled out other explanations and recommended surgery, I gave it a lot of credence. It worked out many times; and, sometimes, didn't. - 4/15/2012 7:28 PM
Ive been having daily diarrhea and nausea for over a month now. On occassion it gets to where I cannot keep liquids down for most of the day and just thinking about or smelling food sends me to heaving or all out vomiting until there is nothing left. The nausea and diarrhea can start in the early a.m. hours or just upon waking and last for several hours. I have had gallbladder attacks since '08, but have not been experiencing many, if any at all, since the nausea and diarrhea has started. Ive been tested twice for c- diff, food poisoning, parasites, etc and all have come back neg. All my bloodwork came back normal(all three times) with the exception of my potassium being low, being slightly anemic, and something to do with my bile being very slightly elevated(phosoha-something). The 1 time those results showed was the day i went to the ER for not being able to keep anything down. My GP thought it was the gallbladder and ordered an ultrasound that showed some wall thickening and a stone( not sure if that was plural or not). He sent me to a specialist surgeon thinking he would order a hida scan, but he did not. He did the Murphy jazz, said it was tender in that area, and since the GB showed thickening and stones, it needs to come out. I am set to go in on Tuesday to have it out, but I'm not completely convinced that is the culprit here. Is it common to have my symptoms for this long with no gallbladder pain? The GP seemed a little skeptical because of the lack of upper quadrant pain, but said I did not need a constant pain for the gallbladder to be causing my other symptoms. I am sick of feeling horrible every day, but I really am hesitant to have surgery on the off chance of it not being the reason behind my problems. Both doctors said I could have the GB removed and still continue to to be sick afterward. The specialist said he THINKS that is what's causing this, I just wish he KNEW for sure. I would feel a lot better about having the surgery had the HIDA shown my GB was not performing as it should, but the doc said I didn't need it done because of the ultrasound findings. Would you suggest putting the surgery off and looking into another cause or do you believe this doc is correct in assuming all my problems are due to th GB? I also was put on blood pressure meds 2 days ago. My BP has been high the last few times ive gone to the doc trying to find out what's wrong with me. Ive been feeling very jittery with the nausea, so I'm not sure if the high BP is being caused by the sickness or IS causing it. The last two days I have still felt sick, but have felt slightly better than usual. I just don't know whet to do in regards to the surgery.
- Sid Schwab said...
Chrissy, there's no way for me to know as much as your own doctors. It's likely I'd not have ordered a HIDA either, since it's most useful when there's no obvious abnormality of the gallbladder. If the sonogram showed both stones and definite inflammation, that's at least as much info as you'd get from a HIDA.
I can say, in general, that when there's chronic inflammation of the GB, diarrhea can be a symptom. Neither I nor anyone can say for sure if it's the cause in your case.
I don't feel I can make specific recommendations. - 4/27/2012 3:20 PM
Thanks for the reply. I guess I will just have to trust the doctors decision and hope for the best.
Just wondering how long after having a lap chole could you still feel gas pains behind your sternum....I had mine done a week ago today and it is constant pressure. Thanks.
- Sid Schwab said...
Typically, pain from the gas is felt in the right (or left) shoulder, and generally is gone is less than a week. Substernal pain is a little unusual, I'd say. Worth bringing up with your surgeon.
- Unknown said...
Hi, I had thE HIDA test and they told my gallbladder is at 0 percent and the most reasonable thing to do is to remove it. I don't have the typical symptoms, no pain, no nauseas. I've just noticed that I have weird bowel movements lately and an get bloated easily. I am taking omeprazole for reflux. They did colonoscopy, checked my stomach, liver , pancreas and esophagus. The doctor found acid damage on the esophagus. I've been taking omeprazole for almost 2 months but I don't feel my reflux symptoms are all gone, especially that watery sensation in my throat after I eat big meals. My GE doctor told me that by removing the gallbladder my symptoms should improve. Shold I get it removed? Is the HIDA test pretty accurate? Can my gallbladder go back to work? If a non functional gallbladder is not removed , what happens? Thanks
- Sid Schwab said...
Laura, I'm not really in a position to say whether or not you should have it removed. You can read what I've written about HIDA scans in another post: http://surgeonsblog.blogspot.com/2007/03/its-galling-diagnostic-dilemmas-and.html It represents my approach to my patients, and shouldn't be considered more useful than that of the docs taking care of you. I can't say, from the information provided, whether you fit into "my" criteria or not. And, since I'm too far away ever to know as much as your own docs, I'd not want to opine no matter what other info I had.
Whether a non-functioning gallbladder can return to function depends on why it was non-functioning at the time of the scan. Same answer to your question regarding what happens if it's not removed: depends on why it was seen to be non-functioning. The HIDA scan can't answer that.
Sorry I can't be specific. Your questions are good ones, and should be directed to the docs on your case; particularly the surgeon if/when you see her/him.
- Unknown said...
Hi Sid,
I am really enjoying your blog site, and wish I would have come across this before I made the huge mistake of getting my GB removed on June 2, 2016.
It all started back in 2009 when I was having RUQ pain. I had all kinds of test done and my GB was found to be normal with no stones or sludge performed during a EUS. Only thing that showed an issue was my HIDA scan which showed a 13% ejection fraction. I did not experience any pain when they injected the CCK.. I know now that was a big clue that was missed as my GI did not mention it as having any meaning. They wanted me to get my GB out, but -
about that time, after dealing with pain for several years (2009 thru 2012) Amazingly my pain stopped, and I had 4 years of relative pain free living. I attribute this to me switching to a low fat diet and figuring out what my trigger foods were for attacks.
Fast forward to Feb 2016 and the pain returned.. I had slipped on my diet some, so I went back to low fat, but was not having much success. All the research and test I had done 4 years before was not fresh in my mind, including my prior suspicions that the root cause may actually be SOD or BK.
So being busy as I am, I called the local surgeon, sent all my info over to him, and he was ready to do the Cholecystectomy after seeing my low ejection fraction.. He told me that I most likely had Acalculous cholecystitis.. I had the surgery, and the pathology was no stones, and only inflamed.
When he told me that, I felt a cold chill come over me as I had a feeling I had made a big mistake. And that feeling has come to fruition, as within two days of getting my GB removed, I started getting burning pain that was worse then before.. Now, two weeks after the surgery I am having 3-4 severe attacks of burning pain every day/night that feels like nerve pain but its visceral and last for hours each time. I even feel this nerve sensation in the bottom of my feet..
So, the end result, is now I am dealing with a condition that 10 times worse then before. I am scared and concerned that I have awakened a dragon and there is no escape.. I am now in major scrambling mode, working to get appointments with specialist in billary diseases, as I am almost certain I have SOD..
To make matters worse, a recent study called EPISOD has been published, that is basically saying SOD is fiction and not fact, and that ERCP methods do not work for SOD, and should not be used..I am reading that based on this study, many medical centers are now pressuring their GI's to not perform this procedure.
I am not sure what to do, as the pain I am in is extreme, and I have a wife and 6 and 9 year old to take care of.. With this pain, I can barely work, and its unlike anything I have ever experienced.
Any suggestions, ideas, or words of encouragement would be greatly appreciated.
David Glaze
- Sid Schwab said...
It's a tough situation, Mr Glaze, and it's hard to know what's going on from this far away; probably even close enough to touch you. It might take lots of patience on your part before it's all worked out. I sympathize with your frustration and long-term concerns.
First of all, two weeks after surgery is still quite early and whereas what you're experiencing may or may not be some sort of postoperative condition, since there's lots that goes on in the post-op period, it could improve on its own with more time. I'd guess docs would be reluctant to start looking at other biliary issues this early.
You should be in touch with your surgeon first, I'd think: he/she would, I'd guess want to rule out issues like bile leak or abscess. Absent findings there, I'd also think they might want to rule out nerve irritation as a source; as you suggested, burning pain is often of neural origin, and it could be indirectly related to the surgery, if you've stressed your back in some way. Feeling pain all the way to your feet even raises the possibility of sciatica.
If you've read what I've written about SOD you'll know I share a certain amount of skepticism about the diagnosis, too. But it may well be on the list of things that need ruling in or out. - 6/16/2016 9:54 PM
Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...
In no way is it false modesty to say that physicians are not healers. At best, what we do is to grease the way, to make conditions as favora...
Finally I'm getting around to writing about the gallbladder. Don't know what took me so long, seeing as how, next to hernias it'...
Among many, many who've needed it and accepted it, I've had two patients who refused colostomy . One is dead, the other alive and we...


text:
My Chemical Romance Announces Re-release of "The Black Parade"
My Chemical Romance has announced a re-release of their album "The Black Parade". The band goes on to say "To celebrate the 10th anniversary of The Black Parade, we will be releasing a special edition of the album on September 23 that includes the album plus 11 previously unreleased demos, rarities, and songs from The Black Parade recording sessions.
Pre-order now to get an instant download of "The Five Of Us Are Dying (rough mix)," and early version of "Welcome To The Black Parade."
Album bundles including the vinyl, CD, and exclusive MCRX Flag are available at MyChemicalRomance.com.
We, the members of MCR, dedicate this release to the memory of Craig Aaronson, our friend, our relentless champion, our A&R man. He was appreciated, he was loved, he will be forever missed."
1. The Five of Us Are Dying (rough mix)
2. Kill All Your Friends (live demo)
3. Party At The End Of The World (live demo)
4. Mama (live demo)
5. My Way Home Is Through You (live demo)
6. Not That Kind Of Girl (live demo)
7. House of Wolves, Version 1 (live demo)
8. House of Wolves, Version 2 (live demo)
9. Emily (rough mix)
10. Disenchanted (live demo)
11. All The Angels (live demo)
You can also pre-order on the following services:
iTunes - http://smarturl.it/MCRX.itunes
Google - http://smarturl.it/MCRX.google
Amazon - http://smarturl.it/MCRX.amazon

subset: commoncrawl


text:
The weekends on All Things Considered series Movies I've Seen a Million Times features filmmakers, actors, writers and directors talking about the movies that they never get tired of watching.
For actor Gabriel Macht, whose credits include The Good Shepherd, The Spirit, Love and Other Drugs and the USA TV show, "Suits," the movie he could watch a million times is the rock musical, The Rocky Horror Picture Show. "Tim Curry is just amazing," Macht says.
Interview Highlights
On when he first saw The Rocky Horror Picture Show
"I grew up in New York till I was 5, and I remember going to see Annie and some musicals as a kid, and I remember my parents being somewhat okay with us watching Rocky Horror Picture Show, which, it boggles my mind that they allowed me to watch it."
On how the movie inspired him to become an actor
"My father's an actor and a bunch of his actor friends and writers, they'd come over to the house, and we'd always sort of bombard them with our little shows. And so, my parents just got the biggest kick out of me coming in there like pretending I was Tim Curry as Frank-N-Furter, prancing around, climbing the bookcase, walking down the dining room table, as, like, this "sweet transvestite." And, you know, [a] couple of years ago, someone asked me, "Why'd you become an actor?" And it's because someone clapped."
Copyright 2021 NPR. To see more, visit https://www.npr.org.


text:
If you run an Atheist website. I will be happy to host a link to it at the Atheist Blogroll resource blog.
Minimum Requirements:
Your blog should be written from an atheist, agnostic, or skeptical point of view. There is no requirement that your blog be exclusively atheist or agnostic themed. Many members write about photography, science, or what they had for dinner. I write about many things here at Deep Thoughts, atheism is only one of many of my passions.
We recommend that display an Atheist Blogroll badge on your blog.
Your blog must be an active. An active blog is defined as a blog that posts regularly. Blogs with no activity in six months are dropped from the full member list.
Photoblogs are acceptable.
To grow, the Atheist Blogroll depends on new members. Getting the word out is important. To help, new members are asked introduce the Atheist Blogroll with a post. Something like this is fine:To Join:
Your blog can contain nudity, but I draw the line at pornography. Blogs that portray pornography will be dropped. I am the sole judge when it comes to determining what is porn, although I do listen to the voice of the community.The Atheist Blogroll. You can see the Atheist Blogroll badge in my sidebar. The Atheist blogroll is a community building service provided free of charge to Atheist bloggers from around the world. If you would like to join, visit Mojoey at Deep Thoughts for more information. [insert your blog's name] has been added to
Simply send me an email. Put "Join the Atheist Blogroll" in the subject line to get past my spam filter. In the body of the email, please indicate that you are an atheist or agnostic blogger and include your URL. I will add your blog after I have verified that your blog meets the minimum requirements. Please allow me some to respond. I have a real job too!Promotional Introductions:
If you would like an introduced to the Atheist blogging community, please write a few short paragraphs which describe your blog's focus and and point-of-view. Email it to me using "Introduction on the Atheist Blogroll" as the subject line. See this post for a good example or check out The Atheist Blogroll in the links on my sidebar.About the Atheist Blogroll:
I maintain the Atheist Blogroll resource blog. You can find out about what is happening on the blogroll there.*** Updates ***
- Feb 1, 2007 - Please use Blogrolling's Ping form when updating your blog. Blogrolling.com is experiencing ping spam, which blogs the update service for normal blogs.
- Feb 5, 2007 - I added a rolling version of the blogroll and made RSS, OPML, and PHP version so the blogrolling code available.
- Aug 10, 2007 - Rule change: To join the Atheist Blogroll, one must be an atheist or agnostic blogger. Also, Added a new promotional introduction feature.
- July 27, 2008 - Cleaned up the rules, updated procedures.
- August 2, 2009 - Updated to change files hosting and clean up rules.
- September 2010 - Updated for content and a link to the Atheist Blogroll resource blog.
- September 2010 - Changed content to reflect the drop of blogrolling.com
- June 2011 - updated membership links.


text:
It has been a while since I last made a really nice mushroom dish and consequently mushrooms have been on my mind a lot lately. The one idea that kept coming up was to do a version of eggs benedict where the English muffins are replaced with roasted portobello mushroom caps. Since I was going with a mushroom theme I figured that a tasty mushroom sauce would be a nice replacement for the hollandaise sauce and spinach seemed like a better fit than the ham. With this idea in place I took the opportunity over the weekend to satisfy my mushroom cravings by making these roasted portobello mushrooms with poached eggs in a creamy mushroom sauce for a lazy Sunday morning brunch.
Since the mushroom sauce was going to be the star of the show I started with some flavour packed, umami ladened, dried porcini mushrooms to which I added shallots, garlic, thyme, cream and parmesan. One trick to getting the most flavour from dried mushrooms is to make sure that you use the water that they are soaked in, in the dish like I do in this sauce. The final results from my mushroom eggs benedict idea were a great success and I am looking forward to making these roasted portobello mushrooms with poached eggs in a creamy mushroom again soon! I was also thinking that if you are a fan of blue cheese, like I am , then a nice alternative would be to replace the parmesan with a creamy mild blue cheese.
Roasted Portobello Mushroom with Poached Egg in a Creamy Mushroom Sauce
Grilled portobello mushrooms topped with steamed spinach, a poached egg and a creamy mushroom sauce.
- 2 tablespoons oil
- 4 small portobello mushrooms, stems removed
- salt and pepper to taste
- 1 ounce dried porcini mushrooms
- 1/2 cup hot water
- 1 tablespoon butter
- 1 shallot, finely diced
- 1 clove garlic, chopped
- 1/2 teaspoon thyme, chopped
- salt and pepper to taste
- 1/2 cup cream
- 1/2 cup parmigiano reggiano (parmesan), grated
- 10 ounces spinach, steamed and squeezed to drain
- 4 eggs
- Soak the dried porcini mushrooms in the hot water for 20 minutes.
- Brush the portobello mushrooms with the oil, season with salt and pepper, bake in a preheated 400F/200C oven until tender, about 10-30 minutes, with the gill side up and set them aside to cool. (Note: Roasting time can vary greatly depending on how thick your mushrooms are.)
- Drain the mushrooms and chop them reserving the water.
- Melt the butter in a pan over medium heat.
- Add the porcini mushrooms, shallots, garlic, thyme, salt and pepper and saute for 2 minutes.
- Add the reserved water and simmer at medium-high until reduced by half, about 3-5 minutes.
- Add the cream and parmigiano reggiano and simmer until it thickens, about 2-4 minutes.
- Bring a large pot of water to a boil and reduce the heat to medium.
- Crack an egg into a bowl, swirl the water in the pot and pour the egg from the bowl into the water and repeat for another egg.
- Let the eggs cook until the whites are set but the yolks are not, about 2-3 minutes and fish them out.
- Divide the mushrooms between two plates, top with the spinach, the poached eggs and then pour on the mushroom sauce.
Morel Mushroom and Asparagus Eggs Benedict
Portobello Mushrooms Stuffed with Spinach and Artichoke Dip
Poached Egg on Toast with Chipotle Mayonnaise, Bacon and Avocado
Asparagus with a Poached Egg in Hollandaise Sauce
Asparagus Quinoa Cake
Steak and Eggs Benedict with Asparagus in Bearnaise Sauce
Caprese BLT Balsamic Roasted Portobello Mushrooms
Roasted Potatoes in Creamy Mushroom and Miso Sauce
Roast Head of Cauliflower in Creamy Mushroom Sauce


text:
We connect you with professional facilities dedicated to helping you overcome your alcohol and drug addiction through supervised detoxification.. Stop by our locations and get a walk-in assessment or a free consultation. Drug assessments for youth under age 21 may be provided at no charge.
Our partner facilities are well-equipped to provide first-class alcohol and drug detox services to patients.
They possess the expertise required to address the intricacies of alcohol detoxification and are thoroughly equipped to offer you safe and comfortable treatment. Withdrawing from alcohol addiction can result in distressing physical effects and debilitation.
You will receive medical assistance to navigate the challenging phase of physical alcohol withdrawal, alongside a comprehensive wellness approach that caters to your mental and emotional well-being.
They also provide detox for multiple drugs including opiates and other prescription drugs. So, if you are struggling with opiate and benzodiazepine addictions you will enjoy professional assistance from highly qualified doctors dedicated to helping you recover fully.
They will take care of your physical, mental, and emotional well-being to ensure your tendency to rely on drugs is fully addressed.
Opting for detox as part of your addiction treatment plan is a critical and strategic decision that offers a multitude of benefits.
Detoxification serves as the initial phase of addiction treatment focusing on how to safely and effectively remove the toxic substances from your body. It lays the foundation for a successful recovery journey by addressing the physical, psychological, and emotional aspects of addiction.
You must remember that the withdrawal symptoms that arise when you stop using drugs or alcohol can be severe and even life-threatening in some cases.
Our partner facilities have designed detox programs conducted in controlled medical environments that ensures you receive appropriate medical attention and supervision during this challenging phase.
They have highly experienced medical professionals on standby to manage potentially dangerous withdrawal symptoms, reducing the risks associated with abrupt substance cessation.
We connect you with professional detox clinics and doctors in your local area
(888) 217-1376We connect you with highly professional detox clinics in your local area. Contact us to get connected with detox clinics in Alexander City near zip code 35010 today. Highly experienced rehab specialists are on standby to offer quality detox services.
We acknowledge that your path to addiction recovery is deeply personal and unique for every patient. That is why we strive to connect you with detox facilities that focus squarely on your individual health and well-being.
These facilities will assess your condition and develop a highly personalized care plan tailored to your specific needs. They will even encourage you to involve your loved ones if you wish.
Their wellness programs are designed to benefit both patients and those in their support network, encompassing a wide range of comprehensive treatments including group therapy, counseling, yoga, and massage.
They take into account your home and work commitments when conducting assessments and developing your treatment plan. This ensures that your daily life experiences aren't disrupted while you're on the .
Embarking on a journey toward recovery from substance abuse is a significant and courageous step. However, things may not be straightforward for many patients, especially those considering detoxification (detox) as part of their recovery process in Alexander City, Alabama. A myriad of questions may arise that need to be addressed to help them make an informed decision. Below we answer some of the frequently asked questions about detox and the role it plays in addiction recovery.
Detoxification, commonly referred to as detox, is a fundamental and critical phase in the process of addiction recovery. It involves the controlled and supervised removal of substances (such as drugs or alcohol) from an individual's body, with the primary goal of managing and alleviating the withdrawal symptoms that often arise when a person stops using these substances. Detoxification serves as the initial step in the broader journey of overcoming addiction and achieving lasting recovery.
Detox is conducted under the supervision of medical professionals, ensuring the safety and well-being of the individual undergoing the process. Medical staff can provide appropriate interventions, medications, and supportive care to address any complications or severe withdrawal symptoms that may arise.
Whether or not you need detox depends on your history of substance abuse and your current health situation. Detox is typically recommended for individuals who have been using drugs or alcohol regularly, usually over an extended period.
It may also be required in cases where the individual has taken a large quantity of substances shortly before seeking treatment, or when there are signs of medical complications as a result of drug or alcohol abuse. Ultimately, the decision to undergo detox will be based on your unique circumstances and requirements.
There are different types of detox programs that can be tailored to meet the patient's specific needs and requirements. This includes inpatient detox, conducted in a residential facility where patients stay for a period of time to receive treatment and support; outpatient detox, which allows patients to remain at home while receiving treatment from professionals; and medically supervised detox, which is conducted by medical professionals at a hospital or treatment center.
The type of detox recommended will be based on the patient's unique circumstances and needs, as well as their level of substance abuse. Medical professionals will assess the patient's situation and advice on which option is best suited for you.
While it is technically possible to detox at home, attempting to do so without medical supervision can be extremely risky and should not be attempted. Detoxing from drugs or alcohol can lead to intense withdrawal symptoms that may require specialized medications and treatments, which are only available through professional support services.
Additionally, the temptation of relapse will be far greater when attempting to detox at home, as the individual will be exposed to environmental triggers and social influences that can be difficult to resist. For these reasons, it is recommended that individuals undertake detox in a professional setting where they can receive appropriate medical care and psychological support.
The primary purpose of detox is to remove all toxins from the body and allow for a safe withdrawal from drugs or alcohol without experiencing severe physical symptoms. The primary purpose of the process is to help minimize any risk of relapse or further harm to the patient.
Benefits of detox include: improved physical health, reduced risk of relapse, improved cognitive abilities, increased self-esteem, and improved overall well-being. Furthermore, detox can provide a safe and supportive environment where patients can begin the process of psychological healing and recovery without the distraction and pressure caused by external influences.
Detox is only the first step in the recovery process and does not guarantee long-term sobriety. After completing detox, it is important to seek professional treatment to ensure lasting recovery. This can involve attending counseling sessions or support groups, participating in addiction education programs, or enrolling in a rehabilitation program. It is also recommended that patients take steps towards building and maintaining a healthy lifestyle.
Copyright © Community Counseling Services | We serve the following Alexander City, Alabama zip codes: 35010


text:
With iOS 5, we've added over 200 new features --- taking a mobile operating system that was already years ahead of anything else and moving it even further ahead.
Notification Center
All your alerts. All in one place.You get all kinds of notifications on your iOS device: new email, texts, friend requests, and more. With Notification Center, you can keep track of them all in one convenient location. Just swipe down from the top of any screen to enter Notification Center. Choose which notifications you want to see. Even see a stock ticker and the current weather. New notifications appear briefly at the top of your screen, without interrupting what you're doing. And the Lock screen displays notifications so you can act on them with just a swipe. Notification Center is the best way to stay on top of your life's breaking news.
- No more interruptions. Notifications don't interrupt you and disappear quickly.
- One-swipe access. Swipe down to reveal Notification Center.
- See more at a glance. View stocks and weather, too.
iPad and iPod touch join the conversation. With iMessage, we've created a new messaging service for all iOS 5 users. You can send unlimited text messages via Wi-Fi or 3G from your iPad, iPhone, or iPod touch to anyone with one of those devices. iMessage is built into the Messages app, so you can send text, photos, videos, locations, and contacts. Keep everyone in the loop with group messaging. Track your messages with delivery receipts and optional read receipts, see when someone's typing, and enjoy secure encryption for text messages. Even start a conversation on one of your iOS devices and pick up where you left off on another.
- Send more than text. Send photos, videos, contacts, or locations.
- See when they're typing. Ellipsis points appear when someone's responding.
- Start here, finish there. Begin a conversation on one iOS device and pick it up on another.
A custom newsstand for all your subscriptions. Read all about it. All in one place. iOS 5 organizes your magazine and newspaper app subscriptions in Newsstand: a folder that lets you access your favorite publications quickly and easily. There's also a new place on the App Store just for newspaper and magazine subscriptions. And you can get to it straight from Newsstand. New purchases go directly to your Newsstand folder. Then, as new issues become available, Newsstand automatically updates them in the background --- complete with the latest covers. It's kind of like having the paper delivered to your front door. Only better.
- All the news. Newsstand keeps your subscriptions in one place.
- Read the latest. Alerts tell you when new issues arrive.
- Shop for more. Tap to shop the App Store for new subscriptions.
A better way to do to-dos. Next time you think to yourself, "Don't forget to...," just pull out your iPhone, iPad, or iPod touch and jot it down. Reminders lets you organize your life in to-do lists --- complete with due dates and locations. Say you need to remember to pick up milk during your next grocery trip. Since Reminders can be location based, you'll get an alert as soon as you pull into the supermarket parking lot. Reminders also works with iCal, Outlook, and iCloud, so changes you make update automatically on all your devices and calendars.
- See what's next. View reminders by date.
- Make a list. Reminders appear in a clean, ordered list.
Integrated right into iOS 5. iOS 5 makes it even easier to tweet from your iPhone, iPad, or iPod touch. Sign in once in Settings, and suddenly you can tweet directly from Safari, Photos, Camera, YouTube, or Maps. Want to mention or @reply to a friend? Contacts applies your friends' Twitter usernames and profile pictures. So you can start typing a name and iOS 5 does the rest. You can even add a location to any tweet, no matter which app you're tweeting from.
- Single sign-on. Sign in once and tweet as you go.
- Tweet from your apps. Twitter is integrated systemwide.
- Add a location. Say where you're tweeting from.
Capture the moment at a moment's notice. Since your iPhone is always with you, it's often the best way to capture those unexpected moments. That's why you'll love the new camera features in iOS 5. You can open the Camera app right from the Lock screen. Use grid lines, pinch-to-zoom gestures, and single-tap focus and exposure locks to compose a picture on the fly. Then press the volume-up button to snap your photo in the nick of time. If you have Photo Stream enabled in iCloud, your photos automatically download to all your other devices.
- Access from Lock screen. Open the Camera app with one tap.
- Shutter button. Press the volume-up button to take a picture.
Enhanced photo enhancements. Turn your snapshots into frame-worthy photos in just a few taps. Crop, rotate, enhance, and remove red-eye without leaving the Photos app. Even organize your photos in albums --- right on your device. With iCloud, you can push new photos to all your iOS devices. So if you're taking photos on your iPhone, iCloud automatically sends copies to your iPad, where you can quickly touch them up before showing them off.
- Edit onscreen. Tap to enhance your photo or remove red-eye.
- Crop and rotate. Adjust your photos with ease.
Even better site-seeing. iOS 5 brings even more web-browsing features to iPhone, iPad, and iPod touch. Safari Reader displays web articles sans ads or clutter so you can read without distractions. Reading List lets you save interesting articles to peruse later, while iCloud keeps your list updated across all your devices. On iPad, tabbed browsing helps you keep track of multiple web pages and switch between them with ease. And iOS 5 improves Safari performance on all your iOS devices.
- Reading List. Tap to save a page to read later.
- Tabbed browsing. Move between sites using tabs on iPad.
- Reader. Tap to read articles without clutter.
PC Free
Independence for all iOS devices. With iOS 5, you no longer need a computer to own an iPad, iPhone, or iPod touch. Activate and set up your device wirelessly, right out of the box. Download free iOS software updates directly on your device. Do more with your apps --- like editing your photos or adding new email folders --- on your device, without the need for a Mac or PC. And back up and restore your device automatically using iCloud.
Your inbox is about to receive some great new features. Format text using bold, italic, or underlined fonts. Create indents in the text of your message. Drag to rearrange names in address fields. Flag important messages. Even add and delete mailbox folders on the fly. If you're looking for a specific email, you can now search in the body of messages. And with iCloud, you get a free email account that stays up to date on all your devices.
Get more perspective on your schedule with year view on iPad and week view on iPhone and iPod touch. Tap to create an event and drag to adjust the time and duration. Add, rename, and delete calendars directly from your device. And view event attachments without leaving the Calendar app. iCloud lets you share calendars with friends and family, and it keeps your events in sync on all your devices.
Game Center
iOS is the world's most popular gaming platform. With iOS 5, you can get your game face on with even more Game Center features. Post a profile picture. Meet your match with new friend recommendations based on the games you play and the players you already know. Discover new games without leaving Game Center. And size up an opponent on the spot with new overall achievement scores.
Wi-Fi Sync
Wirelessly sync your iOS device to your Mac or PC over a shared Wi-Fi connection. Every time you connect your iOS device to a power source (say, overnight for charging), it automatically syncs and backs up any new content to iTunes. So you always have your movies, TV shows, home videos, and photo albums everywhere you want them.
Multitasking Gestures for iPad 2
iOS 5 includes a few new moves and shortcuts to help you get around even quicker on your iPad 2: Using four or five fingers, swipe up to reveal the multitasking bar, pinch to return to the Home screen, and swipe left or right to switch between apps.
AirPlay Mirroring
Wow your audience in the board room, classroom, or living room. AirPlay now supports video mirroring. Which means you can wirelessly --- and securely --- stream whatever's on your iPad 2 or iPhone 4S to your HDTV via Apple TV. Everyone in the room sees exactly what's on your iPad or iPhone display up on the big screen --- even when you rotate your device from portrait to landscape or zoom in and out.
iOS 5 comes with innovative new features that make it easier for people with mobility, hearing, vision, and cognitive disabilities to get the most from their iOS devices. iOS 5 works with specialized hardware accessories. The LED flash and custom vibration settings let you see and feel when someone's calling. And improvements to VoiceOver include custom element labeling. These are just a few of the ways iOS 5 continues making advances in the field of accessibility.
Install Instructions:
- Download the firmware for your device
- OPTION-click (on Macs) or SHIFT-click (on PCs) on the Update / Restore button in iTunes
- Now you will be able to tell iTunes to use the IPSW file you downloaded to update / restore your iPhone/iPod
- May 3, 2021
- Apple iOS
- August 26, 2019
- Apple iOS
- September 14, 2016
- Mac OS X
- September 2, 2016
- Apple iOS
- November 23, 2010
- Windows XP/Vista/7
- July 2, 2014
- Apple iOS
- January 29, 2013
- Mac OS X
- January 29, 2013
- Mac OS X
- November 1, 2012
- Mac OS X
- November 1, 2012
- Mac OS X


text:
By Nirmala George
Associated Press
NEW DELHI, India (AP) — Legal proceedings in the fatal gang-rape attack on a student in India's capital began Monday, Jan. 21, in a fast-track court for crimes against women that has stirred debate over how best to deliver justice to rape victims.
Five men face charges they raped and murdered a 23-year-old woman aboard a moving bus in the capital last month in an assault that shocked many in the country for its brutality. A sixth suspect in the attack claims to be a juvenile and his case is being handled separately.
The court was also to hear arguments Monday from defense lawyers appealing for the case, currently being held in a closed court, to be opened to the public, court officials said.
"There is an immense interest in the public in this case, let it be all out in the open court," one of the defense lawyers, A.P. Singh, said.
Police say the victim and a male friend were heading home from an evening movie on Dec. 16 when they boarded a bus, where they were attacked by the six assailants. The attackers beat the man and raped the woman, causing her massive internal injuries with a metal bar, police said.
The victims were eventually dumped on the roadside, and the woman died two weeks later in a Singapore hospital.
Lawyers for the accused say police mistreated their clients and beat them to force them to confess. One lawyer said he would ask the Supreme Court to move the trial out of New Delhi.
The attack has sparked demands for wholesale changes in the way the country deals with crimes against women. Many families pressure relatives who have been assaulted not to press charges, police often refuse to file cases for those who do, and courts rarely deliver swift justice in the few cases that do get filed.
Indian courts had a backlog of 33 million cases as of 2011. In a small sign of the sluggish pace of justice, only one of the 635 rape cases filed in the capital last year has ended in a conviction so far.
Police spokesman Rajan Bhagat cautioned that many other cases remained pending and it was not realistic to expect crimes committed late last year to have wound their way through the system yet.
New Delhi set up five fast-track courts in recent weeks to deal specifically with sexual assault cases.
The courts were an important step for clearing some of the 95,000 rape cases pending in India, said Ranjana Kumari, a women's activist and director of the Center for Social Research, a New Delhi based think tank.
"We need a system in which women can get justice quickly. Otherwise, in the normal course of things, it can take 10 or 12 or 14 years for cases to be taken up by the court. That is tantamount to denying justice to the victim," she said.
Others, however, worried that fast-track courts sacrifice justice for speed, overlooking evidence, limiting the cross-examination of witnesses, and racing through hearings.
Vrinda Grover, a senior lawyer in the Delhi High Court and a women's rights activist, said the traditional court system needs to be overhauled — not abandoned — to give proper justice to rape victims.
"We don't want these cases of sexual crimes against women to become ghettoized in single courts. These cases have to be dealt with by across-the-board judges," she said. "What we need is that in all courts, these cases have to be taken seriously, and need to be addressed without granting unnecessary adjournments. And we need all judges and prosecutors to be oriented in this manner."
"These (fast-track-court) gimmicks do not work. They have not worked in the past," she said, adding that even these cases get bogged down once they go to appeals courts.
Kumari said victims could not afford to wait the decades it could take to reform the justice system.
"In the meantime, the fast-track courts are an absolute necessity," she said. (end)


text:
Sorry, no results for "리조트 월드 카지노 블록 체인 무역 금융【eggc.vip】AUs" on Food Ingredients First
Please try again or Contact us here
Latest Articles
19 Apr 2024 --- This week in industry news, Cargill and Nestlé Purina began a new partnership to support the adoption of regenerative agriculture practices across more than 200,000 acres of corn and soy farmland in the US... Read More
18 Apr 2024 --- Research and suppliers continue to spotlight the efficacy of prebiotic chicory root fiber, its ability to boost digestive health and to modulate the gut-axes. Emerging research points to chicory root as a critical... Read More
18 Apr 2024 --- FoodChain ID has unveiled a regulatory library module called "Sustainable Packaging Services" as a digital tool to enable food manufacturers to keep up with changing global regulations on sustainable... Read More
18 Apr 2024 --- Emmi Group's Brazilian subsidiary, Laticínios Porto Alegre, will acquire a majority stake in dairy product producer Verde Campo from Coca-Cola in the state of Minas Gerais, subject to approval by the... Read More
18 Apr 2024 --- As the F&B industry grapples with food waste, scientists in Singapore have tapped into a technology to extract 80% of the available protein from beer-brewing leftovers known as brewers' spent grain... Read More
18 Apr 2024 --- Tereos has opened a new Customer Innovation Centre located in Aalst, Belgium. The facility is designed to foster innovation and deepen collaboration with customers by offering a range of services and solidifying... Read More
18 Apr 2024 --- Dutch food-tech and cultivated meat pioneer Meatable achieved an industry milestone by hosting the first-ever legally approved cultivated meat tasting in the EU. According to the company, the event marks a crucial... Read More
17 Apr 2024 --- Ingredion's stevia subsidiary PureCircle has received plant breeders' rights (PBR) for its proprietary stevia plant varietal from Chinese regulators in a move that allows the company to expand in... Read More
17 Apr 2024 --- Irish global nutrition group Glanbia has agreed to purchase the leading independent US flavor platform, Flavor Producers, for an initial consideration of US$300 million and a deferred consideration of up to US$55... Read More
17 Apr 2024 --- Danish-Swedish dairy multinational Arla Foods Ingredients debuts a high-protein beverage called Progamer. The functional drink is geared toward nutrition-conscious gamers and e-sporters who want to boost gaming... Read More


text:
All Products
(56 Total)
View by Size:
Synopsis: | Hitchcock's romantic story of obsession, manipulation and fear. Stewart plays a detective forced to retire after his fear of heights causes the death of a fellow policeman and, perhaps, the death of a woman he'd been hired to follow. The appearance of her double (Novak), whom he compulsively transforms into the dead girl's image, leads to a mesmerizing cycle of madness and lies. Features Herrmann's haunting music. |
Directed by: | Alfred Hitchcock |
Producer(s): | Paramount Pictures Alfred Hitchcock |
Cast: | James Stewart, Kim Novak, Barbara Bel Geddes, Tom Helmore, Ellen Corby, Henry Jones, Raymond Bailey, Lee Patrick |


text:
Voted best florist. Order FTD flowers online with Flowers EzGo for same day flower delivery or any surrounding areas. All of our flower arrangements are hand delivered by the very best local FTD florists. With over 70 years in the floral business and over 500,000 deliveries across Canada and United States, you can trust Flowers EzGo with your all occasion needs.
Order flowers online - anywhere in Canada and the United States. Possibility of delivery the same day if the order is placed before 2PM local time of the recipient. In almost every cities, we deliver 7 days a week. We offer more than 500 beautiful bouquets and flower arrangements delivered by the finest FTD florists. Our website offers fresh flowers for every occasion. All our products are designed by professional experts, prepared locally and delivered by hand to the recipient. Currently, we offer Christmas arrangements, poinsettias, Christmas centerpieces, fruit baskets and gourmet baskets!
Toronto Florist · Calgary Florist · Ottawa Florist · Montreal Florist · Edmonton Florist · Vancouver Florist · Winnipeg Florist · Quebec City Florist · Halifax Florist
New York Florist · San Francisco Florist · Los Angeles Florist · Chicago Florist · Washington Florist · Seattle Florist · Boston Florist · Austin City Florist · Houston Florist · Denver Florist · San Antonio Florist · Philadelphia Florist · San Jose Florist · Dallas Florist ·
Portland Florist · Phoenix City Florist · Atlanta Florist