DR MARTIN SCURR: Is gallbladder op to blame for back pain? 

I have had severe bouts of back pain that were only relieved by taking tramadol. This pain is worse on the right side of my spine around my lower ribs. I had my gallbladder removed 12 years ago – could this be related?

Margaret Holt, Glasgow.

It sounds like you are experiencing postcholecystectomy syndrome, a combination of symptoms that include recurrent pain and dyspepsia (indigestion) after gallbladder removal.

‘Cholecystectomy’, the medical term for the removal of the gallbladder, is one of the most common surgeries performed in the UK, and most people do it to relieve the pain caused by gallstones.

But a fairly significant number continue to suffer afterwards: a 2015 study found that only six out of 10 patients report complete pain relief three months after having their gallbladder removed – in other words, four in 10 have the syndrome, although in most cases it will solve.

There are two categories of postcholecystectomy syndrome: ‘early’, where symptoms appear in the immediate postoperative period (ie, within the first three months); and ‘late’, when they last for months or even years – which I suspect is happening in your case.

We know from research that in half of patients with late post-cholecystectomy syndrome, the problem is related to the bile ducts (which carry bile from the liver) or the pancreas – perhaps due to damage caused by the surgery itself – or gastrointestinal disorders, also as a result of gallbladder surgery.

In the other half of cases, the spinal or intercostal nerves — which wrap around the chest and abdomen — are involved. This suggests that the original symptoms were not actually caused by the (now removed) gallbladder.

In my opinion, any pain so severe that it requires a very strong painkiller – such as the tramadol (an opioid painkiller) you have been prescribed – deserves further investigation.

You say in your longer letter that you had a kidney ultrasound, which ruled out a kidney stone.

But you may have a stone in the biliary system, the network of ducts in and out of the liver, bile ducts and gallbladder: this stone may have been there when you had surgery and has since become enlarged.

I recommend asking your primary care physician for a referral to a gastroenterologist.

I wake up at night with my lips and cheeks glued to my teeth because my mouth is so dry. I don’t drink anything after 6pm because I also wake up to go to the bathroom around 4am and go three or four more times before getting up at 8am. I take oxybutynin, stexerol and tamsulosin every day.

Edward Stark, by email.

Dry mouth as the only symptom is generally not caused by a troubling diagnosis, but it would clearly improve your quality of life if it could be resolved.

Dehydration is a common cause: in your case, it may be related to stopping drinking after 6 p.m. to reduce the need to go to the bathroom at night (known as nocturia).

The main cause of nocturia in men is benign prostatic hyperplasia, in which an enlarged prostate puts pressure on the urethra and bladder, causing urinary symptoms.

While tamsulosin (which you are taking) relieves many of the symptoms, such as poor flow, it is not as effective for nocturia.

Depriving yourself of fluids may be less helpful than you’d hope, leading to unwanted effects like dry mouth. If it hasn’t helped with the nocturia, I’d suggest taking it easy and maybe having a glass of water mid-evening.

Dry mouth is also caused by mouth breathing, which is usually related to nasal congestion.

Finally, and I suspect most significantly to you, dry mouth is a symptom of many medications, including oxybutynin. This medication helps reduce the frequency and urgency of urinating (the symptoms you experience in the early hours).

Since it doesn’t seem to have helped your bladder symptoms, there’s reason to stop taking it and you’ll still get the benefit of tamsulosin. Do discuss this with your doctor.