Postcholecystectomy syndrome

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sunny Kumar MD [2]

The term postcholecystectomy syndrome (PCS) describes the presence of abdominal symptoms after surgery to remove the gallbladder (Cholecystectomy). Common symptoms include nausea, vomiting, bloating and diarrhea and persistent pain in the right upper quadrant of the abdomen. ^[1]

In 1960, a gastroenterologist named Freud M., described this syndrome. He surveyed 114 patients who had undergone cholecystectomy and found 93% of the patients had pain, 24% had jaundice and 38% had fever.^[2]

There is classification of post cholecystectomy syndrome on basis of involvement of intestinal tract.

Most often laproscopic surgeries lead to trauma or remembrance of stone, which are background players of cholecystectomy syndrome. The pathogenesis of post-cholecystectomy syndrome also includes bile leakage from an overlooked transection of normal or aberrant bile ducts, obstructive jaundice due to inadvertent ligation of the common bile duct or its postsurgical stricture, instrumentation injuries induced during biliary tract exploration, and various types of biliary fistulas.^[3]

Post-cholecystectomy syndrome may be caused due to bile duct injury, biliary leak, biliary fistula and retained bile duct stones. If left untreated it can lead to recurrent bile duct stones, and bile duct strictures.^[4][5][6]

Early post-cholecystectomy syndrome

The causes of early post-cholecystectomy syndrome include the following:

• Retained stones in the cystic duct stump and/or common bile duct
• Bile duct injury/ligature during surgery
• Bile leakage

Late post-cholecystectomy syndrome

The causes of late post-cholecystectomy syndrome include the following:

• Recurrent stones in the common bile duct
• Bile duct strictures
• Cystic duct remnant harbouring stones and/or inflammation
• Gallbladder remnant harbouring stones and/or inflammation
• Papillary stenosis
• Biliary dyskinesia

The extrabiliary causes of post-cholecystectomy syndrome may be classified into gastrointestinal causes and conditions outside of the gastrointestinal tract that may lead to this syndrome. The causes are as follows:

• Acute/chronic pancreatitis (and complications)
• Pancreatic tumors
• Pancreas divisum
• Hepatitis
• Esophageal diseases
• Unexplained pain syndromes
• Peptic ulcer disease
• Mesenteric ischemia
• Diverticulitis
• Organic or motor intestinal disorders

• Psychiatric and/or neurological disorders
• Coronary artery disease
• Intercostal neuritis
• Wound neuroma
• Unexplained pain syndromes

Common differentials of post-cholecystectomy syndrome are:

1. Organic extrabiliary diseases: Esophagitis, gastritis, pancreatitis, costochondritis.
2. Organic biliary diseases: Residual stone, strictures, benign or malignant tumors of the Vater papilla and the periampullary, choledochal cyst
3. Functional extrabiliary conditions: Irritable bowel syndrome (IBS)
4. Functional biliary conditions: Sphincter of Oddi dysfunction (SOD)

Category	Disease	RUQ pain	Jaundince	Weight loss	Trans-abdominal ultrasound	LFT	Serum amylase	Endoscopy	ERCP
Organic extrabiliary diseases	Esophagitis	Yes	No	No	Normal	Normal	Normal	Infammation	Not suggested
	gastritis,	Yes	No	No	Normal	Normal	Normal	Infammation	Not suggested
	pancreatitis	Yes	No	No	Inflammation	Normal	High	Normal	Not suggested
	costochondritis.	Yes	No	No	Normal	Normal	Normal	Normal	Not suggested
Organic biliary diseases	Residual stone	Yes	Yes	No	Stone seen	High	Normal\High	Normal	Stone seen
	strictures	Yes	Yes	No	Dilated CBD	High	Normal\High	Normal	Diagnostic
	benign or malignant tumors of the Vater papilla and the periampullary	Yes	Yes	Yes	Dilated CBD	High	Normal\High	Normal	Diagnostic
	choledochal cyst	Yes	Yes	No	Cyst seen	High	Normal\High	Normal	Diagnostic
Functional extrabiliary conditions	Irritable bowel syndrome (IBS)	Yes	No	Yes	Normal	Normal	Nomral	Normal	Not suggested
Functional biliary conditions	Sphincter of Oddi dysfunction (SOD)	Yes	Yes	No	Dilated CBD	High	Normal\High	Normal	Diagnostic

Around 15 to 20 % of patients going through cholecystectomy experience PCS symptoms. Females are known to be affected more frequently than males.^[7]

Following are risk factors of PCS:

• Laparoscopic surgery
• Inexperienced surgeon
• Irritable bowel syndrome

Patients after cholecystectomy may experience symptoms as pain, jaundice and or fever should be evaluated for PCS.

The time of onset of PCS varies from 2 to 25 days after cholecystectomy. If left untreated, PCS may lead to bowel dysmotility such as gastroparesis, esophageal motility disorders, gastritis, alkaline duodenogastric reflux, gastroesophageal reflux and pancreatitis in severe cases. Patients having functional cause are easy to recover in few weeks.

If left untreated PCS, can lead to possible discomfort in life style. In patients having stone left behind in their bile duct or gallbladder may develop obstructive jaundice.

Prognosis depends on the cause behind the cause of PCS. In general, it is good in patients having no underlying cause.

PCS can be diagnosed clinically with persistent abdominal pain after cholecystectomy, and can be confirmed by laboratory tests and/or ultrasound.

Patient may present with abdominal pain, jaundice or dyspeptic symptoms.

Patient may have jaundice or right upper quadrant pain.

Elevated levels of LFT’s would indicate stone retention or stricture formation..

Following are normal levels:

• ALT. 7 to 55 units per liter (U/L)
• AST. 8 to 48 U/L
• ALP. 45 to 115 U/L
• Albumin. 3.5 to 5.0 grams per deciliter (g/dL)
• Total protein. 6.3 to 7.9 g/dL
• Bilirubin. 0.1 to 1.2 milligrams per deciliter (mg/dL)
• GGT. 9 to 48 U/L
• LD. 122 to 222 U/L
• PT. 9.5 to 13.8 seconds

Post cholecystectomy pain

History & Physical Examination

Lab CBC LFT Serum amylase lipase

Transabdominal ultrasound TUS

Normal TUS & LFT

TUS CBD>10mm &/or abnormal LFT

TUS with stones

Biloma

Abcess

Workup for non-bilary causes

endoscopic US

ERCP

Percutenous drainage

Workup for non-bilary causes

If stone: removal of stone with sphincterotomy If no stone: manomatery with or without sphincterotomy

Trans abdominal ultrasound and ERCP helps in obtaining exact cause of post cholecystectomy syndrome.

Treatment of PCS depends on the cause and symptoms. Once the cause is established the treatment can be wither surgical or medical.^[8]

Treat options are available for following symptoms of PCS:

1. 1 Irritable bowel syndrome :

• Bulking agents
• Sedatives
• Antispasmodics

1. 2 Irritable sphincter:

• High-dose calcium channel blockers
• Nitrates

1. 3 Gastroesophageal reflux disease 

• Antacids,
• Histamine 2 (H2) blockers,
• Proton pump inhibitors (PPIs) 

Surgery is helpful for :

1. Remnant gallbladder or remnant cystic duct lithiasis
2. Sphincterotomy through for patient have debilitating, intermittent right-upper-quadrant pain, and no diagnosis is found.
3. Bile duct injury/ligature during surgery
4. Bile leakage
5. Papillary stenosis
6. Biliary dyskinesia

Good surgical technique, and searching the common bile duct for remaining stones may prevent postcholecystectomy syndrome.

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