Postcholecystectomy syndrome

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Postcholecystectomy syndrome
ICD-10 K91.5
ICD-9 576.0

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

Overview

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]

Historical Perspective

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]

Classification

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

Pathophysiology

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]

Causes

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]

Biliary causes:

Early post-cholecystectomy syndrome

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

Late post-cholecystectomy syndrome

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

Extrabiliary causes:

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:

Gastrointestinal causes
Extra-intestinal causes

Differentiating Postcholecystectomy syndrome from Other Diseases

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

Epidemiology and Demographics

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

Risk Factors

Following are risk factors of PCS:

Screening

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

Natural History, Complications, and Prognosis

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.

Natural History:

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:

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

Diagnosis

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

History and Symptoms:

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

Physical Examination:

Patient may have jaundice or right upper quadrant pain.

Laboratory Findings:

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
 
 
 
 
 
 

Imaging Findings:

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

Treatment

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

Medical Therapy

Treat options are available for following symptoms of PCS:

  1. Irritable bowel syndrome :
  1. 2 Irritable sphincter:
  • High-dose calcium channel blockers
  • Nitrates
  1. 3 Gastroesophageal reflux disease 

Surgery

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

Prevention

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

References

  1. Womack, NA (1947). "The Persistence of Symptoms following Cholecystectomy". Annals of Surgery. 126: 31–55. 
  2. FREUD M, DJALDETTI M, DE VRIES A, LEFFKOWITZ M (1960). "Postcholecystectomy syndrome: a survey of 114 patients after biliary tract surgery.". Gastroenterologia. 93: 288–93. PMID 13824916. 
  3. Ghahremani GG (1997). "Postsurgical biliary tract complications.". Gastroenterologist. 5 (1): 46–57. PMID 9074919. 
  4. Jaunoo SS, Mohandas S, Almond LM (2010). "Postcholecystectomy syndrome (PCS).". Int J Surg. 8 (1): 15–7. PMID 19857610. doi:10.1016/j.ijsu.2009.10.008. 
  5. Schofer JM (2010). "Biliary causes of postcholecystectomy syndrome.". J Emerg Med. 39 (4): 406–10. PMID 18722735. doi:10.1016/j.jemermed.2007.11.090. 
  6. Coakley FV, Schwartz LH, Blumgart LH, Fong Y, Jarnagin WR, Panicek DM (1998). "Complex postcholecystectomy biliary disorders: preliminary experience with evaluation by means of breath-hold MR cholangiography.". Radiology. 209 (1): 141–6. PMID 9769825. doi:10.1148/radiology.209.1.9769825. 
  7. Zhou PH, Liu FL, Yao LQ, Qin XY (2003). "Endoscopic diagnosis and treatment of post-cholecystectomy syndrome". HBPD INT. 2 (1): 117–20. PMID 14607662. 
  8. Terhaar OA, Abbas S, Thornton FJ, Duke D, O'Kelly P, Abdullah K; et al. (2005). "Imaging patients with "post-cholecystectomy syndrome": an algorithmic approach.". Clin Radiol. 60 (1): 78–84. PMID 15642297. doi:10.1016/j.crad.2004.02.014. 

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