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). Symptoms include gastrointestinal distress and persistent pain in the upper right abdomen. [1]

Historical Perspective

In 1960, Freud M, gastroenterologist, surveyed 114 Post cholecystectomy patients and found 93% had pain, jaundice in 24% and 38% had fever.[2]

Classification

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

Pathophysiology

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

Causes

The causes can be due to bile duct injury, biliary leak, biliary fistula and retained bile duct stones. If untreated it can lead to include recurrent bile duct stones and bile duct strictures.[4][5][6]

Biliary causes:

Early PCS

Retained stones in the cystic duct stump and/or common bile duct

Bile duct injury/ligature during surgery

Bile leakage

Late PCS

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

Extrabiliary causes:

Gastrointestinal causes
  • Acute/chronic pancreatitis (and complications)
  • Pancreatic tumours
  • Pancreas divisum
  • Hepatitis
  • Oesophageal diseases
  • Unexplained pain syndromes
  • Peptic ulcer disease
  • Mesenteric ischaemia
  • Diverticulitis
  • Organic or motor intestinal disorders
Extra-intestinal causes
  • Psychiatric and/or neurological disorders
  • Coronary artery disease
  • Intercostal neuritis
  • Wound neuroma
  • Unexplained pain syndromes

Differentiating Postcholecystectomy syndrome from Other Diseases

Common differentials of cholecystectomy syndrome are:

  1. Organic Extrabiliary Diseases: esophagitis, gastritis, pancreatitis, costosondritis.
  2. Organic Biliary Diseases: Residual stone, strictures, benign or malignant tumors of the Vater papilla and the periampullary, Choledochal cyst,
  3. Functional Extrabiliary Causes: irritable bowel syndrome (IBS)
  4. Functional Biliary Causes: Sphincter of Oddi dysfunction (SOD)

Epidemiology and Demographics

Around 15 to 20 % of patients going through cholecystectomy experience PCS symptoms.

Risk Factors

Following are risk factors of PCS:

  • Laparoscopic surgery
  • Inexperienced surgeon
  •  Irritable bowel syndrome

Screening:

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

Natural History, Complications, and Prognosis

PCS complications depend on the cause of behind it. 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 is diagnosis for time being. Work done after symptoms com to medical attention help in categorizing the cause as either functional or organic.

Diagnostic Criteria:

Patient presenting with symptoms should be evaluated with Abdominal ultrasound and blood tests for CBC and LFT's.

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.[7]

Medical Therapy

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

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

Rowachol is being used to prevent PCS.[8]

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. 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. 
  8. Doran J, Keighley MR, Bell GD (1979). "Rowachol--a possible treatment for cholesterol gallstones.". Gut. 20 (4): 312–7. PMC 1412390Freely accessible. PMID 447112. 
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