Postcholecystectomy syndrome

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.

Historical Perspective

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

Classification

There is no recognized classification of post cholecystectomy syndrome.

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.

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.

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.

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.

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.

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 cystic duct lithiasis
2. Sphincterotomy through for patient have debilitating, intermittent right-upper-quadrant pain, and no diagnosis is found.

References

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