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Postcholecystectomy Syndrome

Postcholecystectomy syndrome refers to persistence or development of symptoms after cholecystectomy. Both biliary and nonbiliary causes that disrupt normal bile flow may be responsible, and clinical presentation most commonly involves dyspepsia and abdominal pain. Additional symptoms include jaundice, fever and diarrhea. The diagnosis is made through use of various imaging techniques. Treatment depends on the underlying cause, and includes surgery in most cases.


Presentation

Symptoms of PCS are primarily related to gastrointestinal complaints, because alterations in bile flow primarily affect the gastrointestinal system. The hallmark of PCS is the presence of dyspepsia and pain in the right upper quadrant of the abdomen as well as chest pain [10]. Symptoms may appear de novo after cholecystectomy, or persist despite adequate surgical treatment. Depending on the cause, the onset may be abrupt, within days after surgery, or insidious. Symptoms can last from months to sometimes years. Additional symptoms include jaundice, diarrhea, dysphagia, fever and bloating. Symptoms encountered in these patients should lead the physician to conduct a detailed diagnostic workup, so that the underlying cause can be determined.

Wound Infection
  • infection 998.59 Postcholecystectomy syndrome 576.0 Reformed gallbladder 576.0 Remnant cystic duct, postcholecystectomy 576.0 Syndrome - see also Disease cystic duct stump 576.0 postcholecystectomy 576.0[icd9data.com]
  • infection - treatment (Medical Encyclopedia) Urinary catheters (Medical Encyclopedia) Urine drainage bags (Medical Encyclopedia) Using an incentive spirometer (Medical Encyclopedia) [ Read More ] Bile Duct Diseases Your liver makes a digestive juice[icdlist.com]
  • infection that healed slowly but with my immune system i expected this.I have been fine since and I have lost 22 lbs .I went on a liquid diet optifast and all my dr monitor me but one thing they all agree ,My health is improving.since I am not eating[3fatchicks.com]
Lymphedema
  • […] see Complications, mechanical, graft other body system NEC 997.99 peripheral vascular NEC 997.2 postcardiotomy syndrome 429.4 postcholecystectomy syndrome 576.0 postcommissurotomy syndrome 429.4 postgastrectomy dumping syndrome 564.2 postmastectomy lymphedema[icd9data.com]
Italian
  • Erenbourg", year "1986", language "Italian", volume "77", pages "1755--1762", journal "Minerva Medicolegale e Archivio di Antropologia Criminale", issn "0026-4806", publisher "Edizioni Minerva Medica S.p.A.[moh-it.pure.elsevier.com]
Nightmare
  • I'm blowing it up to nightmare proportions in my head, mostly from horror stories on the Internet (cf. availability heuristic , misleading vividness ), while simultaneously being embarrassed that I'm doing so when others have it far worse.[ask.metafilter.com]
Biliary Colic
  • Before cholecystectomy, biliary colic was present in 26 patients and dyspepsia in 20 patients; 16 patients also had biliary colic. After surgery, biliary colic disappeared in all patients.[ncbi.nlm.nih.gov]
  • The most common symptoms are dyspepsia or otherwise nonspecific symptoms rather than true biliary colic.[merckmanuals.com]
  • The functional aspect of biliary colic persistent after cholecystectomy. ( 13887771 ) Dreiling D.A. 1962 47 Radiographic small intestine changes in cholelithiasis and postcholecystectomy syndrome. ( 13926184 ) Virtama P....VIRANKO M. 1962 48 Postcholecystectomy[malacards.org]
  • The surgery was without complications, and her classic biliary colic disappeared afterward. Histologic evaluation of the surgical specimen revealed chronic cholecystitis with multiple small, mixed gallstones.[mdedge.com]
  • Biliary colic is self-limiting and dissipates over time. For most patients, the colic does recur, but the interval is extremely variable between patients and can be days to months.[racgp.org.au]

Workup

The diagnosis of PCS is made by obtaining various blood tests and imaging techniques in order to determine the cause of the symptoms.

Prior to performing laboratory studies, a detailed patient history regarding cholecystectomy, including information regarding its course, and the onset, as well as the severity of symptoms should be ascertained. This data may provide significant information to the physician so that tests for illnesses with similar symptoms can be performed and ruled out to reach a diagnosis.

Once a suspicion toward PCS is made, initial laboratory findings include complete blood count (eosinophilia may point to biliary ascariasis), levels of bilirubin, amylase, lipase, prothrombin time (PT), liver transaminases (alanine aminotransferase and aspartate aminotransferase, or ALT and ALT), gamma-glutamyl transpeptidase (GGT), alkaline phosphatase (ALP), lactate dehydrogenase (LDH), to fully assess the status of the hepatobiliary system [11]. Viral hepatitis should be ruled out, while both thyroid hormones and cardiac enzymes, including troponin and creatine kinase (CK), should be evaluated as well.

Ultrasonography is the initial method of choice to evaluate patients with abdominal pain and other findings suggestive of PCS, because it is noninvasive, widely accessible, and almost equally effective as other imaging techniques [12]. Through ultrasonography, the presence of stones, dilation of ducts, and the presence of tumors may be observed. Computed tomography (CT scan) may provide a good view into the abdomen, but the most useful and most specific test used is endoscopic retrograde cholangiopancreatography (ERCP) [13]. This procedure implies the introduction of an endoscope from the upper gastrointestinal tract into the duodenum and provides a direct view of the biliary and pancreatic ducts, as well as the ampulla. Because it is a non-invasive procedure with state-of-the-art ability to produce images with almost equal sensitivity and specificity as ERCP and an effective diagnostic procedure, magnetic retrograde cholangiopancreatography (MRCP) is being used more commonly in clinical practice[14]. MRCP can provide images that are sufficient for the planning of surgical procedures, and thus minimize the risk of damage from instrumentation that can occur with ERCP. The use of contrast during MRCP has been implied to help determine bile leakage [15].

Treatment

Treatment of PCS depends on the underlying cause and may include conservative therapy or various surgical procedures, but endoscopy is considered as the gold standard in both diagnosis and treatment [16].

In the case of lithiasis, biliary stenting may be indicated, to allow passage of bile through the bile ducts. For patients in whom dysfunction of the sphincter of Oddi and papillary stenosis are the causes of PCS, sphincteroplasty or sphincterotomy may be indicated [17], which comprises either correction or removal of the sphincter that regulates bile flow from the cystic and bile ducts into the duodenum. Other surgical procedures that are indicated, depending on the cause, include choledochojejunostomy, choledocholithotomy, and the use of T-tube for drainage and common bile duct repair.

Symptomatic therapy is used for alleviating some of the symptoms, including non-steroidal anti-inflammatory drugs (NSAIDs) for pain, use of antacids, proton pump inhibitors and histamine receptor antagonists for reflux, while rehydration therapy may be essential in patients with severe diarrhea.

Prognosis

Because of the fact that various diseases may cause PCS, the prognosis significantly depends on the underlying cause. Additionally, complications may occur during the process of treatment, but certain studies have established very low rates of complications (around 5%) [9].

Etiology

Causes of PCS include both biliary and extrabiliary disorders, and biliary disorders may be further divided into those that cause symptoms relatively soon after surgical procedure, and those that cause symptoms months or years later. The most common biliary cause is common bile or cystic duct stone remnants. Lithiasis may develop after surgery, due to biliary stasis, or they may have been present before surgery was performed. Additional biliary causes include injury to the bile duct during surgery and bile leakage [3]. These conditions cause early manifestations of PCS, within days or weeks, while causes such as biliary dyskinesia (dysfunction of the sphincter of Oddi), stenosis of the papilla and biliary strictures lead to PCS months or years after surgery.

Non-biliary causes are numerous. Gastrointestinal disorders include various pancreatic diseases, such as acute or chronic pancreatitis and tumors of this organ. Hepatitis, esophageal reflux disease, diverticulitis, development of peptic ulcers, and mesenteric ischemia are also potential causes of PCS. Coronary artery disease, development of neuromas at the wound site, and certain psychiatric disorders are described as causes outside of the gastrointestinal tract. In rare cases, biliary ascariasis, a parasitic infection of the biliary pathway by Ascaris lumbricoides, may be responsible for PCS.

Epidemiology

The incidence of PCS varies significantly from study to study. Overall incidence is presumed to be between 5-40% [4]. Certain studies have determined a slight gender predilection for female patients [5], but overall rates do not suggest a tendency toward either gender. Ethnic predilection has not been established. Slight variations in incidence among age groups have been documented more than 50 years ago [6], but so far, no major correlations have been made.

Sex distribution
Age distribution

Pathophysiology

The pathogenesis of PCS has not been completely unraveled yet, but several factors have been determined to play a role. The exact pathophysiological mechanism can depend on the underlying cause. The primary function of the gall bladder is storage of bile, and when the gall bladder is removed, bile flow becomes disrupted. Additionally, various conditions may cause further changes, such as sphincter dysfunction and lithiasis, resulting in either bile stasis or release of bile into the upper gastrointestinal tract, causing damage to the gastric mucosa and giving characteristic symptoms of dyspepsia [7]. In fact, certain studies have established higher rates of gastritis postoperatively, which supports the fact that bile leakage to the upper GI tract may be the cause of PCS [8]. Alternatively, bile can be released into the lower gastrointestinal tract and causing diarrhea. Inflammation and scarring are often encountered in patients who develop PCS months or years after surgery, suggesting inflammatory mechanisms in the development of this disease.

Prevention

Significant steps can be taken to reduce the overall burden of PCS in clinical practice. Patient awareness, minimizing injury during surgery that may lead to this disease, and regular follow-up of patients in whom cholecystectomy is performed can significantly reduce the incidence.

Patients should be warned that it is not uncommon to experience similar symptoms that were reported prior to gall bladder removal, and they should let their physician know about these complaints as soon as they appear. Since surgical instrumentation is a well known risk factor for PCS, surgeons should perform cholecystectomy with great care. More importantly, a thorough diagnostic workup prior to surgery should minimize the risk of PCS by excluding the presence of stones in the bile ducts, or chronic pancreatitis.

Most importantly, all patients should be regularly followed up after surgery. Ultrasonography is, as mentioned, a quick and widely accessible diagnostic tool that can detect any malformations in the hepatobiliary system, and should be conducted regularly in all patients after cholecystectomy.

Summary

Postcholecystectomy syndrome (PCS) is a term that describes various diseases that may cause symptoms after cholecystectomy [1]. The causes may be numerous, both of biliary and extrabiliary origin [2]. Most common biliary causes include retained stones in the cystic and bile ducts, bile leakage, strictures, injury during surgery, and dysfunction of sphincters in the biliary duct system. On the other hand, nonbiliary causes include various forms of pancreatitis, pancreatic tumors, and other gastrointestinal diseases. Rough estimates suggest that the incidence of PCS ranges from 5-40% and these numbers significantly vary across different studies. Although many causes have been implicated in this syndrome, the pathogenesis uniformly includes alterations in normal bile flow and storage, which can manifest with diverse complaints. Symptoms can appear within days or months or even years after cholecystectomy. Patients most commonly present with dyspepsia and pain in the upper right quadrant of the abdomen. Jaundice, fever, heartburn, odynophagia, dysphagia (all signs of reflux disease), diarrhea and other gastrointestinal (GI)-related complaints have been reported as well. The diagnosis of this syndrome is made by performing various blood tests to evaluate the hepatobiliary system, while imaging techniques may identify the underlying cause. Ultrasonography and computed tomography may provide a good view into the abdomen, but the two procedures of choice include endoscopic retrograde cholangiopancreatography (ERCP) and magnetic retrograde cholangiopancreatography (MRCP), each having their own advantages and limitations. Treatment depends on the underlying cause, and includes various surgical procedures, such as sphincterotomy, biliary stenting, choledocholithotomy, and others. Supportive therapy is recommended, including use of non-steroidal anti-inflammatory drugs (NSAIDs), proton pump inhibitors, and other gastric acid-regulating drugs. Significant steps can be taken to prevent this syndrome through regular follow-ups and careful preoperative examination.

Patient Information

Postcholecystectomy syndrome is used to describe the presence of symptoms such as abdominal pain and indigestion after gall bladder removal. This syndrome can occur due to various diseases that impair normal bile flow, such as the presence of stones in the bile ducts, dysfunction of the sphincter that is unable to regulate normal bile flow, and injury of the biliary system during surgery. Other causes, such as various forms of pancreatitis, tumors of the gastrointestinal tract, and many other can also be responsible for the development of this syndrome. Patients most commonly report indigestion, abdominal pain, diarrhea, jaundice, fever, and other gastrointestinal complaints. The diagnosis achieved by obtaining various blood tests that evaluate the liver function and electrolytes, and imaging studies which are vital in determining the underlying cause. Ultrasound is a good screening method, and is frequently performed in the assessment of patients with abdominal pain, while computed tomography (CT scan) can be used as well. However, the principal method used for the diagnosis of postcholecystectomy syndrome is endoscopic retrograde cholangiopancreatography (known as ERCP). This procedure includes insertion of a camera through the oral cavity, esophagus, stomach, and into the duodenum by using an endoscope, so that a direct view into the bile ducts and the sphincter that regulate bile flow can be achieved. Magnetic resonance cholangiopancreatography (known as MRCP) is a novel imaging technique that is non-invasive and is being increasingly used in clinical practice, since it provides almost identical images as ERCP, but without any risk of injury. Treatment depends on the underlying cause and generally includes various surgical procedures. Symptomatic therapy is commonly used to alleviate symptoms such as pain and indigestion.

References

Article

  1. Womack NA, Crider RL. The Persistence of Symptoms Following Cholecystectomy. Ann. Surg. 1947;126(1):31–55.
  2. Mahid SS, Jafri NS, Brangers BC, et al. Meta-analysis of cholecystectomy in symptomatic patients with positive hepatobiliary iminodiacetic acid scan results without gallstones. Arch Surg. 2009;144(2):180-187.
  3. Schofer JM. Biliary causes of postcholecystectomy syndrome. J Emerg Med. 2010;39(4):406-410.
  4. Porter RS, Kaplan JL. The Merck Manual Of Diagnosis and Therapy 19th Edition. Whitehouse Station, N.J.:Merck Sharp & Dohme Corp.;2011.
  5. Bodvall B, Overgaard B. Cystic duct remnant after cholecystectomy: incidence studied by cholegraphy in 500 cases, and significance in 103 reoperations. Ann Surg. 1966;163:382–390.
  6. Freud M, Djaldetti M, deVries A, Leffkowitz M. Postcholecystectomy syndrome: a survey of 114 patients after biliary tract surgery. Gastroenterologia. 1960;93:288-293.
  7. Iwamura K. Pathogenetic significance of bile acid metabolism in the postcholecystectomy syndrome. Tokai J Exp Clin Med. 1980;5(2):217-232.
  8. Abu Farsakh NA, Stietieh M, Abu Farsakh FA. The postcholecystectomy syndrome. A role for duodenogastric reflux. J Clin Gastroenterol. 1996;22(3):197-201.
  9. Zhou PH, Liu FL, Yao LQ, Qin XY. Endoscopic diagnosis and treatment of post-cholecystectomy syndrome. Hepatobiliary Pancreat Dis Int. 2003;2(1):117-120. 
  10. Bisgaard T, Rosenberg J, Kehlet H. From acute to chronic pain after laparoscopic cholecystectomy: a prospective follow-up analysis. Scand J Gastroenterol. 2005;40:1358–1364.
  11. Terhaar OA, Abbas S, Thornton FJ, et al. Imaging patients with “post-cholecystectomy syndrome”: an algorithmic approach. Clin Radiol. 2005;60:78–84.
  12. Rogoveanu I, Gheonea DI, Saftoiu A, Ciurea T. The role of imaging methods in identifying the causes of extrahepatic cholestasis. J Gastrointestin Liver Dis. 2006;15:265-271. 
  13. Filip M, Saftoiu A, Popescu C, et al. Postcholecystectomy syndrome - an algorithmic approach. J Gastrointestin Liver Dis. 2009;18(1):67-71. 
  14. Girometti R, Brondani G, Cereser L, et al. Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography. Br J Radiol. 2010;83(988):351–361.
  15. Vitellas KM, El-Dieb A, Vaswani KK, et al. Using contrast-enhanced MR cholangiography with IV mangafodipir trisodium (Teslascan) to evaluate bile duct leaks after cholecystectomy: a prospective study of 11 patients. AJR Am J Roentgenol. 2002;179:409–416.
  16. Redwan AA. Multidisciplinary approaches for management of postcholecystectomy problems (surgery, endoscopy, and percutaneous approaches). Surg Laparosc Endosc Percutan Tech. 2009;19(6):459-469.
  17. Moody FG, Vecchio R, Calabuig R, Runkel N. Transduodenal sphincteroplasty with transampullary septectomy for stenosing papillitis. Am J Surg. 1991;161(2):213-218.

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Last updated: 2018-06-21 20:02