Postcholecystectomy syndrome is the persistence of pain or abdominal symptoms after cholecystectomy.
(See also Overview of Biliary Function.)
Postcholecystectomy syndrome occurs in 5 to 47% of patients after cholecystectomy (1, 2). It refers to presumed gallbladder symptoms that continue or that develop after cholecystectomy, or to other symptoms that result from cholecystectomy. The most common symptoms are dyspepsia or otherwise nonspecific symptoms, including vague abdominal discomfort, bloating, or indigestion, rather than true biliary colic.
Removal of the gallbladder usually has few adverse effects on biliary tract function or pressures. In up to 30% of patients with postcholecystectomy syndrome, biliary colic appears to result from functional or structural abnormalities of the sphincter of Oddi, resulting in altered biliary pressures or heightened sensitivity. Other causes include a retained bile duct stone, pancreatitis, and gastroesophageal reflux. Papillary stenosis, which is rare, is fibrotic narrowing around the sphincter, perhaps caused by trauma and inflammation due to pancreatitis, instrumentation (eg, endoscopic retrograde cholangiopancreatography), or prior passage of a stone.
After cholecystectomy, some patients also develop diarrhea (bile acid diarrhea) due to excessive bile acids entering the colon. Often this diarrhea resolves spontaneously but may require dietary adjustment or treatment with bile acid–binding resins.
Care should be taken to identify preoperative conditions such as functional gastrointestinal disorders (disorders of gut-brain interaction) or pre-existing choledocholithiasis, as their symptoms can be misattributed to postcholecystectomy syndrome if they occur postoperatively (2).
General references
1. Lamberts MP, Den Oudsten BL, Gerritsen JJGM, et al. Prospective multicentre cohort study of patient-reported outcomes after cholecystectomy for uncomplicated symptomatic cholecystolithiasis. Br J Surg. 2015;102(11):1402-1409. doi: 10.1002/bjs.9887
2. Nam C, Lee JS, Kim J, et al. Clinical perspectives on post-cholecystectomy syndrome: a narrative review. Ann Med. 2025;57(1):2496408. doi:10.1080/07853890.2025.2496408
Diagnosis of Postcholecystectomy Syndrome
Exclusion of extrabiliary pain
Laboratory tests
Abdominal ultrasound
Sometimes endoscopic retrograde cholangiopancreatography (ERCP) with biliary manometry, magnetic resonance cholangiopancreatography (MRCP) or CT, or biliary nuclear scanning
Patients with postcholecystectomy pain should be evaluated as indicated for extrabiliary (eg, gastroesophageal reflux disease, functional dyspepsia, pancreatic disease) as well as biliary causes. If the pain suggests biliary colic, alkaline phosphatase, bilirubin, alanine aminotransferase (ALT), amylase, and lipase should be measured. Imaging modalities for evaluation of postcholecystectomy pain include abdominal ultrasound, CT, MRCP, ERCP with biliary manometry, and biliary nuclear scanning, depending upon clinical suspicion and initial laboratory findings (see Laboratory Tests of the Liver and Gallbladder and Imaging Tests of the Liver and Gallbladder).
Elevated liver enzymes suggest sphincter of Oddi dysfunction; elevated amylase and lipase suggest dysfunction of the sphincter’s pancreatic portion. Sphincter of Oddi dysfunction is best detected by biliary manometry performed during ERCP, although ERCP with biliary manometry can induce pancreatitis in up to 30% of patients (1), and specific procedural guidelines exist for prevention of acute pancreatitis. Manometry shows increased pressure in the biliary tract when pain is reproduced. A slowed hepatic hilum-duodenal transit time on a scan also suggests sphincter of Oddi dysfunction.
Diagnosis of papillary stenosis is based on a clear-cut history of recurrent episodes of biliary pain and abnormal liver (or pancreatic) enzyme tests. Imaging studies such as ultrasound, CT, or MRCP can demonstrate nonspecific findings associated with symptoms of papillary stenosis.
Diagnosis reference
1. Tenner S, Vege SS, Sheth SG, et al. American College of Gastroenterology Guidelines: Management of Acute Pancreatitis. Am J Gastroenterol. 2024;119(3):419-437. doi:10.14309/ajg.0000000000002645
Treatment of Postcholecystectomy Syndrome
Sometimes medication
Sometimes dietary intervention
Sometimes endoscopic sphincterotomy
Treatment depends on the cause.
For bile acid diarrhea, bile acid binders such as cholestyramine are used (For bile acid diarrhea, bile acid binders such as cholestyramine are used (1). For functional gastrointestinal disorders such as functional dyspepsia or irritable bowel syndrome, a stepwise approach with lifestyle modification, dietary changes, and medications may be helpful. For symptoms that are specifically postprandial, promotility agents may be used. Finally, for chronic postoperative pain without a clear etiology, multidisciplinary care may be required, sometimes including the use of serotonin-norepinephrine reuptake inhibitors (eg, duloxetine) for symptomatic relief.reuptake inhibitors (eg, duloxetine) for symptomatic relief.
Endoscopic sphincterotomy can relieve recurrent pain due to sphincter of Oddi dysfunction, particularly if due to papillary stenosis. Endoscopic retrograde cholangiopancreatography (ERCP) and manometry have been used to treat postcholecystectomy pain; however, no evidence indicates that this treatment is efficacious if patients have no objective abnormalities. However, symptoms should be treated.
Treatment reference
1. Nam C, Lee JS, Kim JS, et al. Clinical perspectives on post-cholecystectomy syndrome: a narrative review. Ann Med. 2025;57(1):2496408. doi:10.1080/07853890.2025.2496408
Drugs Mentioned In This Article
