(See also Overview of Biliary Function Overview of Biliary Function The liver produces about 500 to 600 mL of bile each day. Bile is isosmotic with plasma and consists primarily of water and electrolytes but also organic compounds: bile salts, phospholipids... read more .)
Postcholecystectomy syndrome occurs in 5 to 40% of patients. It refers to presumed gallbladder symptoms that continue or that develop after cholecystectomy Surgery Cholelithiasis is the presence of one or more calculi (gallstones) in the gallbladder. In developed countries, about 10% of adults and 20% of people > 65 years have gallstones. Gallstones tend... read more , or to other symptoms that result from cholecystectomy. Removal of the gallbladder, the storage organ for bile, normally has few adverse effects on biliary tract function or pressures. In about 10% of patients, biliary colic appears to result from functional or structural abnormalities of the sphincter of Oddi, resulting in altered biliary pressures or heightened sensitivity.
The most common symptoms are dyspepsia or otherwise nonspecific symptoms rather than true biliary colic. 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. Other causes include a retained bile duct stone Choledocholithiasis and Cholangitis Choledocholithiasis is the presence of stones in bile ducts; the stones can form in the gallbladder or in the ducts themselves. These stones cause biliary colic, biliary obstruction, gallstone... read more , pancreatitis Overview of Pancreatitis Pancreatitis is classified as either acute or chronic. Acute pancreatitis is inflammation that resolves both clinically and histologically. Chronic pancreatitis is characterized by histologic... read more , and gastroesophageal reflux Gastroesophageal Reflux Disease (GERD) Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain. Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia... read more .
After cholecystectomy some patients develop diarrhea due to excessive bile acids entering the colon. Often this diarrhea resolves spontaneously but may require treatment with bile acid–binding resins.
Diagnosis of Postcholecystectomy Syndrome
Endoscopic retrograde cholangiopancreatography (ERCP) with biliary manometry or biliary nuclear scanning
Exclusion of extrabiliary pain
Patients with postcholecystectomy pain should be evaluated as indicated for extrabiliary as well as biliary causes. If the pain suggests biliary colic, alkaline phosphatase, bilirubin, ALT, amylase, and lipase should be measured, and ERCP with biliary manometry or biliary nuclear scanning should be done (see Laboratory Tests of the Liver and Gallbladder Laboratory Tests of the Liver and Gallbladder Laboratory tests are generally effective for the following: Detecting hepatic dysfunction Assessing the severity of liver injury Monitoring the course of liver diseases and the response to treatment... read more and Imaging Tests of the Liver and Gallbladder Imaging Tests of the Liver and Gallbladder Imaging is essential for accurately diagnosing biliary tract disorders and is important for detecting focal liver lesions (eg, abscess, tumor). It is limited in detecting and diagnosing diffuse... read more ). Elevated liver tests suggest sphincter of Oddi dysfunction; elevated amylase and lipase suggest dysfunction of the sphincter’s pancreatic portion.
Dysfunction is best detected by biliary manometry done during ERCP Endoscopic retrograde cholangiopancreatography (ERCP) Imaging is essential for accurately diagnosing biliary tract disorders and is important for detecting focal liver lesions (eg, abscess, tumor). It is limited in detecting and diagnosing diffuse... read more , although ERCP has a 15 to 30% risk of inducing 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.
Treatment of Postcholecystectomy Syndrome
Sometimes endoscopic sphincterotomy
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 current evidence indicates that this treatment is efficacious if patients have no objective abnormalities. These patients should be treated symptomatically.