(See also Overview of Biliary Function.)
Postcholecystectomy syndrome occurs in 5 to 40% of patients. It refers to presumed gallbladder symptoms that continue or that develop after cholecystectomy, 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, pancreatitis, and gastroesophageal reflux.
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 and Imaging Tests of the Liver and Gallbladder). 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, 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.
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.