Postcholecystectomy Syndrome - Causes, Symptoms, Diagnosis, and Treatment

Introduction

Cholecystectomy is a surgical treatment that removes the gallbladder. When the gallbladder functions abnormally due to disease, it sometimes develops a blockage in the bile duct, creating a complete or partial blockage. This condition is treated with cholecystectomy.

Sometimes, the recurrence of similar symptoms is seen after performing a cholecystectomy. The patient is presented with a group of symptoms seen before cholecystectomy and associated with a specific disease or condition. This group of recurrent symptoms is called postcholecystectomy syndrome, in which the recurrence of abdominal pain is the most common. Various diagnostic tools are available to identify the cause, out of which endoscopic retrograde cholangiopancreatography is the most effective and helpful diagnostic tool. A combination of medication and a surgical approach is performed to treat the condition based on the symptoms and cause.

What Is Postcholecystectomy Syndrome?

When abdominal symptoms such as pain recur after cholecystectomy, it is called postcholecystectomy syndrome. This condition is termed a syndrome because a group or set of symptoms occurs together, and these symptoms are associated with a specific disease or condition.

What Causes Postcholecystectomy Syndrome?

The common cause of postcholecystectomy syndrome is a disease of the bile duct, gallbladder, liver, etc. Biliary disorders and conditions of the intestine such as:

• Pancreatitis - Inflammation of the pancreas.

• Pancreatic Cancer - Cancer of the pancreas.

• Hepatitis - Inflammation of the liver.

• Peptic Ulcer - Formation of sore on the lining or wall of the abdomen.

• Mesenteric Ischemia - Blockage of an artery that supplies to the intestine.

• Diverticulitis - A bulge formation in the digestive tract.

• Intercostal Neuralgia - Pain in the nerve affecting the chest, area below the ribs, or upper abdomen.

• Neuroma - A ball-like lesion caused by a nerve that occurs during the healing process.

What Are the Postcholecystectomy Syndrome Symptoms?

The symptoms are:

• Pain in the upper right quadrant of the abdomen.

• Intolerance of fatty food items.

• Nausea and vomiting.

• Heartburn.

• Diarrhea.

• Jaundice.

• Gas in the stomach - flatulence.

What Is the Pathophysiology of Postcholecystectomy Syndrome?

It is associated with the altered flow of the bile juice after the gallbladder removal (cholecystectomy) because the gallbladder stores the bile juice. Although the researchers do not very well understand the pathophysiology, it is believed that this syndrome is caused by different diseases of the gastrointestinal tract, as mentioned above.

How to Diagnose Postcholecystectomy Syndrome?

1) Patient’s Medical History: It is essential to examine the medical history, previous treatment, diagnosis, etc. Carefully identify the cause of the syndrome.

2) Laboratory Test: Complete blood count must be done to identify the presence of infection. The complete metabolic panel, prothrombin time, and amylase. It will help to determine liver or pancreas-related disease. The blood gas test or analysis will help in examining the toxicity. Other tests that may be helpful to identify the cause are hepatitis panel, thyroid function, gamma-glutamyl transpeptidase, etc.

3) Imaging Test: The following tests are recommended:

• An X-ray of the chest will be helpful to assess the lung condition.

• Ultrasound of the abdomen is suggested to examine abdominal organs.

• Computed tomography will identify the presence of abnormalities developed as a complication of pancreatitis, such as pseudocysts.

• A hepatobiliary iminodiacetic acid scan may reveal the leakage of the bile juice and dysfunction of the sphincter of the Oddi.

• Esophagogastroduodenoscopy may help the doctor directly visualize the ampulla of Vater. This type of endoscopy also examines the esophagus, stomach, and duodenum to check for the presence of any abnormalities or blockages.

• Endoscopic retrograde cholangiopancreatography is the most effective and helpful diagnostic tool. It identifies the remnants of the stones.

• Magnetic resonance cholangiopancreatography or percutaneous transhepatic cholangiography is recommended for those who cannot undergo endoscopic retrograde cholangiopancreatography.

How to Treat Postcholecystectomy Syndrome?

Giving patients medications mainly aims to prevent further complications and reduce the risk of death. For this purpose, the following medicines must be administered:

• Bulking Agents - These are made of synthetic material or bovine collagen such as bran, and Espagnol. It increases the fecal or stool mass. This enhances the wave-like movement of muscles to move the food through the entire digestive tract - peristalsis.

• Antispasmodics - These medications relieve muscle spasms.

• Sedatives - These slow down the brain's activity, reduce anxiety, and make the patient feel relaxed.

• Cholestyramine - These prevent the accumulation of cholesterol in the blood vessels and are helpful in diarrhea.

• Antacids - These neutralize the effects of the acid present in the stomach to relieve heartburn and indigestion.

• Histamine-2 Blockers and Proton Pump Inhibitors - They reduce the stomach's acid.

Surgical treatment is suggested when the specific cause of postcholecystectomy syndrome is diagnosed. It includes the following methods:

• Exploratory Surgery: Sometimes, when the cause of postcholecystectomy syndrome is not diagnosed, exploratory surgery is required.

• Sphincteroplasty: It is a procedure to correct the sphincter muscles through surgery. These muscles control the movement of the bowel. When these muscles do not function normally, then the leakage of fecal material occurs.

• Sphincterotomy: It is a procedure in which the sphincter muscles are removed or corrected through stretching. It is the most effective and suggested treatment when other options fail.

• Biliary Stent Placement: In this surgical procedure, a stent a thin hollow tube is inserted into the bile duct. This helps keep the duct open, remove the blockage, and prevent the blockage's recurrence.

• Biliary Drainage: When the bile duct is blocked, the extra bile in the duct is drained out through a surgical procedure. A hollow tube is inserted into the liver, so bile is drained and collected in the bag. This procedure is done with X-rays and contrast injections.

What Are the Complications of Postcholecystectomy Syndrome?

The possible complications are:

• Diarrhea.

• Bloating (feeling of fullness in the stomach due to gas).

• Formation of stone.

• Mirizzi syndrome (obstruction of the hepatic duct due to impacted stone).

• Cholangitis (inflammation of the bile duct).

Conclusion

Up to 15 % of cholecystectomy patients develop postcholecystectomy syndrome. These patients develop a group of symptoms, such as severe and recurrent pain in the upper right quadrant of the abdomen associated with a specific disease. It is essential to carefully assess the patient's medical history, such as the previous surgery, diagnosis, treatment, etc to identify the exact cause of the recurrence. Sphincterotomy is the most effective treatment option available to treat the syndrome. Early diagnosis and identification of the symptoms will improve the outcome and prevent further complications.