Post-cholecystectomy syndrome



OVERVIEW

Definition.

Post cholecystectomy syndrome is a collective term for abdominal symptoms such as abdominal pain, bloating, and dyspepsia that patients experience after cholecystectomy. It is also known as post-cholecystectomy syndrome.

The etiology is complex, including mild nonspecific abdominal symptoms that may not be related to biliary tract disease, and is a very general and vague concept with no specific criteria for diagnosis.

Specific manifestations include abdominal pain, bloating, diarrhea, nausea, and vomiting.

Morbidity

Foreign scholars reported the incidence of post-cholecystectomy syndrome as 5.0% to 40.8%, and domestic scholars reported 11.5% to 50.0% [2]. Females are more common than males.

The incidence of post-cholecystectomy syndrome is slightly higher in open surgery than in laparoscopic surgery, and patients with better preoperative assessment of gallbladder function are more likely to develop post-cholecystectomy syndrome after surgery [2].

Etiology

Pathogenesis

Altered bile acid metabolism

Mostly associated with bile acid malabsorption.

Studies have shown that the absence of gallbladder after cholecystectomy can cause rapid enterohepatic circulation, unconcentrated bile, an imbalance of acidity and alkalinity in the intestinal tract, and a decrease in bile secretion after eating, resulting in intestinal dysfunction leading to dyspepsia, causing a series of gastrointestinal symptoms, especially intermittent or persistent diarrhea.

Oddi sphincter dysfunction

Mainly caused by the narrowing or relative narrowing of Oddi sphincter, the sphincter is in spasm, the bile is not easy to be discharged, the common bile duct is dilated, and the tension of the wall is increased, which may cause right upper abdominal pain.

Common bile duct stones

Residual stones in the common bile duct are the most common cause of post-cholecystectomy syndrome. The incidence is as high as 10% to 15% [1].

It is mostly due to secondary choledochal stones missed before surgery or due to small intraoperative gallbladder stones falling into the common bile duct, or it may be a new choledochal stone, which can present with symptoms of colic, biliary obstruction, and septic cholangitis.

Gallbladder duct residue is too long

It is recommended that the length of residual cholecystic duct in cholecystectomy should be 0.3~0.5cm. If the length of residual cholecystic duct is too long, more than 1.0cm, or if the residual “small gallbladder” is left behind, inflammation and stones may appear, which may cause pain and other symptoms.

As the mucous membrane in the residual small gallbladder still has the function of secretion, it is the basis for secondary infection and recurrence of stones.

Others

Benign stenosis of duodenal papilla, biliary tract infection and biliary tract tumor.

Triggers

Post-cholecystectomy syndrome is often triggered by mental anxiety, stress, alcohol consumption, and consumption of oily food.

High risk factors

People with preoperative co-morbidities of functional and/or organic diseases of the gastrointestinal tract are susceptible to post-cholecystectomy syndrome after cholecystectomy, e.g., co-morbidities of reflux esophagitis, peptic ulcer, esophageal hiatal hernia, pancreatic achalasia, irritable bowel syndrome.

Symptoms

Main symptoms

Abdominal pain

Recurrent epigastric pain is predominant, and the pain is mostly confined to the middle-upper abdomen or the right upper abdomen, presenting as vague or dull pain, usually similar to that before cholecystectomy.

The number of episodes of pain is variable, occurring several times a year or almost daily.

Most patients do not experience symptoms immediately after cholecystectomy, and a few experience them before they are discharged from the hospital after surgery, but some feel a recurrence of their pre-surgical symptoms months or even years after surgery.

Painful episodes may be accompanied by nausea and vomiting. A few severe patients may experience chills, high fever and jaundice.

Other symptoms

Some patients may be accompanied by non-specific digestive symptoms, such as dyspepsia, lack of appetite, epigastric bloating, constipation, belching, diarrhea, etc. Symptoms are mostly mild, and can be relieved without treatment in some patients.

Consultation

Department of Medicine

Hepatobiliary Surgery

When abdominal pain, diarrhea, abdominal distension, nausea, vomiting, accompanied by fever, jaundice, liver insufficiency and other symptoms occur after cholecystectomy, it is recommended to go to the Department of Hepatobiliary Surgery or the Department of General Surgery in time for treatment.

Gastroenterology

If symptoms such as abdominal pain, diarrhea, abdominal distension, nausea, vomiting and liver insufficiency occur after cholecystectomy, you can also go to the Department of Gastroenterology.

Preparation for medical treatment

Preparing for your visit: registering, preparing your documents, and frequently asked questions.

Tips for medical treatment

Bring along relevant cholecystectomy medical records and test results for your doctor’s reference.

Preparation Checklist

Time of onset of symptoms, special manifestations, etc.

Are there any symptoms such as abdominal pain, diarrhea, bloating, nausea, vomiting, etc.?

Is there fever? What is the temperature?

How long have these symptoms been present?

Under what circumstances do they resolve or worsen?

Is there a history of cholecystectomy?

Test results in the last six months, which can be brought with you to the doctor’s office

Laboratory tests: blood routine, blood biochemistry, tumor marker tests, etc.

Imaging examination: abdominal ultrasound, abdominal CT, etc.

Endoscopic examination: barium contrast of digestive tract, ERCP (retrograde cholangiopancreatography via endoscopy), etc.

Other tests: isotope 99Tcm-HDA hepatobiliary scanning, SOM (Sphincter of Oddi pressure measurement), morphine-neostigmine excitation test, etc.

Diagnosis

Diagnosis is based on

Medical history

The patient has a history of cholecystectomy.

Clinical manifestations

The patient has abdominal pain, diarrhea, bloating, belching, nausea, and vomiting.

It may be accompanied by fever and jaundice.

Some patients may have yellowing of the skin and sclera.

Some patients may have pressure pain in the epigastrium and right upper abdomen.

Laboratory tests

Routine tests are performed to determine the presence or absence of infection.

Biliary tract infections usually indicate an increase in white blood cells and neutrophils.

Biochemical tests are performed to determine liver function and the presence of biliary obstruction.

Elevated values of alanine aminotransferase, alanine aminotransferase, direct bilirubin, and total bilirubin may indicate abnormal liver function and possible biliary tract obstruction.

Tumor marker tests are performed to rule out neoplastic diseases.

If the results show markedly elevated alpha-fetoprotein (AFP) and CA199, the presence of a tumor may be suspected and can be differentiated from post-cholecystectomy syndrome.

Imaging

It can determine whether the patient has bile duct stones, bile duct dilatation, and residual gallbladder.

If the results show a strong echogenic light mass in the bile duct, dilatation of the common bile duct ≥ 1 cm, and gallbladder with visualization, it can suggest bile duct stones and residual gallbladder [7].

To determine whether the patient has bile duct stones and bile duct dilatation.

If the results show that the bile ducts present high-density shadow or mixed density shadow, there is proximal bile duct dilatation, which can suggest bile duct stones, bile duct dilatation.

It can help to show biliary system lesions, equivalent to indirect cholangiography, with high sensitivity and specificity for the diagnosis of choledocholithiasis, and can show grade 3 bile ducts.

Endoscopy

To determine whether there are stones, occupancy and other lesions in the biliopancreatic duct, and can take pathology and give treatment at the same time.

If it shows the stone of distal choledochal duct and jugular abdomen, residual stone, mass of lower end of bile duct, it can assist in the diagnosis of post cholecystectomy syndrome.

Others

Isotope 99Tcm-HDA hepatobiliary scanning, sphincter of Oddi manometry (SOM), and morphine-neostigmine provocation test can determine whether a patient has sphincter of Oddi dysfunction. Clinical use is now rare.

Differential diagnosis

Post-cholecystectomy syndrome is differentiated from peptic ulcer and hepatocellular carcinoma:

Peptic ulcer

Similarities: both can present with abdominal pain, bloating, nausea and vomiting.

Differences:

Liver cancer

Similarities: both can present with symptoms such as abdominal bloating, nausea, and vomiting.

Differences:

Treatment

Aim of treatment: eliminate the cause of the disease, release the stenosis, clear the bile duct drainage, control the infection.

Principle of treatment: choose appropriate drugs and surgery according to the different causes of the disease. For those who can’t find the exact cause for the time being, medication can be given to treat the symptoms first.

Medications

Antispasmodics

Common drugs include scopolamine and pivacurium bromide.

Adverse effects include dry mouth, red face, increased heart rate, mild pupil dilation, blurred vision, and so on. Glaucoma, prostate hypertrophy patients are prohibited.

Choleretic drugs

Can promote bile secretion.

Common drugs include ursodeoxycholic acid, anti-inflammatory choleretic tablets and so on.

Adverse reactions are mainly nausea, vomiting, constipation and other gastrointestinal disorders, allergies, headache, dizziness and so on.

Antibiotics

The main effect is to kill bacteria.

Common drugs include levofloxacin, metronidazole, ceftazidime and so on.

Adverse reactions include abdominal discomfort or pain, diarrhea, nausea or vomiting.

Digestive aid drugs

The main effect is to promote peristalsis of the gastrointestinal tract.

Common drugs include polypeptide tablets, compound azimuth enteric-coated tablets and so on.

Endoscopic treatment

ERCP

It is suitable for patients with choledochal stones, residual or recurrent stones, and acute purulent cholangitis.

Surgical procedures include transendoscopic duodenal papillary sphincterotomy (EST), balloon dilatation, and stent placement.

Surgical treatment

Patients with bile duct stones that have failed to be removed by other methods, or patients with a remnant gallbladder or a long stump of the cystic duct can have the bile duct stones removed by open or laparoscopic surgery, or the remnant gallbladder can be removed.

Choledochal jejunostomy can be performed in patients with incompetent, stenotic, or occluded lower end of the common bile duct, recurrent stones or residual stones after biliary surgery, residual gallbladder duct, sphincter of Oddi stenosis or high pressure, postoperative abscess, and difficulty repairing the common bile duct after injury.

Diverticulitis can be treated with diverticulectomy, diverticular intracavity or absenteeism.

Chinese medicine treatment

Chinese medicine believes that this disease mainly lies in the liver, gallbladder, spleen and stomach, the nature of the pathology has deficiency and solid, with the solid evidence is common, Western medicine treatment can be combined with traditional Chinese medicine to dredge the liver and gallbladder, clearing heat and removing dampness.

Commonly used proprietary Chinese medicines include biliary capsule, biliary tablets, rhubarb gallbladder capsule, etc., which can help to improve symptoms such as lack of appetite, bloating, belching, acid reflux, and so on.

Treatment requires evidence-based therapy or empirical prescriptions with additions or subtractions, such as Shu Liver and Qi Tang, Shu Liver and Spleen Tang, and Chai Hu Shu Liver and Bile Tang, etc. On the basis of evidence-based therapy, it can also be combined with comprehensive therapies such as protocol prescriptions and external treatment with acupuncture and moxibustion in order to improve the symptoms, alleviate the pain, and prevent further dysfunction of sphincter muscles.

Other treatments

If the patient has mental disorder such as mental tension, fear, anxiety, depression, etc., appropriate psychological counseling and treatment can be carried out. If necessary, if the tension and anxiety are obvious, add sedative and sleeping drugs such as eszopiclone and alprazolam, etc., and if there are depressive manifestations, give antidepressant drugs such as amitriptyline and duloxetine, etc., to treat, which can effectively alleviate the symptoms of abdominal pain.

Prognosis

Cure

Early diagnosis and early treatment of post-cholecystectomy syndrome have a better prognosis.

Post cholecystectomy syndrome is a cluster of symptoms after surgery, and patients may experience bad moods such as irritability, anxiety and restlessness because they still have preoperative symptoms after surgery.

Daily

Daily management

Dietary management

Eat a low-fat diet with less animal protein, cholesterol and eggs, and more vegetables.

Drink more water.

Life Management

Stop smoking and drinking.

Ensure sufficient sleep time in daily life and less staying up late.

It is recommended to strengthen outdoor physical exercise in daily life, such as walking, brisk walking, etc., to maintain good health.

Pay attention to keep the abdomen warm.

Psychological support

Post cholecystectomy syndrome, may appear the symptoms before surgery, at the same time, the disease course is long, the patient will have irritability, anxiety, uneasiness and other adverse emotions, it is recommended to strengthen the communication with the patient, to encourage the patient to maintain an optimistic state of mind.

Disease monitoring

Patients after treatment should be told to self-observe changes in abdominal pain and diarrhea, such as which part of the pain, the nature of the pain, and the number and amount of diarrhea.

Follow-up review

Patients suffering from post-cholecystectomy syndrome can be reviewed at 3, 6, and 12 months after surgery, and then annually thereafter.

The main review includes physical examination, abdominal ultrasound, liver function, and so on.

Prevention

Maintain a pleasant mood.

Patients are advised to have a light diet, avoiding greasy food, overeating, etc.