Postcholecystectomy Syndrome

Postcholecystectomy syndrome is persistence or recurrence of abdominal symptoms after gallbladder removal. It is a group of conditions with biliary and non-biliary causes, not a single disease.

It affects 10% to 40% of patients, and many had symptoms before surgery that were not of gallbladder origin. Women and patients with a pre-operative functional disorder or without gallstones are at higher risk.

Biliary causes: retained or recurrent common bile duct stones, bile duct injury or stricture, bile leak, cystic duct remnant, papillary stenosis and sphincter of Oddi dysfunction. Non-biliary causes: gastro oesophageal reflux, peptic ulcer, chronic pancreatitis, irritable bowel syndrome, functional dyspepsia, bile acid diarrhoea, hepatic disease and abdominal wall pain.

Pathophysiology.

Loss of the gallbladder alters bile acid circulation, causing more bile acid to reach the colon and altering sphincter coordination. In many patients symptoms were never of biliary origin.

Right upper quadrant or epigastric pain, dyspepsia, bloating, nausea, fatty food intolerance, diarrhoea, jaundice or fever (when biliary complications occur).

Red flags.

• Jaundice or dark urine.
• Fever with rigors.
• Weight loss.
• Gastrointestinal bleeding.
• Pain with raised liver enzymes.

Start with the history, then liver tests, lipase, full blood count and C-reactive protein, and ultrasound. Magnetic resonance cholangiopancreatography or endoscopic ultrasound detects stones, strictures and remnants. Perform upper endoscopy for reflux and ulcer, and consider hepatobiliary scintigraphy for leaks. Test for bile acid diarrhoea with the selenium-75 homotaurocholic acid retention test, serum 7-alpha-hydroxy-4-cholesten-3-one, or a short course of a bile acid binder. Exclude coeliac disease and pancreatic insufficiency.

Differential diagnosis.

• Retained common bile duct stone.
• Bile duct stricture or leak.
• Papillary stenosis.
• Peptic ulcer or reflux disease.
• Chronic pancreatitis.
• Irritable bowel syndrome.

Treat the identified cause.

• Retained stones and papillary stenosis: endoscopic retrograde cholangiopancreatography with sphincterotomy and clearance.
• Strictures and leaks: endoscopic stenting or surgical repair.
• Reflux or ulcer: omeprazole 20 to 40 mg orally once daily for 4 to 8 weeks; maximum 80 mg daily; monitor symptoms and magnesium; reduce to 20 mg daily in severe hepatic impairment.
• Bile acid diarrhoea: colestyramine 4 g orally once daily, increased every 3 to 7 days to 4 g two to four times daily as needed; long term; maximum 16 g daily; monitor bowel function and fat soluble vitamins; take 4 hours before or 1 to 2 hours after other drugs; avoid in complete biliary obstruction.
• Functional pain: amitriptyline 10 mg orally at night, increased to 25 to 50 mg; maximum 75 mg daily in this use; monitor ECG and anticholinergic effects; avoid in recent myocardial infarction and arrhythmia; reduce in older adults.

Avoid repeat operations without an objective cause.

Monitoring. Symptom review at 4 to 8 weeks after treatment; liver tests when biliary disease is treated.

Referral and escalation. Gastroenterology and pancreaticobiliary endoscopy; hepatobiliary surgery for strictures and remnants.