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Postcholecystectomy Syndrome - StatPearls - NCBI Bookshelf
Postcholecystectomy Syndrome - StatPearls - NCBI Bookshelf
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Postcholecystectomy Syndrome
Rasiq Zackria; Richard A. Lopez.
Objectives:
Describe how enhanced coordination of the interprofessional team can lead to more rapid
detection of post-cholecystectomy syndrome and subsequently enhance the detection of
pathology and allow for treatment when indicated.
Introduction
Post-cholecystectomy syndrome (PCS) is the term used to describe the persistence of biliary
colic or right upper quadrant abdominal pain with a variety of gastrointestinal symptoms, which
are similar to the features experienced by an individual before cholecystectomy.[1] As the name
suggests, this syndrome can represent either a continuation of symptoms caused by gallbladder
pathology or development of new symptoms that usually correlate with the gallbladder. The
symptoms include fatty food intolerance, nausea, vomiting, heartburn, flatulence, indigestion,
diarrhea, jaundice, and intermittent episodes of abdominal pain.[2] Post-cholecystectomy
syndrome can present early, typically in the post-operative period, but can also manifest months
to years after surgery.
Etiology
Early studies focused primarily on anatomic abnormalities identified at the time of exploratory
surgery. An improved understanding of disorders/etiologies has grown with improvements in
technology and imaging studies affecting the preoperative approach to these patients. Post-
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cholecystectomy syndrome may result from organic or functional diseases of the gastrointestinal
tract and can be further classified based on the origin of symptoms[2][3][4]:
Epidemiology
Approximately 500000 cholecystectomies were performed each year in the late 1990s in the
United States; mostly laparoscopic. About 50000 or more cases of PCS occurred each year with
at least 10% of patients developing PCS. The frequency of PCS varies widely in the literature
with 5 to 30% of patients reported to have post-cholecystectomy syndrome. International
incidence of post-cholecystectomy syndrome is almost identical to the United States. One study
found that 65% of patients had no symptoms, 28% presented with mild symptoms, while only
2% had severe symptoms.[5] This study also found that the cause of post-cholecystectomy
syndrome was by functional disorders in 26% of patients. Previous investigations attempted to
evaluate the preoperative risk of cholecystectomy on the symptoms, but results were
contradictory due to variations of the study design.[6] Although no preoperative risk
stratification exists, certain factors make an individual more likely to develop PCS[7]:
There is an exponential increase in the risk of developing PCS with increasing duration of
preoperative symptoms
About 20% of patients will develop PCS whether choledochotomy is performed or not
One study identified age and sex differences in the incidence of PCS with patients aged 20 to 29
years with an incidence of 43% while those aged 30 to 69 years had an incidence of 21 to 31%
and a female-to-male incidence ratio of 1.8:1.[8]
Pathophysiology
The pathophysiology is related to alterations in bile flow suggested by the removal of the
reservoir function of the gallbladder altering bile flow. Bile is thought to be the main trigger in
patients with mild gastroduodenal symptoms or diarrhea. While our current knowledge about the
pathophysiology of post-cholecystectomy syndrome has improved since the introduction of
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Evaluation
Initial post-cholecystectomy syndrome workup would usually include:
Complete metabolic panel (CMP), amylase, lipase, and prothrombin time (PT) to evaluate
for possible hepatobiliary or pancreatic diseases
If the above are within reference ranges, repeating these studies when symptoms are present
should be considered. Also, other laboratory studies may be indicated to rule out other etiologies
including gamma-glutamyl transpeptidase (GGT), hepatitis panel, thyroid function, and cardiac
enzymes.
Radiographic studies should also be pursued with chest radiography to screen for pulmonary and
mediastinal conditions. Abdominal films should also be obtained in most cases. An abdominal
ultrasound is a quick, inexpensive and noninvasive method to evaluate the hepatobiliary system,
pancreas, and surrounding areas. Common bile duct (CBD) dilation of up to 10mm is normal,
while dilation exceeding 10mm, in most cases, is diagnostic of obstruction distally suggestive of
retained stone, CBD stricture, or ampullary stenosis. Computed tomography (CT) can assist in
identifying pancreatitis or complications from pancreatitis such as pseudocysts. Nuclear imaging
such as a hepatobiliary iminodiacetic acid (HIDA) scan may demonstrate a biliary leak or help
identify sphincter of Oddi dysfunction as a potential cause although differentiation between
stenosis and dyskinesia is difficult. Endoscopic ultrasonography (EUS) is a valuable tool for
determining which patients would require endoscopic retrograde cholangiopancreatography
(ERCP); the use of EUS aided in reducing the number of patients who received ERCP by 50%
and may be useful in identifying cystic remnant stones.[9] Esophagogastroduodenoscopy (EGD)
allows direct visualization of the ampulla of Vater and evaluates the mucosa throughout from the
esophagus to the duodenum for signs of disease. ERCP is considered the most helpful test for
diagnosis of the postcholecystectomy syndrome as about half the patients with PCS have a
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biliary etiology for the disease. Therapeutic maneuvers including stone extraction, sphincter
dilation, or sphincterotomy can be performed at the time of the ERCP. Percutaneous transhepatic
cholangiography (PTC) or magnetic resonance cholangiopancreatography (MRCP) is an option
for those patients who are unable to undergo ERCP.
Treatment / Management
Post-cholecystectomy syndrome is generally a temporary diagnosis as further workup establishes
an organic or functional diagnosis. Upon determining the diagnosis, treatment should be guided
by the specific diagnosis made and may include pharmacologic or procedural approaches.
Pharmacologic approach
The goal of pharmacotherapy is to prevent complications and reduce morbidity. The following
approaches may be pursued in the management of patients with PCS[10]:
For patients with GERD or gastritis symptoms, antacids, histamine-2 blockers, or proton-
pump inhibitors may provide relief from symptoms
One study demonstrated that patients with dyspeptic symptoms correlated with the
concentration of gastric bile salt - however, this has not been reproducible; these patients
may benefit from bile acid binders such as cholestyramine.
Procedural approach
Procedural therapy should point towards the specific diagnosis, just like pharmacologic
therapy[3][11]. Surgery is an option when there is a well established and identifiable etiology
known to respond to operative intervention. ERCP is the most commonly pursued procedure as it
can be both diagnostic and therapeutic. Rarely, no cause of PCS is identifiable on initial workup
and ERCP. In these cases, that may also prove to be refractory to medical therapy; exploratory
surgery may be necessary. If exploration is unrevealing, the patient may respond to
sphincteroplasty.
Differential Diagnosis
As symptoms of post-cholecystectomy syndrome may originate from other organic diseases of
the gastrointestinal tract, differential diagnosis can be difficult and often extensive. To identify an
underlying organic disorder, a thorough history, physical examination, laboratory studies,
abdominal imaging, and/or endoscopy may be useful, which will help identify or rule out either
biliary or non-biliary etiologies of PCS.
Prognosis
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The outcome and prognosis in post-cholecystectomy syndrome vary by the patients and
conditions encountered including the procedures that may be performed. One study showed that
75% of patients demonstrated good relief of pain on long-term follow-up.[13] Follow-up care
should be emphasized by the physician to ensure appropriate postoperative management.
Complications
Complications after undergoing cholecystectomy include the development of diarrhea or bloating
due to alteration of biliary flow. There is also the possibility of having a cystic duct remnant that
could potentially lead to stone formation and cause Mirizzi syndrome. In patients with stent
placement during ERCP, it is crucial to ensure timely removal of the biliary stent within 3 to 6
months to prevent the development of occlusion, migration of the stent or cholangitis.
Review Questions
References
1. Jaunoo SS, Mohandas S, Almond LM. Postcholecystectomy syndrome (PCS). Int J Surg.
2010;8(1):15-7. [PubMed: 19857610]
2. Schofer JM. Biliary causes of postcholecystectomy syndrome. J Emerg Med. 2010
Oct;39(4):406-10. [PubMed: 18722735]
3. Redwan AA. Multidisciplinary approaches for management of postcholecystectomy
problems (surgery, endoscopy, and percutaneous approaches). Surg Laparosc Endosc
Percutan Tech. 2009 Dec;19(6):459-69. [PubMed: 20027088]
4. Girometti R, Brondani G, Cereser L, Como G, Del Pin M, Bazzocchi M, Zuiani C. Post-
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