Postcholecystectomy Syndrome

What is Postcholecystectomy Syndrome?

Postcholecystectomy Syndrome is considered as a complication of the cholecystectomy, which arises after the surgical removal of the gallbladder.

In postcholecystectomy syndrome, gallbladder pathology related symptoms are persisted or gallbladder attributed symptoms are newly developed.

The by removal of the gallbladder-related symptoms like gastritis and diarrhea are also included into the postcholecystectomy syndrome^1,2.

Incidence

Postcholecystectomy Syndrome is associated condition of cholecystectomy. Those who had a cholecystectomy (surgical removal of the gallbladder), among them approximately 5 percent to 40 percent of patients have the chance to experience postcholecystectomy syndrome.

The female patients are more susceptible to the development of postcholecystectomy syndrome than male, the investigation showed that among total incidence rate, almost 28 percent female and only 15 percent male get affected with the postcholecystectomy syndrome.

It has been also found that young adults (20 to 19 years old) and elderly people with age between 60 to 69 years are mostly affected with the postcholecystectomy syndrome. however, Individuals more than 70 years of age do not have the risk to develop the postcholecystectomy syndrome^1,2,3.

Pathophysiology

Bile disorder is main pathophysiological condition responsible for the postcholecystectomy syndrome, which provides mild gastroduodenal symptoms or diarrhea.

In a healthy individual, gallbladder acts as a reservoir of bile. But after cholecystectomy, bile circulation altered, which also affects enterohepatic bile circulation.

The detailed knowledge of pathophysiology in regards of bile flow alteration is not completely understood.

The early pathophysiological concept is based on exploratory surgery, but later imaging technology showed that biliary tract disorder is primary culprit for the development of the postcholecystectomy syndrome. Therefore, in association with gallbladder ailments, disorders of the biliary tract (including irritable sphincter) the most common causes of the postcholecystectomy syndrome.

It has been also found that almost 10 percent postcholecystectomy syndrome related biliary colic develops due to defective structural or functional disorder of the sphincter of Oddi. This consequentially alters biliary pressures or increases sensitivity¹.

Symptoms

The symptoms of the postcholecystectomy syndrome are as follows:

• Dyspepsia
• Biliary colic
• Stomach Upset
• Nausea
• Vomiting
• Gas formation in the stomach
• Bloating
• Flatulence
• Diarrhoea
• Repetitive pain in the right side of the upper abdomen
• Papillary stenosis (rare symptoms), in which the sphincter of bile duct become narrow. This can develop due to a variety of reasons include pancreatitis, ERCP or another type of instrumentation, stone present in the biliary passage.
• Stone in biliary duct, gastroesophageal reflux can also associate.

However, most of the above-mentioned symptoms also associated with other ailments like irritable bowel syndrome, peptic ulcers, and pancreatitis ^{1, 2,3}.

Diagnosis

Following are some diagnostic methods applied for detection of the postcholecystectomy syndrome.

• In postcholecystectomy syndrome, it is very important to evaluate the cause of pain symptom i.e. related to biliary causes or extra-biliary. Depending upon this finding, further prepare the workup plan. In the case of biliary colic, bilirubin, alkaline phosphatase, alanine amino transaminase (ALT), amylase, and lipase level need to check through a laboratory test.
• A higher level of liver enzymes indicates dysfunction of the sphincter of Odd
• Increased level of amylase and lipase indicates sphincter’s pancreatic dysfunction.
• Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with biliary nuclear scanning or biliary manometry or biliary nuclear scanning are the tests perform for evaluate the liver and gallbladder condition.
• In 15 to 30 percent of cases, conduction of ERCP associated with risk of inducing pancreatitis. However, biliary manometry conduction during ERCP is the best diagnostic tool for detection of the postcholecystectomy syndrome. The increased pressure in the biliary tract can be detected by biliary manometry.
• The scan can detect hepatic hilum-duodenal transit time and delayed timing indicates dysfunction of the sphincter of Oddi.
• Abnormal level of pancreatic or liver enzymes finding through laboratory test report and frequent occurrence of biliary pain indicates papillary stenosis³.

Treatment

After detection of underlying dysfunction which causes postcholecystectomy syndrome generation, the treatment plan is made accordingly.

Medication

Antispasmodics, bulking agents, or sedatives provide symptomatic relief from irritable bowel syndrome.

Some experts may prescribe high-dose calcium channel blockers or nitrates for controlling the symptoms of the irritable sphincter, but research findings did not get any supportive clinical efficacy data in this regard.

To control diarrhea, cholestyramine can be prescribed

Sometimes, histamine blockers and antacids and proton pump inhibitors can be used to reduce the gastritis symptoms and gastroesophageal reflux disease (GERD).

Surgical interventions

Following are surgical interventions can be applied to the patients depending on the condition and underlying cause

• Sphincteroplasty
• Transduodenal sphincteroplasty can be applied after a normal exploratory laparotomy.
• Endoscopic therapy can be suggested also postcholecystectomy syndrome (PCS)¹.

Diet

The following diet plan assists in preventing postcholecystectomy syndrome (PCS) or reducing the associated symptoms:

• Omega-3 fatty acids rich foods, acidic foods, and some vegetables like avocados, beets, cucumbers, okra, sweet potatoes etc are good food items need to include in the diet for the patient after cholecystectomy. This can prevent postcholecystectomy syndrome.
• Some researchers found that deficiency of magnesium trigger postcholecystectomy syndrome, which can be prevented by magnesium supplementation intake.
• Saturated fats, trans fats, eggs, dairy items, vegetables like cabbage, and radishes, beverages like black tea, coffee, alcohol, fruit juices, chocolate, should be avoided after cholecystectomy⁴.

Prognosis

The resultant of the postcholecystectomy syndrome and prognosis of the condition varies with the patient to patient. Almost 75% patients with postcholecystectomy syndrome recover with a long-term follow-up therapy.

Hyperamylasemia is one of the short-term complication and almost 5 to 40 percent patients develop this problem. But recovered after 10 days of the cholecystectomy. Almost 5 percent patients have a risk of further complication like pancreatitis and 1 percent patients have a risk of death¹.

References

1. Steen W Jensen, (2016); Postcholecystectomy Syndrome; http://emedicine.medscape.com/article/192761-overview
2. Postcholecystectomy Syndrome – Topic Overview; http://www.webmd.com/digestive-disorders/tc/postcholecystectomy-syndrome-topic-overview
3. Ali A. Siddiqui, (2016); Postcholecystectomy Syndrome; http://www.msdmanuals.com/professional/hepatic-and-biliary-disorders/gallbladder-and-bile-duct-disorders/postcholecystectomy-syndrome
4. Robyn Broyles, (2009); Does Diet Play a Role in Post-Cholecystectomy Syndrome? http://www.healthguideinfo.com/gallbladder-disease/p33425/