Cholecystectomy, Pre- & Post- Syndrome

In a few patients (mostly women) with biliary pain, conventional radiographic studies of the upper GI tract and gallbladder, including cholangiography, are unremarkable

• However, emptying of the gallbladder is markedly reduced on gallbladder scintigraphy after injection of cholecystokinin

• Similar symptoms may also be caused by sphincter of Oddi dysfunction

Continued complaints of right upper quadrant pain, flatulence, and fatty food intolerance

Pain has been associated with

• Choledocholithiasis

• Bile duct stricture

• Dilation of the cystic duct remnant

• Neuroma formation in the ductal wall

• Foreign body granuloma

• Anterior cutaneous nerve entrapment syndrome

• Traction on the bile duct by a long cystic duct

Endoscopic ultrasonography or retrograde cholangiography may be necessary to demonstrate a stone or stricture

Patients with elevated liver enzymes or amylase (twofold) and a dilated bile duct (> 12 mm) can be assumed to have sphincter stenosis

For those patients without all the features of sphincter stenosis, biliary manometry may be performed to document elevated baseline sphincter of Oddi pressures typical of sphincter dysfunction

Biliary scintigraphy after intravenous administration of morphine and magnetic resonance cholangiopancreatography following intravenous secretin show promise as screening tests for sphincter dysfunction

Precholecystectomy syndrome: cholecystectomy is often curative

Postcholecystectomy syndrome

• Endoscopic sphincterotomy is most likely to relieve symptoms in patients with a sphincter disorder or stenosis

• A calcium channel blocker, long-acting nitrate, phosphodiesterase inhibitor (eg, vardenafil), or possibly injection of the sphincter with botulinum toxin may be beneficial in some cases