Cholecystectomy, Pre- & Post- Syndrome

Precholecystectomy

• 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

Postcholecystectomy

• 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

Diagnosis

• 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

Treatment

• 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