Medicine:Postcholecystectomy syndrome
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Postcholecystectomy syndrome (PCS) describes the presence of abdominal symptoms after a cholecystectomy (gallbladder removal).
Symptoms occur in about 5 to 40 percent of patients who undergo cholecystectomy,[1] and can be transient, persistent or lifelong.[2][3] The chronic condition is diagnosed in approximately 10% of postcholecystectomy cases.
The pain associated with postcholecystectomy syndrome is usually ascribed to either sphincter of Oddi dysfunction or to post-surgical adhesions.[4] A recent 2008 study shows that postcholecystectomy syndrome can be caused by biliary microlithiasis.[5] Approximately 50% of cases are due to biliary causes such as remaining stone, biliary injury, dysmotility and choledococyst. The remaining 50% are due to non-biliary causes. This is because upper abdominal pain and gallstones are both common but are not always related.
Non-biliary causes of PCS may be caused by a functional gastrointestinal disorder, such as functional dyspepsia.[6]
Chronic diarrhea in postcholecystectomy syndrome is a type of bile acid diarrhea (type 3).[3] This can be treated with a bile acid sequestrant like cholestyramine,[3] colestipol[2] or colesevelam,[7] which may be better tolerated.[8]
Presentation
Symptoms of postcholecystectomy syndrome may include:[9]
- Dyspepsia, nausea and vomiting.
- Flatulence, bloating and diarrhea.
- Persistent pain in the upper right abdomen.[10]
Diagnostics
- Ultrasound of the abdominal cavity.
- General and biochemical blood.
- Intravenous cholangiography.
- Esophagogastroduodenoscopy for examination of the stomach, duodenum and the area major duodenal papilla.
- Retrograde cholangiopancreatography.
- Analysis of biliary sludge obtained through endoscopic retrograde cholangiopancreatography (ERCP)
- SeHCAT or other test for bile acid diarrhea
Treatment
Some individuals may benefit from diet modification, such as a reduced fat diet, following cholecystectomy. The liver produces bile and the gallbladder acts as reservoir. From the gallbladder, bile enters the intestine in individual portions. In the absence of a gallbladder, bile enters the intestine constantly, but in small quantities. Thus, it may be insufficient for the digestion of fatty foods. Postcholecystectomy syndrome treatment depends on the identified violations that led to it. Typically, the patient is recommended a dietary restriction table with fatty foods, enzyme preparations, antispasmodics, and sometimes cholagogue.[citation needed]
If the pain is caused by biliary microlithiasis, oral ursodeoxycholic acid can alleviate the condition.[5]
A trial of bile acid sequestrant therapy is recommended for bile acid diarrhea.[2][8]
Functional dyspepsia is subdivided into Epigastric Distress Syndrome (EPS) and Post-Prandial Distress Syndrome (PDS).[11] Treatment for EPS and PDS can both include proton pump inhibitors and dopamine antagonists. Tricyclic antidepressants have also been proven effective for nausea, vomiting, early satiety, impaired motility and other related symptoms.[12]
When investigation reveals no abnormalities within the abdominal cavity, the attending physician may consider Anterior cutaneous nerve entrapment syndrome (ACNES) as a possible cause. ACNES may present with pseudovisceral symptoms, including nausea, bloating, diarrhea and early satiety.[13]
References
- ↑ "Postcholecystectomy syndrome". WebMD. http://www.webmd.com/hw-popup/Postcholecystectomy-syndrome.
- ↑ 2.0 2.1 2.2 "Postcholecystectomy diarrhea: What relieves it?". The Journal of Family Practice 60 (10): 632c–d. October 2011. PMID 21977493. http://www.jfponline.com/Pages.asp?AID=9932.
- ↑ 3.0 3.1 3.2 "Post-cholecystectomy diarrhea: evidence of bile acid malabsorption assessed by SeHCAT test". The American Journal of Gastroenterology 87 (12): 1852–4. December 1992. PMID 1449156.
- ↑ "Intestinal adhesions: an overlooked cause of the postcholecystectomy syndrome". Hepatogastroenterology 37 (Suppl 2): 58–61. December 1990. PMID 2083937.
- ↑ 5.0 5.1 "Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis". Gastrointestinal Endoscopy 68 (1): 69–74. July 2008. doi:10.1016/j.gie.2007.09.046. PMID 18577477.
- ↑ "Post-cholecystectomy symptoms were caused by persistence of a functional gastrointestinal disorder.". World Journal of Gastroenterology 18 (12): 1365–72. 28 March 2012. doi:10.3748/wjg.v18.i12.1365. PMID 22493550.
- ↑ "Effects of chenodeoxycholate and a bile acid sequestrant, colesevelam, on intestinal transit and bowel function". Clinical Gastroenterology and Hepatology 8 (2): 159–65. February 2010. doi:10.1016/j.cgh.2009.10.020. PMID 19879973.
- ↑ 8.0 8.1 "Review article: bile acid diarrhoea - pathogenesis, diagnosis and management". Aliment. Pharmacol. Ther. 43 (8): 884–898. 2016. doi:10.1111/apt.13570. PMID 26913381.
- ↑ nhs.uk, Complications of a gallbladder removal
- ↑ "Persistent and de novo symptoms after cholecystectomy: a systematic review of cholecystectomy effectiveness". Surg Endosc 27 (3): 709–18. 2013. doi:10.1007/s00464-012-2516-9. PMID 23052498.
- ↑ "Overlap between postprandial distress and epigastric pain syndromes in functional dyspepsia: its implications for research and clinical practice (am j gastroenterol 2013;108:767-774)". Journal of Neurogastroenterology and Motility 19 (3): 409–11. July 2013. doi:10.5056/jnm.2013.19.3.409. PMID 23875111.
- ↑ "Antidepressants in functional dyspepsia". Expert Review of Gastroenterology & Hepatology 4 (1): 5–8. February 2010. doi:10.1586/egh.09.73. PMID 20136584.
- ↑ Suleiman, Saud; Johnston, David E. (August 2001). "The Abdominal Wall: An Overlooked Source of Pain". American Family Physician 64 (3): 431–438. PMID 11515832. https://www.aafp.org/afp/2001/0801/p431.html.
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