Kaiser Health Plan - Post-Cholecystectomy Syndrome (Symptoms After Gallbladder Surgery)
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An estimated 20 million Americans have gallstones (cholelithiasis), and about 30 percent of these patients will finally invent symptoms of their gallstone disease. The most tasteless symptoms specifically linked to gallstone disease consist of upper abdominal pain (often, but not always, following a heavy or greasy meal), nausea, and vomiting. (The upper abdominal pain often radiates nearby towards the right side of the back or shoulder.)
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Patients with complications of untreated cholelithiasis may caress other symptoms as well, in expanding to an increased risk of severe illness, or even death. These complications of gallstone disease include:
- Severe inflammation or infection of the gallbladder (cholecystitis)
- Blockage of the main bile duct with gallstones (choledocholithiasis), which can cause jaundice or/and bile duct infection (cholangitis), as well as pancreatitis
More than 500,000 patients feel dismissal of their gallstones and gallbladders every year in the United States, making cholecystectomy one of the most generally performed major abdominal surgical operations. In 85 to 90 percent of cholecystectomies, the execution can be performed laparoscopically, using multiple small "band-aid" incisions instead of the former large (and more painful) upper abdominal incision.
For the vast majority of patients with cholelithiasis, cholecystectomy effectively relieves the symptoms of gallstones. In 10 to 15 percent of patients undergoing cholecystectomy, however, persistent or new abdominal or Gi symptoms may arise after gallbladder surgery. Although there are many personel causes of persisting post-cholecystectomy abdominal or Gi symptoms, the proximity of such symptoms following gallbladder surgical operation are collectively referred to as "post-cholecystectomy" syndrome (Pcs) by many experts.
I routinely receive inquiries from patients who have previously undergone cholecystectomy, and who report troubling abdominal or Gi symptoms following their surgery. In many cases, these patients have already undergone rather widespread evaluations, but without any specific findings. Understandably, such patients are troubled and frustrated, both by their persisting symptoms and the ongoing uncertainty as to the cause (or causes) of these symptoms.
The most tasteless symptoms attributed to Pcs consist of persisting abdominal pain, nausea, vomiting, bloating, inordinate intestinal gas, and diarrhea. Fever and jaundice, which most generally arise from complications of gallbladder surgery, are much less common, fortunately. While the spoton cause, or causes, of Pcs symptoms can ultimately be identified in about 90 percent of patients following a thorough evaluation, even the most widespread work-up can fail to recognize a specific ailment as the cause of symptoms in some patients. It is foremost to stress that there is no universal consensus on the topic of Pcs among the experts, although most agree that there are multiple and diverse causes of persisting post-cholecystectomy symptoms. Thus, it can be very difficult to counsel the small minority of patients with persisting symptoms after surgical operation when a widespread work-up fails to recognize specific causes for their suffering.
Because Pcs is, in effect, a non-specific clinical analysis assigned to patients with persisting symptoms following cholecystectomy, it is critically foremost that an thorough work-up be performed in all cases of persisting Pcs, so that an spoton analysis can be identified, and thorough treatment can be initiated. As the known causes of Pcs are numerous, however, physicians caring for such patients need to tailor their evaluations of patients with Pcs based upon clinical findings, as well as frugal laboratory, ultrasound, and radiographic screening exams. This logical clinical coming to the assessment of Pcs symptoms will recognize or eliminate the most tasteless diagnoses linked with Pcs in the majority of such patients, sparing them the need for added unnecessary and invasive testing.
In reviewing the etiologies of Pcs that have been described so far, both patients and physicians can gain a good insight of how complicated this clinical problem is:
- Irritable bowel syndrome (Ibs)
- Bile gastritis (inflammation of the stomach)
- Gastroesophageal reflux (Gerd)
- Hypersensitivity of the nervous system of the Gi tract
- Abnormal flow of bile into the Gi tract after dismissal of the gallbladder
- inordinate consumption of fatty and greasy foods
- Painful surgical scars or incisional (scar) hernias
- Adhesions (internal scars) following surgery
- Retained gallstones within the bile ducts or pancreatic duct
- Stricture (narrowing) of the bile ducts
- Bile leaks following surgery
- Injury to bile ducts during surgery
- Infection of the bile ducts (cholangitis), incisions, or abdomen
- Residual gallbladder or cystic duct remnant following surgery
- Fatty changes of the liver or other liver diseases
- persisting pancreatitis or pancreatic insufficiency
- Abnormal function or anatomy of the main bile duct sphincter muscle (the "Sphincter of Oddi")
- Peptic ulcer disease
- Diverticulitis
- Crohn's disease or ulcerative colitis
- Stress
- Psychiatric illnesses
- Tumors of the liver, bile ducts, pancreas, stomach, small intestine, colon, or rectum
In reviewing the widespread list of inherent causes of Pcs, it is clear that some causes of Pcs are directly attributable to cholecystectomy, while many other etiologies are due to unrelated conditions that arise either prior to surgical operation or after surgery.
While it is impossible to predict which patients will go on to invent Pcs following cholecystectomy, there are some factors that are known to growth the risk of Pcs following surgery. These factors consist of cholecystectomy performed for causes other than confirmed gallstone disease, cholecystectomy performed on an urgent or emergent basis, patients with a long history of gallstone symptoms prior to undergoing surgery, patients with a prior history of irritable bowel syndrome or other persisting intestinal disorders, and patients with a history of confident psychiatric illnesses.
In my own practice, the initial assessment of patients with Pcs must, of course, begin with a thorough and spoton history and corporal examination of the patient. If this initial assessment is with regard to for one of the many known corporal causes of Pcs, then I will commonly ask the patient feel any initial screening tests, which typically consist of blood tests to collate liver and pancreas function, a faultless blood count, and an abdominal ultrasound. Based upon the results of these initial screening tests, some patients may then be advised to feel added and more sophisticated tests, including endoscopic ultrasound (Eus), upper or/and lower Gi endoscopy (including, in some cases, Ercp, or endoscopic retrograde cholangiopancreatography), bile duct manometry, or Ct or Mri scans, for example. (The decision to order any of these more invasive and more precious tests must, of course, be dictated by each personel patient's clinical scenario.)
Fortunately, as I indicated at the beginning of this column, a thoughtful and logical coming to each personel patient's presentation will lead to a specific analysis in more than 90 percent of all cases of Pcs. Therefore, if you (or person you know) are experiencing symptoms consistent with Pcs, then referral to a physician with expertise in evaluating and treating the assorted causes of Pcs is primary (such physicians can consist of house physicians, internists, Gi specialists, and surgeons). Once a specific cause for your Pcs symptoms is identified, then an thorough treatment plan can be initiated.
Disclaimer: As always, my guidance to readers is to seek the guidance of your physician before making any primary changes in medications, diet, or level of corporal activity.
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