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Postcholecystectomy syndrome (PCS) is a complex variety of symptoms which consists of upper abdominal pain and dyspepsia, recurring and or after cholecystectomy (removal of gallbladder). Postcholecystectomy is defined as recurring chronic pain with no clear source but depends on several different factors. It also marked with biliary and non-biliary disorders which may not be related to cholecystectomy. Early post-operative period symptoms include upset stomach, nausea, vomiting, gas, bloating, and diarrhea . Late post- operative period symptoms normally caused by inflammatory scarring structures of sphincter of Oddi (SO)or bile duct, recurrent calculi or biliary dyskinesia .

About 5 to 40 percent of cholecystectomy patients have symptoms which can be transient, persistent or lifelong. Chornic diarrhea can be noticed in patients due to a type bile acid diarrhea and can be treated with bile acid sequestrant like cholestyramine or colesevelam . In PCS patients, diet modification such as low fat diet, may help in reducing the symptoms .

Mechanisms

PCS can begin soon after cholecystectomy or decades later. In PCS patients with mild gastroduodenal symptoms, alteration in bile flow is the cause. However, the pathophysiology of PCS due to the changes in bile flow still remains poorly understood . Spincter of Oddi dysfunction is another reason for abdominal pain in PCS patients. The removal of gallbladder causes surplus passage of hepatic bile only into the duodenum and this, increases frequency of gallbladder-independent enterohepatic circulation of bile acids. In patients after the gallbladder removal, there is only gallbladder-independent enterohepatic circulation of bile acids. The increase in gallbladder-independent enterohepatic circulation of bile acids leads to increase in concentration of bile acids in the hepatocytes and decrease in the accumulation function and excretion function of the liver (i.e. formation of chronic “bland” intrahepatic cholestasis). Absence of the gallbladder after the removal also causes the increase in passage of hepatic bile into the duodenum and the gallbladder-independent enterohepatic circulation of biliary cholesterol and bilirubin . Increase in the gallbladder-independent enterohepatic circulation of biliary cholesterol leads to the increased amount of absorption of biliary cholesterol in the small intestine, the biliary cholesterol entering hepatocytes, and hypersecretion into hepatic bile . This will lead to the formation of the “lithogenic” hepatic bile and predisposes to choledocholithiasis (formation of gallstones in bile ducts) . Furthermore, in patients after the removal of gallbladder the output of gallbladder dependent biliary cholesterol and the concentration of total bile acids in duodenal bile cause causes the precipitation of cholesterol monohydrate crystals in the duodenum lumen. Moreover, due to the sphincter of Oddi dysfunction surplus hepatic bile passage into the duodenum causes duodeno-gastral refluxes and development of chronic atrophic (bile-acid-dependent) antral gastritis, often accompanied by intestinal metaplasia, and gastroduodenitis. It also leads to high degree of COX-2 expression in the smooth muscle and epithelial cells of the sphincter of Oddi which will hinder the passage of hepatic bile into the duodenum and cause the development of functional biliary hypertension in the common bile duct . It may also cause the functional hypertension in the Wirsung’s duct, the pain syndrome in the left hypochondrium, and the symptoms of chronic biliary pancreatitis (pancreatic type) .

Symptoms

Symptoms of postcholecystectomy includes stomach upset, nausea, vomiting, gas trouble, bloating, diarrhea and continuous pain in the upper right portion of the abdomen. The symptoms may be a continuation of the troubles that were caused by gallbladder or it could be developed after cholecystectomy. Due to the loss of the reservoir function of the gallbladder, there are changes in the bile flow and it could lead either into esophagitis and gastritis in the upper gastrointestinal tractor in the lower gastrointestinal tract it may result abdominal pain and diarrhea. Early symptoms start immediately after the removal of gallbladder and late PSC starts after decades of the surgery.

Diagnosis

Patient examination begins with patient's previous medical records and physical examination giving particular attention to preoperative workup and diagnosis, the surgical findings and pathologic examination, and any postoperative problems, In patients with PCS, complete blood count screening is done to screen for infectious etiologies, a basic metabolic panel (BMP) and amylase to screen for pancreatic disease, a hepatic function panel (HFP) and prothrombin time (PT) to screen for possible liver or biliary tract diseases, and, if the patient is acutely ill, a blood gas analysis is performed,. Furthermore, laboratory studies that may be include lipase, gamma-glutamyl transpeptidase (GGT), hepatitis panel, thyroid function, and cardiac enzymes,. Diagnosis for postcholecystectomy can be done through an ultrasound of the abdominal cavity, general and biochemical blood test and intravenous cholangiography. For the examination of the stomach, duodenum, and major area of the duodenal papilla an Esophagogastroduodenoscopy can be done , . Retrograde cholangiopancreatography test can be done for the examination pancreases also, for the analysis of the biliary sludge an endoscopic retrograde cholangiopancreatography (ERCP) can be performed. Laproscopic cholecystectomy shows lesser post symptoms than open surgery however, cases of gallbladder cancer is reported in 0.3%-1.0% patients after laproscopic cholecystectomy. Bile duct balloon sweeps are performed to find abnormalities in patients who have undergone endoscopic treatment for postcholeocystectomy bile duct leakage. Magnetic resonance cholangiopancreatography is a new diagnostic tool to find biliary disorders.

Treatment and Prognosis

Treatment for PCS depend on the diagnosis and etiology. Patients with irritable bowel disorder can be treated with the use of laxatives, antispasmodics, or sedatives. If the patient suffers from diarrhea alone then Cholestyramine might help. PCS patients with gastritis symptoms occasionally are provided with Antacids, histamine 2 (H2) blockers, or proton pump inhibitors (PPIs). PCS patients with functional disorder of sphincter of Oddi may given calcium channel blocker. Pain killers such as spasmolytics and analgesics also given to patients with PCS. In patients with gallbladder remnant, removal of the remnant might eliminates the symptoms of PCS. Surgical removal procedure for long cystic duct remnant is not warranted if a demonstrable stone is remote. Postcholecystecomic patients are advised to follow strict low fat diet as well as enzyme preparations, as they do not have a gall bladder. Ursodeoxycholic acid treatment can be used for patients with postcholecystectomy pain and bile microlithiasis. Laproscopic cholecystectomy shows lesser post symptoms than open surgery however, cases of gallbladder cancer is reported in 0.3%-1.0% patients after laproscopic cholecystectomy. PCS patients have normal life expectancy however, gastrointestinal distress and persistent pain in the upper right abdomen are common and patients develop chronic diarrhea which can be controlled with drugs.

Recent Research

100 cholecystectomic surgeries using the da Vinci Surgical system shows less complications of the gallbladder removal surgery, meaning, they have less infection, less pain and fast recovery. In a 2010 study it was observed that Rabeprazole combined with hydrotalcite was effective for patients with bile reflux gastritis after cholecystectomy and this study was done in patients regardless of their surgical technique. Recent studies show cholecystectomy have an altered risk of pancreatic cancer. A 2013 study shows that laproscopic cholecystectomy patients have moderate to severe abdominal pain . Another study shows that laproscopic cholecystectomy patients had remnant gallbladder and long cystic duct stump with impacted stone and this will cause inflammation. Hence, the laproscopic procedure should be done only in centers of expertise. To monitor the esophageal alkaline reflux in post -cholecystectomy patients a study was performed in patients with galbladder stone and the change of reflux patterns after cholecystectomy in such patients. However, there was not much difference in the reflux symptom . In a structured questionaire filled out by 153 patients with a clinical and ultrasonographic diagnosis of gallstones on abdominal pain symptoms and functional gastrointestinal disorder (FGID) before and at six months after cholecystectomy it was found that FGID was a dominant cause of PCS .