What is Postcholecystectomy Syndrome?
Post-cholecystectomy syndrome (PCS) is a condition that describes the continuation of certain symptoms such as abdominal pain in the top right part of the belly and other digestive issues, that are similar to those a person might have experienced before getting their gallbladder removed (a procedure commonly known as a cholecystectomy). As the name suggests, these symptoms can either be a continuation from an already existing issue related to the gallbladder or they can be new symptoms that usually link back to the gallbladder.
These symptoms might include an intolerance to fatty foods, nausea, vomiting, heartburn, excessive gas, indigestion, diarrhea, yellowing of the skin and eyes (known as jaundice), and sporadic episodes of abdominal pain. PCS can show up soon after surgery, typically during the recovery period, but can also start several months to years later.
What Causes Postcholecystectomy Syndrome?
In the past, understanding the causes of certain medical conditions relied heavily on what could be seen during surgery. Nowadays, with advanced technology and improved imaging studies, we’re much better equipped to figure out what’s causing your symptoms without opening you up.
One of these conditions is post-cholecystectomy syndrome, which is a set of symptoms that might appear following gallbladder surgery. These symptoms can be the result of either organic or functional diseases—meaning diseases that have obvious physical signs like inflammation or ulcers, or diseases that affect how your body works.
Lots of these diseases could have nothing to do with your gallbladder! Sometimes, healthcare providers might miss common diseases outside of the gallbladder that could cause these symptoms—like reflux, peptic ulcers, irritable bowel syndrome, or pancreatitis.
There are many non-gallbladder related causes for your symptoms. These can happen due to problems in the digestive system like pancreatitis, pancreatic tumors, hepatitis, esophagus diseases, a lack of blood supply to the mesentery (tissue that attaches your intestines to the wall of your abdomen), diverticulitis (inflammation in your digestive tract), and peptic ulcer disease. But there’s also problems that could still come from the gallbladder area—bile salt-induced diarrhea, leftover gallstones, leaks of bile from the gallbladder, blockages or narrowings in the bile ducts, or problems with a muscle near the base of the gallbladder.
Even conditions not related to your digestive system can sometimes cause symptoms—like psychiatric and neurologic disorders, intercostal neuritis (inflammation near your ribs), wound neuroma (abnormal nerve growth at the site of a surgery or injury), coronary artery disease, and unexplained pain syndromes.
Risk Factors and Frequency for Postcholecystectomy Syndrome
In the late 1990s, around 500,000 gallbladder surgeries were done each year in the United States, most of them using a minimally invasive technique called laparoscopy. Each year, 50,000 or more people developed Post-Cholecystectomy Syndrome (PCS), a condition that might be prevalent in anywhere from 5% to 30% of people who have had their gallbladder removed. This condition is not unique to the United States; the cases are almost identical worldwide. But not everyone who undergoes gallbladder surgery develops PCS. One study found that, after surgery, 65% of patients had no symptoms, 28% had mild symptoms, and only 2% had severe symptoms. And in 26% of the cases, functional disorders were found to be the cause of PCS. Though studies have attempted to identify factors that could predict who is likely to develop PCS, results have been unclear due to differences in the study design.
Despite the lack of preoperative risk assessment available, there are certain factors that have been found that increase the likelihood of developing PCS:
- Emergency surgeries lead to a higher incidence of PCS.
- If gallstones are present, 10-25% of patients develop PCS. If absent, approximately 30% develop PCS.
- The longer the symptoms before surgery, the greater the risk of PCS.
- About 20% of patients will develop PCS irrespective of whether a specific type of gallbladder surgery (choledochotomy) is performed or not.
Interestingly, both age and gender seem to affect the incidence of PCS. For example, PCS is seen in 43% of patients aged 20 to 29 years and 21 to 31% of those aged 30 to 69 years. Women also have a higher propensity to develop PCS, with a female-to-male incidence ratio of 1.8:1.
Signs and Symptoms of Postcholecystectomy Syndrome
If you’ve had your gallbladder removed and are experiencing certain symptoms afterwards, this is known as post-cholecystectomy syndrome. Sometimes these symptoms can be the same as those experienced before the operation, such as abdominal pain, and they can also include fever, jaundice, and diarrhea or nausea. Doctors consider your medical history and carry out physical checks to find out the cause of these symptoms and to make sure there aren’t any serious complications from the operation. They also take into account your previous diagnoses, surgical findings, and any problems that might have come up after the operation. This helps them make the most likely diagnosis, while also considering other possibilities.
- Abdominal pain (reported by 90% of patients)
- General pain (75% of patients)
- Fever (38% of patients)
- Jaundice, or yellowish skin (25% of patients)
- Diarrhea or nausea (35% of patients)
Testing for Postcholecystectomy Syndrome
In the case of post-cholecystectomy syndrome, which is when you continue experiencing similar symptoms after having your gallbladder removed, several tests may be carried out to find out what the issue might be:
The first test your doctor may suggest is a complete blood count (CBC), which checks if you have any infections. They might also recommend a complete metabolic panel (CMP), which looks at how well your liver and pancreas are working, as well as a prothrombin time (PT) test, which measures how quickly your blood clots – an important factor when assessing liver function. Certain blood tests looking at amylase, lipase are also used to check pancreatic function. If you seem very unwell, a blood gas analysis might be needed to examine your blood’s pH and oxygen levels.
If all the initial tests come back normal but your symptoms persist, you might need to repeat the tests or have additional ones. This might include tests to check thyroid function, liver function (GGT test), a panel for hepatitis, or tests for heart issues (cardiac enzymes).
Alongside the blood tests, imaging tests such as x-rays, ultrasound, or computed tomography (CT) scans can help doctors see the organs in your body. An ultrasound can check your liver, pancreas, and nearby areas. It’s a safe, quick and low-cost method. Here, your doctor checks the common bile duct (a tube that carries bile from the liver to small intestine) where dilation (widening) up to 10mm is normal. If it’s more than 10mm, it could mean there’s a blockage suggesting a stuck stone, narrowing or tightened opening of the duct (strictures or stenosis).
CT scans can help spot issues like pancreatitis (inflammation of the pancreas) or its complications like fluid-filled sacs (pseudocysts). Your doctor might suggest nuclear imaging like a HIDA scan. This scan provides pictures of your liver, gallbladder, bile ducts and small intestine to help detect problems. It’s particularly useful in finding leaks in your bile ducts or issues with the sphincter of Oddi (a muscular valve that controls the flow of digestive juices to the first part of your small intestine). However, this scan might struggle to differentiate between a stricture (tightening) and dyskinesia (abnormal movement).
Another useful test can be endoscopic ultrasonography (EUS), which uses sound waves to create detailed images and help decide who needs an endoscopic retrograde cholangiopancreatography (ERCP). EUS can reduce the number of patients who require an ERCP by half and it could help find leftover stones. An ERCP allows a closer look at your bile and pancreatic ducts and helps identify and treat issues on the spot. This technique can be really useful for diagnosing post-cholecystectomy syndrome. In fact, about half of patients with this syndrome have problems related to their bile ducts.
If you can’t have an ERCP, other imaging techniques like percutaneous transhepatic cholangiography (PTC, a way to see your bile ducts using x-rays) or magnetic resonance cholangiopancreatography (MRCP, a type of MRI that provides images of your bile ducts and pancreatic duct) could work.
Treatment Options for Postcholecystectomy Syndrome
Post-cholecystectomy syndrome, or the health problems that you might experience after your gallbladder removal surgery, is usually a temporary diagnosis. After further examination, doctors will be able to figure out a more specific diagnosis related to functional or physical health issues. Once the specific diagnosis is determined, treatment will depend on that diagnosis and could involve a medicinal approach or a specific medical procedure.
Medicinal approach:
The goal of prescribing medicine is to stop complications and decrease health problems.
Doctors might recommend:
1. Bulking agents, antispasmodics (medicines used to prevent muscle spasms), or sedatives if you have symptoms of irritable bowel syndrome, a common disorder affecting the large intestine.
2. Cholestyramine (a drug that reduces harmful substances in the body) if you’re suffering from diarrhea.
3. Antacids, histamine-2 blockers (medications that reduce stomach acid), or proton-pump inhibitors (which also reduce acid production) if gastroesophageal reflux disease (also known as GERD – a chronic disease when stomach acid frequently flows back into the tube connecting your mouth and stomach) or gastritis (inflammation of the stomach lining) cause discomfort.
4. Certain patients whose symptoms involve stomach discomfort may benefit from bile acid binders like cholestyramine. Bile acid is a substance produced by the liver and stored in the gallbladder and helps with digestion.
Procedural Approach:
Treatment could also involve specific medical procedures depending on your detailed diagnosis. For example, surgery can be an option if the source of the problem can be clearly identified and is known to respond well to surgery. ERCP (Endoscopic Retrograde Cholangio-Pancreatography, a procedure combining upper gastrointestinal endoscopy and x-ray) is the most common procedure because it can both identify and treat the problem. In some cases, no specific condition may be found using normal diagnostic methods or ERCP. If these cases are also resistant to medicine; exploratory surgery might be necessary. If exploration during surgery doesn’t reveal anything, the patient might respond to a procedure called sphincteroplasty, which enlarges the muscle between the pancreas and the small intestine.
In specific cases of post-cholecystectomy syndrome where there’s a gallstone stuck in the remnant cystic duct (a small duct that carries bile to the larger bile duct and then to the small intestine) or Mirizzi syndrome (a condition where a gallstone blocks the bile duct), extracting the stone by endoscopy (a nonsurgical procedure using an endoscope to examine the digestive tract) might be enough. However, in some cases, surgical removal of the remnant cystic duct could be necessary to prevent subsequent development of post-cholecystectomy syndrome.
What else can Postcholecystectomy Syndrome be?
Post-cholecystectomy syndrome symptoms can be tricky to diagnose because they can sometimes mimic the symptoms of other digestive tract diseases. This means the process to distinguish post-cholecystectomy syndrome from other conditions might take some time and need several steps.
To find out if there’s an existing digestive system disorder causing the symptoms, doctors might do the following things:
- Talk to the patient to gather a thorough medical history
- Conduct a physical examination
- Carry out laboratory tests
- Perform imaging tests on the abdomen due to symptoms
- Possibly perform an endoscopy
These tests and examinations will help the doctor confirm or eliminate the possibility of post-cholecystectomy syndrome, whether it’s related to bile duct issues or other non-bile duct related causes.
What to expect with Postcholecystectomy Syndrome
The results and future outlook of post-cholecystectomy syndrome can differ based on the individual and their specific circumstances, as well as the procedures that may be carried out. According to a study, about 75% of patients experienced significant pain relief in the long run. Doctors should emphasize the importance of follow-up care to ensure that the patient is managed appropriately after the operation.
Possible Complications When Diagnosed with Postcholecystectomy Syndrome
After gallbladder surgery, or a cholecystectomy, some people might experience complications like diarrhea or a bloated feeling due to changes in the flow of bile. There’s also a risk of having a leftover part of the cystic duct which could, in turn, lead to the development of stones causing a condition known as Mirizzi syndrome. For those who had a biliary stent put in place during a specific kind of procedure called ERCP, it’s essential to have the stent removed within 3 to 6 months. If not, it could lead to blockage, the stent moving out of place, or an infection known as cholangitis.
Potential Complications:
- Diarrhea
- Bloating
- Mirizzi syndrome due to stone formation in duct residue
- Blockage in biliary stent
- Movement of the biliary stent from its position
- An infection known as cholangitis
Preventing Postcholecystectomy Syndrome
About 10 to 15% of patients who have their gallbladders removed (a procedure called a cholecystectomy) can experience a condition known as post-cholecystectomy syndrome. It’s important that these patients understand, prior to the surgery, that this condition can arise. In fact, good communication between the doctor and the patient about usual problems that occur after the surgery can help identify the subtle signs of post-cholecystectomy syndrome more easily.
