Post-Cholecystectomy Syndrome (Symptoms After Gallbladder Surgery)

Kaiser Permanente - 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 ultimately found symptoms of their gallstone disease. The most common symptoms specifically associated to gallstone disease include upper abdominal pain (often, but not always, following a heavy or greasy meal), nausea, and vomiting. (The upper abdominal pain often radiates colse to towards the right side of the back or shoulder.)

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Patients with complications of untreated cholelithiasis may contact other symptoms as well, in addition 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 endure extraction of their gallstones and gallbladders every year in the United States, manufacture cholecystectomy one of the most generally performed major abdominal surgical operations. In 85 to 90 percent of cholecystectomies, the operation 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 individual causes of lasting post-cholecystectomy abdominal or Gi symptoms, the nearnessy 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 record troubling abdominal or Gi symptoms following their surgery. In many cases, these patients have already undergone rather extensive evaluations, but without any specific findings. Understandably, such patients are troubled and frustrated, both by their lasting symptoms and the ongoing uncertainty as to the cause (or causes) of these symptoms.

The most common symptoms attributed to Pcs include lasting 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 exact cause, or causes, of Pcs symptoms can finally be identified in about 90 percent of patients following a thorough evaluation, even the most extensive work-up can fail to identify a specific ailment as the cause of symptoms in some patients. It is prominent 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 lasting post-cholecystectomy symptoms. Thus, it can be very difficult to counsel the small minority of patients with lasting symptoms after surgical operation when a extensive work-up fails to identify specific causes for their suffering.

Because Pcs is, in effect, a non-specific clinical pathology assigned to patients with lasting symptoms following cholecystectomy, it is critically prominent that an thorough work-up be performed in all cases of lasting Pcs, so that an exact pathology can be identified, and thorough medicine 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 approach to the evaluation of Pcs symptoms will identify or eliminate the most common diagnoses associated with Pcs in the majority of such patients, sparing them the need for further unnecessary and invasive testing.

In reviewing the etiologies of Pcs that have been described so far, both patients and physicians can gain a better understanding of how complicated this clinical qoute is:

- Irritable bowel syndrome (Ibs)

- Bile gastritis (inflammation of the stomach)

- Gastroesophageal reflux (Gerd)

- Hypersensitivity of the nervous principles of the Gi tract

- Abnormal flow of bile into the Gi tract after extraction 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 while 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

- lasting 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 extensive list of possible causes of Pcs, it is evident that some causes of Pcs are directly attributable to cholecystectomy, while many other etiologies are due to unrelated conditions that arise whether prior to surgical operation or after surgery.

While it is impossible to predict which patients will go on to found Pcs following cholecystectomy, there are some factors that are known to growth the risk of Pcs following surgery. These factors include 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 lasting intestinal disorders, and patients with a history of sure psychiatric illnesses.

In my own practice, the initial evaluation of patients with Pcs must, of course, begin with a thorough and exact history and corporal test of the patient. If this initial evaluation is about for one of the many known corporal causes of Pcs, then I will regularly ask the outpatient endure some initial screening tests, which typically include blood tests to compare 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 endure further 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 individual patient's clinical scenario.)

Fortunately, as I indicated at the beginning of this column, a thoughtful and logical approach to each individual patient's presentation will lead to a specific pathology in more than 90 percent of all cases of Pcs. Therefore, if you (or man you know) are experiencing symptoms consistent with Pcs, then referral to a doctor with expertise in evaluating and treating the discrete causes of Pcs is necessary (such physicians can include house physicians, internists, Gi specialists, and surgeons). Once a specific cause for your Pcs symptoms is identified, then an thorough medicine plan can be initiated.

Disclaimer: As always, my advice to readers is to seek the advice of your doctor before manufacture any necessary changes in medications, diet, or level of corporal activity.

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