Postcholecystectomy syndrome.

Postcholecystectomy syndrome is a collective term that unites a complex of pathological conditions observed after gallbladder removal. It occurs immediately or some time after surgery. Dissatisfaction with the operation is noted in 12% of patients who have undergone cholecystectomy.

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Reasons

The reasons for development are varied, but they can be divided into 2 groups:

1. Associated with surgical interventions: unresolved or newly developed cicatricial stenosis of the ampulla of Vater, unresolved choledocholithiasis, cicatricial stricture of the common bile duct, a retained portion of the gallbladder, indurative pancreatitis with compression of the common duct that developed after surgery, obliteration of the biliodegestive anastomosis, terminal cholangitis, adhesive processes, etc.
2. Not related to surgery, caused by atypically occurring diseases of the abdominal organs, unrecognized gastritis and duodenitis, perigastritis and periduodenitis, peptic ulcer, hernia of the esophageal opening (often combined with cholelithiasis), nephroptosis, spondyloarthritis, etc.

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Symptoms

Postcholecystectomy syndrome occurs in 5-40% of patients; however, most symptoms are related to dyspepsia, and the remaining symptoms are also nonspecific rather than true biliary colic. In some cases, another cause is present (eg, forgotten bile duct stone, pancreatitis, gastroesophageal reflux). In about 10% of cases, biliary colic is due to functional or structural changes in the sphincter of Oddi. Papillary stenosis, which is rare, is a fibrous narrowing around the sphincter, possibly caused by trauma and inflammation in pancreatitis, instrumentation (eg, ERCP), or a migrating stone.

Diagnostics

Patients with postcholecystectomy pain should be evaluated to exclude both extrabiliary and biliary etiologies. If the pain pattern suggests biliary colic, alkaline phosphatase, bilirubin, ALT, amylase, and lipase are measured, as well as ERCP with biliary manometry or MRI scanning. Elevated biochemical parameters suggest dysfunction of the sphincter of Oddi, whereas elevated amylase and lipase indicate dysfunction of the pancreatic portion of the sphincter. Dysfunction is best demonstrated by biliary manometry, which detects elevated pressure in the biliary tract causing the pain, although ERCP carries a risk of developing pancreatitis. Delayed passage from the liver to the duodenum, demonstrated by scanning, also suggests dysfunction of the sphincter of Oddi. Diagnosis of papillary stenosis is based on ERCP data. Endoscopic sphincterotomy can relieve pain caused by sphincter of Oddi dysfunction and especially papillary stenosis, but this is problematic in patients who have postcholecystectomy pain syndrome without objective disorders.

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