Dr. Ertan Beyatlı

What is Postcholecystectomy Syndrome?

(Update: ) - Digestive System Diseases

The term Postcholecystectomy Syndrome (PKS) describes the presence of symptoms after gallbladder surgery (cholecystectomy).

Related article: How to make the right decision for gallbladder surgery?

These symptoms may result in symptoms thought to be caused by gallbladder pathology. or It may indicate the development of new symptoms attributed to the gallbladder.

PKS also gallbladder removal the development of symptoms caused by (eg, Gastritis and diarrhea).

generally PKS is a preliminary diagnosis and should be renamed in relation to the disease identified as a result of an adequate study. Gall bladder loss of reservoir function due to changes in bile flow. Two types of problems can arise.

  • firstIncreased bile flow in the upper digestive (gastrointestinal GI tract) tract, eg. esophagitis ve gastritis.
  • Latter, diarrhea ve stomach pain such as the lower digestive (GI tract) system. This article generally addresses the general issues of PKS.

Approximate of PKS patients 10-15%Reportedly affect the.

In order to uncover suspicious symptoms of PKS, a specific investigation into the occurrence of often anticipated postoperative problems is between patients and their physicians. effective communication It requires.

Treatment should be based on the specific diagnosis made and may include pharmacological or surgical approaches.

Pathophysiology and Etiology

Even mild digestive problems are considered to be the cause of PKS in patients. The elimination of the reservoir function of the gallbladder increases the flow of bile and bile. enterohepatic circulation changes. The pathophysiology of PKS is associated with changes in bile flow and is not yet fully understood. Postcholecystectomy Syndrome by Anatomical Location Etiology is as follows:

Postcholecystectomy Syndrome - PKS
Postcholecystectomy Syndrome - PKS

Gallbladder remnants and cystic duct

  • Residue (residual) or partial gall bladder (Partial Cholecystectomy)
  • Stump Cholelithiasis (stones caused by leaving the bile duct long)
  • Neuroma (tumor of nerve cells)

Liver

  • Fatty infiltration of the liver (hepatostheating)
  • Hepatitis
  • Hydrohepatosis (as a result of obstruction of the common bile duct)
  • Cirrhosis
  • Chronic idiopathic jaundice
  • Gilbert's disease
  • Dubin-Johnson syndrome
  • Hepatolithiasis (liver stone formation)
  • Sclerosing cholangitis (biliary tract inflammation)
  • Cyst

Biliary duct (Bile ducts)

  • cholangitis
  • Adhesions (adhesions)
  • Strictures (stricture)
  • Trauma
  • Cyst
  • Malignancy and cholangiocarcinoma
  • Blockage (obstruction)
  • choledocholithiasis (formation of stones in the main biliary tract)
  • Obstructed dilatation (enlargement without obstruction)
  • Hypertension or nonspecific enlargement
  • Dyskinesia
  • Fistula

Periampullar (ampulla of Vater)

  • Dyskinesia, spasm or hypertrophy in the Oddi sphincter
  • Stricture in the Oddi sphincter
  • Papilom (wart)
  • Cancer

pankreas

  • Pancreatitis
  • Pancreatic stone
  • Pancreatic cancer
  • Pancreatic cysts
  • Benign tumors

Esophagus (esophagus)

  • Aerophagia (swallowing too much air and loud burping)
  • Diaphragmatic hernia
  • Hiatal hernia
  • Achalasia (lower esophageal spasm and darkness)

Measure

Small and Large Intestine

Vein

  • Intestinal angina (bowel attack)
  • Coronary angina (heart attack, angina pectoris)

Boundary

  • Neuroma
  • Intercostal neuralgia (rib bone pain at the surgery site)
  • Spinal nerve lesions
  • Sympathetic imbalance
  • Neurosis
  • Mental tension or anxiety

Bone

  • Arthritis

Other

  • Adrenal cancer
  • thyrotoxicosis
  • Foreign bodies, including gallstones and surgical clips

In some studies, in the postoperative period gastritis has been found to be more frequent (Abu Farsakh et al. 30% versus 50%). It was shown that fasting gastric bile acid concentration increased after cholecystectomy and the increase was higher in patients with PCS.

Even in the second surgical interventions, 8% of the patients are not diagnosed.

Studies have shown that 14% of patients who undergo gallbladder surgery have a risk of PKS. It was also found that the risk of PKS was not associated with preoperative findings.

gallbladder

Some Important considerations for gallbladder surgery:

  • In emergency conditions The risk of developing PKS is higher in operations performed.
  • If there are stones in the gallbladder, in 10-25% of patients; if there is no stone29% of patients may develop PKS.
  • Before surgery complaint period If less than 1 year, in 15.4% of patients; If 1-5 years, 21%; If it is 6-10 years, 31%, and if more than 10 years, 34% may develop PKS.
  • During surgery If the bile ducts open (Choledochotomy), in 23% of patients; If choledochotomy is not performed, 19% may develop PKS.
  • Benefits and harms of gall bladder surgery

Demographic information based on age and gender

PKS rate in women %28 while in men %15is. According to the studies, the age difference is as follows:

  • 20% in those between the ages of 29-43
  • 30% in those between the ages of 39-27
  • 40% in those between the ages of 49-21
  • 50% in those between the ages of 59-26
  • 60% in those between the ages of 69-31
  • Patients over 70 years old did not develop PKS
  • Dr. Ertan BEYATLI

weather

The outcome and prognosis vary according to the patient's variety, the conditions encountered and the surgeries that can be performed. Moody's %75It showed good pain reduction in long-term follow-up. Short-term complications are common (5-40%). Hyperamylasemia It is the most common complication, but it usually resolves on the 10th postoperative day. Pancreatitis in 5% of cases, %1Death is expected in patients.

History

A wide variety of symptoms can be seen in patients with Postcolectomy Syndrome (PCS). Symptoms are sometimes considered to be related to the gallbladder. Freud found colic in 93% of patients, pain in 76%, jaundice in 24%, and fever in 38%. The PKS rate in the author's patient group is 14%. 71% of patients have pain, 36% have diarrhea or nausea, 14% have bloating or gas. The cause of PKS can be identified in 95% of patients. Dr. Ertan BEYATLI

Physical examination

How PKS works is different. In an attempt to identify a specific cause of symptoms and rule out serious post-cholecystectomy complications, the patient a comprehensive study must be done. On re-examination surgical intervention should be considered as a last resort.

The patient examination begins with a thorough history and a careful physical examination. Special attention should be paid to preoperative examination and diagnosis, surgical findings and pathological examination, and postoperative problems. Inconsistencies can make diagnosis easier (Dr. Ertan BEYATLI).

Operation Method

Laboratory studies

Initial laboratory studies in studies for Postcholecystectomy Syndrome (PKS) usually include:

  • To screen for infectious etiologies complete blood count (CBC)
  • pankreas basic metabolic panel (TMP) to screen for disease and amylase level
  • Liver or bile ducts for screening in diseases liver function panel (HFP) and prothrombin time (PT)
  • If the patient is acutely ill, blood gas analysis

If laboratory findings are within reference ranges, care should be taken to repeat these studies when symptoms are found. (important!!)

Other laboratory studies are as follows:

  • lipase
  • Gamma-glutamyl transpeptidase (GGT)
  • Hepatitis panel
  • Thyroid function
  • Cardiac enzymes

Radiography

Chest radiography should be performed to screen for lower lung, diaphragm and mediastinal diseases; In most cases, abdominal films should also be obtained. In patients with back problems or a history of arthritis, a lower dorsal spine series should also be acquired.

For patients with right upper quadrant pain, intestinal tract, barium swallow (OMD), upper gastrointestinal (GI) and small bowel follow-up (SBFT) studies will evaluate for signs of esophagitis, including gastroesophageal reflux disease (GERD) and peptic ulcer.

These studies are not always implemented, because endoscopy (esophagogastroduodenoscopy) is more reliable in identifying these diseases and also allows direct visualization of the Vater bulb. When the pain in the abdomen is lower, a barium enema should be done.

Also, in some cases, angiography may be performed for vascular disorders such as coronary or intestinal angina.

Ultrasonography

An ultrasonographic study is almost always done; It is a fast, noninvasive and relatively inexpensive way to assess the liver, biliary tract, pancreas and surrounding area.

Common bile duct (CBD) 10 to 12 mm an enlargement is commonly observed. Dilatation exceeding 12 mm Often a blocked stone can indicate distal obstruction, such as a narrowing of the CBD or an ampullary stenosis.

In a study involving 80 patients with PKS, Filip et al. endoscopic ultrasonography (EUS) to determine which patients require ERCP (endoscopic retrograde cholangiopancreatography) a valuable tool They decided that it was. The sensitivity and specificity of EUS were 53% and 96.2%, respectively, in the subgroup of 88.9 patients diagnosed with biliary or pancreatic disease.

The researchers found that the use of EUS helped reduce the number of patients receiving ERCP by 51%.

Endoscopy and Colonoscopy

Endoscopy can be of great help in PKS studies. It is a good procedure to assess the mucosa for signs of disease through the esophagus through the duodenum.

Endoscopy also allows direct imaging of the ampulla of Vateri. For more detailed information about endoscopy, you can check out my article here (see; Endoscopy, Dr.Ertan BEYATLI).

Total colonoscopy can reveal colitis, and a biopsy of the terminal ileum can confirm Crohn's disease.

ERCP (Endoscopic Retrograde Cholangiopancreatography)

ERCPIn the diagnosis of PKS is the most useful test.

For imaging of the ampulla, biliary and pancreatic ducts is unique. At least 50% of patients with PCS have biliary tract disease and most of these patients have functional conditions.

An experienced endoscopist It can confirm this diagnosis in most of these patients and also provide additional diagnostic studies such as biliary and bulb manometry.

Delayed unloading can be observed during ERCP as well as during hepatoiminodiacetic acid (HIDA) screening. CBD should stay away from contrast within 45 minutes.

Biliary manometry is performed with perfusion catheter in sedated patients without narcotics; The pull technique is used for the sphincter manometer. The sphincter is 5-10 mm long and normal pressures are less than 30 mmHg.

As technology advances, it will be easier to detect backward contractions or increased frequency of contractions (also called tachydoids).

Therapeutic maneuvers such as dilatation, stone extraction, stricture dilatation or sphincterotomy can be performed for Oddi sphincter stenosis with ERCP.

Percutaneous transhepatic cholangiography (PTC) or magnetic resonance cholangiopancreatography (MRCP) may be useful in patients who are not candidates for ERCP or have failed ERCP attempts. (For more detailed information about ERCP, you can check my article here. ERCP: what is it and how is it done?)

CT and MR

Computed tomography (CT) can be helpful in detecting chronic pancreatitis or pseudocysts in alcoholic patients or those with a history of pancreatitis.

In patients who are not candidates for endoscopy and ERCP, helical CT scan or MRCP may reveal the cause of PKS.

Nuclear Imaging

Nuclear imaging postoperative may show bile leakage. Sometimes a HIDA scan or similar scintigraphy study may indicate delayed evacuation or a prolonged half-time.

However, these studies, dilation, stricture and so on. it does not have the resolution required to define it. More than two hours Delayed evacuation or a prolonged part-time event can help identify the Oddi sphincter as a potential cause, but cannot distinguish between stenosis and dyskinesia.

Other tests

In addition to review, physical examination, and review of old records, electrocardiography (ECG) should be performed to screen for coronary disease. It can be indicated by a stress test or Holter monitoring, signs of the past, physical, laboratory tests, or EKG.

Provocation tests such as the morphine-neostigmine test for pain or the secretin stimulation test for pancreatic duct dilation have not been widely accepted.

Treatment Phase

Approach Considerations

Postcholecystectomy Syndrome (PKS) is usually a temporary diagnosis. In many patients, an organic or functional diagnosis is made after a full study. Once a diagnosis has been made, treatment should continue as prescribed for that diagnosis. Treatment can be medical or surgical. Dr Ertan BEYATLI

Pharmacological Therapy

Patients with irritable bowel syndrome may benefit from bulking agents, antispasmodics, or sedatives. Irritable sphincter may respond to high doses of calcium channel blockers or nitrates; however, the available evidence is not yet convincing. Colestyramine alone was beneficial for patients with diarrhea.

Antacids, histamine 2 (H2) blockers, or proton pump inhibitors (PPIs) can sometimes provide relief for patients with symptoms of gastroesophageal reflux disease (GERD) or gastritis. One study showed that lovastatin can provide at least some relief in 67% of patients.

Surgical intervention

Like medical therapy, surgical treatment should be directed towards the specific diagnosis. [Dr.Ertan BEYATLI]. Surgical intervention can of course be performed in cases where it is determined that a good response will be obtained from the surgery.

The most common procedure is endoscopic retrograde cholangiopancreatography (ERCP), which can be both diagnostic and therapeutic. Exploratory surgery (diagnostic diagnostic intervention) may be a last resort in an undiagnosed patient who is refractory to medical treatment.

In 1947, Womack proposed resection of the scar and nerve tissue around the cystic duct stump; however, this method is somewhat controversial. Others suggested neuroma, cystic duct debris, sphincter dilation, sphincterotomy, sphincterotomy, bile duct bypass, common bile duct (CBD) exploration, and stone removal. With ERCP, most of these diagnoses have been rejected or treated, and the idea of ​​cessation of the neuroma is controversial.

Patients who use alcohol or drugs are particularly difficult to treat, and diagnostic intervention should be delayed until the abuse of these drugs is stopped.

In some patients, the cause is not identified, but the condition may respond to sphincteroplasty, including bile and pancreatic ducts. This patient group has not been defined preoperatively yet.

After a complete evaluation (including sphincterotomy with ERCP), if the patient continues to weaken, intermittent right upper abdominal pain persists and is not diagnosed, transduodenal sphincteroplasty may be preferred after a normal diagnostic laparotomy.

ERCP is usually sufficient for stones falling into the bile ducts or residual stones. However, in some cases, surgical excision of these stones may be required.Dr. Ertan BEYATLI

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