POST CHOLECYSTECTOMY SYNDROME

Nuwan GunapalaRegistrar wd40B/ 21

OBJECTIVES

Definition Epidemiology Aetiology Pathophysiology Clinical features Investigations Management

OUR EXPERIENCE……

Mrs Dhanuka perera Later found to have duodenal carcinoma

Mrs Nei Sherine Expired from caecal carcinoma

Mr H A Jyasena Has undergone emergency subtotal

cholecystectomy later found to have retained stones and underwent choledocho-jejunostomy and currently recovering from surgery.

WHAT IS IT ?

First describe in 1947

It is persistence of symptoms following

cholecystectomy

continuation of symptoms which was thought

to be caused by gall bladder

development of new symptoms usually

attributed to gall bladder

symptoms due to absence of gall bladder

EPIDEMIOLOGY

15% of patients develop the symptoms Incidence is high in patients who didn’t

have gallstones Also high in emergency surgery patients Pre-operative secure diagnosis reduce

incidence Functional disorders are the most common

causes Prior surgery, bile spillage or stone spillage

doesn’t increase the incidence More common in females

PATHOPHYSIOLOGY Due to increase bile flow in to upper GI

tract bile reflux gastritis and esophagitis

Due to bile in the lower GI tract diarrhoea and lower abdominal pain

Other symptoms could be resulting from structures in biliary tree or extra biliary structures

AETIOLOGY

Hepato-biliary system Cystic duct and gall bladder remnant

Residual or reformed gall bladder Stump cholelithasis Neuroma

Liver Fatty liver, sclerosing cholangitis, cirrhosis

Biliary tract Cholangitis Adhesions Strictures Cyst Choledocholithiasis Fistula

Periampullary Sphincter oddi dyskinesia, spasm,

hypertrophy Stricture Papilloma

Pancreas Pancreatitis Pancreatic stones Pancreatic cancer

EXTRA BILIARY

Oesophagus Hiatal hernia Achalasia

Stomach Bile gastritis PUD Cancer

Duodenum Adhesions Diverticulum

OTHER PATHOLOGIES

Colon Vascular

Angina Small bowel

A cause can be identified in 95% of patients

CLINICAL FEATURES

Colic Pain Fever Jaundice Diarrhoea, Bloating Nausea

INVESTIGATIONS

Aim is to exclude complication of cholecystectomy and identify other causes

Serology FBC LFT Amylase

Imaging chest x ray, abdominal x ray, barium swallow and follow through USS, MRCP

Invasive procedures UGIE ERCP

MANAGEMENT

If cause is identifiable manage specifically Patients with IBS – bulking agents, anti

spasmodics sedatives Antacids and H2 receptor blockers

Surgery for operable diseases If no obvious cause is identifiable

ERCP Open surgery

OPEN SURGERY

Ex lap Look for another cause Intra op cholangiogram Dissect neuroma and scar tissue around

cystic duct If pancreatic head is normal can do

sphincteroplasty If pancreatic head has chronic pancreatitis

proceed with choledocho duodenostomy

SPHINCTER OF ODDI DYSFUNCTION

Complex muscular structure Surrounds distal CBD, pancreatic duct, ampulla

of Vater Caused by structural or functional

abnormalities Fibrosis of sphincter from gallstone migration,

operative or endoscopic trauma, pancreatitis or nonspecific inflammatory processes

Sphincter dyskinesia or spasm ~1% of patient undergoing cholecystectomy

Labs: ↑ amylase, LFT ERCP: delayed emptying of contrast

medium from CBD ↑ basal sphincter pressure >40mmHg US: dilated CBD

MANAGEMENT

High-dose Ca channel blockers or nitrates, but evidence not convincing

Sphincterotomy (endoscopic or transduodenal)

Mucosa-mucosa apposition in surgical approach can minimize scarring and restenosis

60-80% successful if have documented objective evidence

THANK YOU……………….