BILIARY CAUSES OF RECURRENT PAIN AFTER CHOLECYSTECTOMY AND [621401]

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BILIARY CAUSES OF RECURRENT PAIN AFTER CHOLECYSTECTOMY AND
THERAPEUTIC APPROACH

Mariana Ungur1, Rita Kiss3, Maghiar Adrian4, Feder Bogdan5

1Faculty of Medicine and Pharmacy -Surgery Department, University of Oradea;
2Medical and Health Science Center, 3rd Department of Internal Medicine, University of
Debrecen
3Faculty of Medicine, Institute of Pharmacology and Pharmacotherapy, University of Debrecen,
4Pelican Clinical Hospital Oradea, Faculty of Medicine and Pharmacy -Surgery Department,
University of Oradea,
5Faculty of Medicine and Pharmacy – Surgery Department, University of Oradea, County
Clinical Emergency Hospital Oradea – Surgery I

Mailing address:

Dr. Mariana Ungur – Surgery Department, Faculty of Medicine and P harmacy, University of
Oradea
1 Decembrie Street, 410068, Oradea, Romania
Email: [anonimizat]

Abstract . Postcholecystectomy syndrome is a set of symptoms, particularly in the digestive field
that does not disappear after surgical removal of the gallbladder, on the contrary, they worsen the
symptoms.
Objectives. The main objective of this paper is to study the biliary causes of the
postcholecystectomy syndrome and the ways of therapeutic approach.
Material and method . In the present study, there have been used clinical observation sheets of
the patients hospitalized in surgical wards, from January 2010 to October 2015 with the
diagnosis of the postcholecystectomy syndrome.
Results . Between January 2010 and – October 2015 were hospitalized 221 pati ents, accounting
for 67.42% of females. Clinical examinations and laboratory examinations showed the presence
of a postoperative cholangitis with a share of 92.30%. Of the 221 cases admitted to surgery with
a postcholecystectomy syndrome, the biliary cause s weight was 14%, in 190 of the cases, the
treatment was by drugs 85,97%). In the other 31 cases, it was used an endoscopic and/or surgical
intervention.
Conclusions . Cholangitis in postcholecystectomy generates changes in intrahepatic and
extrahepatic bi le ducts which are translated by imaging, by their expansion, with or without
parietal modifications, with or without obstruction lesions of the distal bile duct , with a share of

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21.26%. The main therapeutic approach in postcholecystectomy syndrome is non invasive, by
drugs, accounting for 85,97%.
Keywords : postcholecystectomy syndrome, cholangitis endoscopic sphincterotomy.

Introduction

Postcholecystectomy syndrome is defined as the recurrence of the similar symptoms occurred
before surgery. These symptoms are representing especially by pain localized in the right upper
abdominal quadrant, dyspeptic phenomena, and presence or ab sence of jaundice. [1] Frequently,
this postcholecystectomy syndrome, occurs when cholecystectomy was performed in the absence
of a rigorous indication (i.e. a patient with dyspeptic manifestations in the absence of gallstones).
Draws attention to the chol ecystectomy indications, in the absence of typical clinical
manifestations specific for gallstones and echo argumentation of this gallstones.
The postcholecystectomy syndrome affects approximately 10 -15% of the patients with the
surgical history of cholec ystectomy – classical or laparoscopy. It does not reflect objectively the
causes of suffering patients with cholecystectomy in history, as cholecystectomy causes some
functional disorders of the bile ducts, with a low frequency, 0.21% of the cases. Most of the
sufferings for operated bile have another cause.
The postcholecystectomy syndrome is usually a temporary diagnosis. An organic or functional
diagnosis is established for most patients after clinical investigations and rigorous laboratory
investigatio ns. A complete preoperative assessment is important to reduce as much as possible,
the occurrence of this postcholecystectomy syndrome.[2,3,4]. Furthermore, there must be a prior
notice of the patients, so to be warned of the possibility of such symptoms fo r immediate or
delayed postoperative period.[2,3,4]
Female patients are more likely to develop a postcholecystectomy syndrome, also, in analogy
with the higher incidence and gallstones. The postcholecystectomy syndrome high prevalence for
women is caused b y the activity of estrogens, especially during childbearing age (young age,
regnancy status, treatment with oral contraceptives). [5]
The objective of this paper is to highlight the biliary pathology of the postcholecystectomy
syndrome for cases hospitaliz ed in surgical wards of a county clinical emergency hospital and
therapeutic ways of solving the generating cause.

Material and method

In the present study there have been used, as a reference, the hospitalized patients' clinical
observation sheets betw een January 2010 – October 2015, with the diagnosis of the
postcholecystectomy syndrome, in Oradea County Hospital Surgery I and II ward.
The research was conducted using as criteria, the selection of cases by sex, age and the diagnose
framing, historical data, methods of clinical investigation, imaging and laboratory methods, the

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association of cholecystectomy with other interventions performed to bile ducts, therapeutic
conduct non -invasive versus invasive.
The anamnesis revealed a previous history of c holecystectomy, patients' subjective complaints –
the presence of the painful syndrome in the right upper quadrant, of the dyspeptic syndrome, of
jaundice syndrome.
Useful laboratory examinations for establishing the diagnosis: biliary -retention samples of serum
bilirubin, bile pigments in the urine alkaline phosphatase; hepatic cytolysis tests: transaminases,
serum iron, lactic dehydrogenases; cellular -albumin hypofunction tests, serum
pseudocholinesterase, clotting factors; exploration of hepatic functi on in lipid metabolism.
Other laboratory tests very helpful for establishing a positive diagnosis were: mesenchymal
hyperactivity tests (electrophoresis tests dysproteinemia, immunoelectrophoresis), immunoassay,
erythrocyte sedimentation rate, changes in b lood counts, blood urea.
Erythrocyte sedimentation rate is higher in jaundice with cholangitis and the neoplastic ones.
Blood count changes; this anemia suggests neoplastic etiology or hemolytic in prehepatic
jaundice and cirrhosis. Hyperleukocytosis is present in biliary ducts lithiasis in cholangitis and
liver cancer; it is unusual in acute hepatitis.
Blood Urea is impor tant in a case of mechanical jaundice; nitrogen retention associated with
obstructive jaundice syndrome has a poor prognosis, preceding hepatic -renal failure.
The methods used in the diagnosis of the postcholecystectomy syndrome were cholangiography,
ultrasonography, computed tomography of the abdomen, Cholangio -IRM, upper gastrointestinal
endoscopy, duodenal gastroesophageal barium swallow.
Therapeutic options for the postcholecystectomy syndrome consisted of noninvasive medicinal
methods and imaging metho ds or invasive surgical methods.[6]
If the bile sufferings have an organic substrate, then it is performed a surgical intervention
(example digestive biliary fistula, long cystic blunt) or endoscopic sphincterotomy (common bile
duct lithiasis, stenosis, sc lerosis oddities).[6]

Results

Between January 2010 and October 2015 were hospitalized with a diagnosis of a
postcholecystectomy syndrome in the two surgical clinical sections of the county hospital 221
patients, with a share of females of 149 patients, representing 67.42% and a share of males, of
72 patients representing 32,57%.
Decades of age most frequently used for the diagnosis of a postcholecystectomy syndrome in
surgical wards were, in descending order by the number of cases: 55 -64; 65 -74; 75 -84 and 45 -54
years.

Biliary pathology of the postcholecystectomy syndrome.

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In 47 cases out of 221 hospitalized cases, the imaging investigations revealed intrahepatic and /
or extrahepatic biliary ducts dilatation.
In 31 cases(14%) is highlighted the extrahepatic biliary ducts dilatation, with or without the
association of obstructive modifications duct stones calculi or oddian stenosis.
Of the 31 cases with extrahepatic biliary tract dilatation in 15 cases, imagin g examination
revealed the presence of duct stones lithiasis, as the cause of the postcholecystectomy syndrome.
Of the total hospitalized cases with the postcholecystectomy syndrome in 3 cases, the imaging
revealed the presence of sclerosing odditis and i n other 3 cases, oddian stenosis.
In 4 cases, postcholecystectomy cholangitis was consecutive to iatrogenic injuries of main bile
ducts after laparoscopic cholecystectomy.
It was also reported the presence of postcholecystectomy cholangitis after surgery for Klatskin
biliary tumor (1 case), ampulla of Vater (2 cases) and cholangiocarcinoma of the hepatic hilum
(1 case)
In the baseline study, it was reported the presence of cholangitis after bile digestive anastomoses
(anastomoses, choledochal -jejunal anast omosis, duodenal -jejunal hepatic, on Y a la Roux) in 10
cases, out of the 221 hospitalized cases with a postcholecystectomy syndrome. Also, statistics
showed 3 cases of cholangitis after sphincterotomy / transduodenal sphincteroplasty.
There were also hosp italized patients with endoscopic post -sphincterotomy cholangitis, a total of
4 cases from the total of 221 patients hospitalized with the postcholecystectomy syndrome.

Table I. Biliary causes in postcholecystectomy syndrome at admitted patients

Patholog y Cases
Number Percentages
Bile duct lithiasis 15 6,78%
Sclerosis odditis 3 1,35%
Oddian stenosis 3 1,35%
Iatrogenic biliary lesions 4 1,80%
Roux -en-Y anastomosis stenosis 1 0,45%
Klatskin bile ducts tumor 1 0,45%
Ampulla of Vater 2 0,90%
Hepatic hilum cholangiocarcinoma 1 0,45%
Intrahepatic biliary tract lithiasis 1 0,45%
Total 31 14 %

The treatment of postcholecystectomy syndrome can be done by medication, endoscopic or
surgical. Of the 221 cases hospitalized in surgical wards with the postcholecystectomy syndrome

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in 190 cases, the treatment was by medication. In the other 31 cases, it was endoscopic and / or
surgical.
In eight cases, it was a surgical procedure (table II) and in another 23 cases was performed
retrograde endoscopic colecistopancreatography with sphincterotomy and extraction of stones.
In two of the 8 cases after surgery , because of the persistence of biliary cause that generated the
postcholecystectomy syndrome, it is performed the endoscopic sphincterotomy; In the first case,
for a bile tract fistula, and in the second case for installing a duct stent (lower duct divert iculum)

Table II. Surgical approach – techniques
Share of different surgical techniques used Number of
cases
Anastomosis dilatation and biliary transit restoration, after the stenosis of Roux –
en-Y hepaticojejunostomy 1
Transduodenal papilosfincterotomy for oddian stenosis 1
Duodenal choledochal anastomosis for iatrogenic injury of bile, with bile leak in
the line of Kehr drainage tube 2
Roux -en-Y hepaticojejunostomy, for CBP lesion 1
Choledocotomy extraction of gallstones and cole doco – duodenal anastomosis,
Floren type 1
Intrahepatic biliary drainage with Kehr tube for bile leak and bile tract fistula
laparoscopic postcholecystectomy (later, ERCP guidance) 1
Lavage and laparoscopic drainage in Morrison space; persistent perihepatic
collection with externalization on the drain tube 500 ml bile / 24 h; it is
advisable to perform ERCP, sphincterotomy by installing a duct stent 1

Discussions

The biliary causes of the postcholecystectomy syndrome with the highest representation in the
baseline study are choledochal stones, oddian stenosis, and tumor pathology.
In cases with cholangitis postcholecystectomy, the researchers conducted to cases hospitalized
in surgical war ds revealed most commonly an inflammatory syndrome with leukocytosis and
neutrophils, and/or bile excretory syndrome, and/or hepatic cytolysis syndrome, cholestasis;
imaging argumentation of the changes of the intrahepatic and extrahepatic biliary tract is absent
most of the times.
Cholangitis from postcholecystectomy syndrome produces changes to intrahepatic and
extrahepatic bile ducts which are translated by imaging, by their expansion, with or without
parietal modifications, with or without obstructi ve lesions of the distal common bile duct, with a
share of 21.26%.

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The prevalence of postcholecystectomy syndrome due to biliary causes is higher for patients who
were associated with primary cholecystectomy surgery and other surgery,
choledocholithotomies , sphincteroplasties, biliary -digestive anastomoses.
The main therapeutic approach for the postcholecystectomy syndrome is noninvasive, by drugs,
accounting for 90.04%.
Pharmacologic treatment consists of antibiotics, antispasmodics, analgesics, proton pum p
inhibitors, prokinetics, hepatoprotective, bile acid substituents (ursodeoxycholic acid), pancreatic
enzymes (Creon); in oddian dyskinesia – nifedipine, nitroglycerin, amyl nitrite.
The endoscopic retrograde cholangiopancreatography is the modern therape utic method, that by
sphincterotomy / sphincteroplasty allows both removal of common bile duct stones and papillary
dyskinesia problems solving; in the reference study, were carried out 23 sphincterotomies /
endoscopic sphincteroplasty (10,40%).
Choledoch olithotomy associated with choledochoduodenal anastomosis or duodenal Roux -en-Y
hepaticojejunostomy is chosen as a surgical approach when there is a marked dilatation of the
main biliary tract, gritted biliary duct stones, stretched stenosis, stenosis of a biliary -digestive
anastomosis and oddian restenosis after sphincterotomy.
The statistical data above demonstrates a high prevalence of the postcholecystectomy syndrome
to female patients hospitalized in surgical clinical wards (67.42%)
Female patients ar e more likely to develop the postcholecystectomy syndrome, also in analogy
with higher incidence and with gallstones. This increased prevalence is due to the estrogen
hormone during childbearing age (young age, state of pregnancy, oral contraceptives)
Estrogens increase the cholesterol content in bile and have triggered the cholesterol uptake
stimulus by hepatic cells. Consequently, it is installed the classic cholestasis "early estrogen." the
ratio of cholesterol and phospholipids increases; hepatic bile s ecretion volume decreases. [ 5] As
an effect occur: increase of the cholesterol synthesis and cholesterin secretion, the decrease of
the bile acids and cholesterin ratio. Thus, female gender, pregnancy status, and oral
contraceptives are considered risk fac tors in the formation of cholesterol gallstones. [5]
Of the 221 cases admitted to surgery, with the postcholecystectomy syndrome, in 204
cases (92,30%) , clinical and laboratory examinations showed the presence of postoperative
cholangitis. These inflammator y processes produce intrahepatic and extrahepatic changes to bile
ducts which are translated by imaging, by their expansion, with or without parietal modifications,
with or without obstructive lesions of the distal common bile duct
In 47 cases out of 221 hospitalized cases, imaging investigations conducted revealed dilated
biliary tract inter and/or extrahepatic. Small stones can cross the papilla but during bile gorge
crossing they can create a barrier to a consecutive expansion of main bile ducts; all imaging
examination will show a dilated bile but uninhabited (bile passage) This extrahepatic biliary tract
swelling may be associated with intrahepatic biliary tract ectasia. Cholangitis may have as an
imaging expression, an abno rmal highlighting of bile ducts, after the thickening of their walls .[7]
Postcholecystectomy sclerosing cholangitis have as a consequence, multiple stenoses of bile
ducts inter – and/or extrahepatic and usually lead to biliary cirrhosis. In terms of imaging , stenosis

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may have a multifocal distribution, causing stenosis and consecutive dilation with different
intensities, depending on the location in question [ 7]
In 31 cases, it is highlighted the extrahepatic biliary tract dilatation with or without
association with obstructive changes – gallstones or oddian stenosis.
The biliary causes of postcholecystectomy syndrome include: intrahepatic biliary tract lithi asis,
choledochal lithiasis, biliary tract tumors and large duodenal papilla tumors, long stump cystic
duct stenosis, residual oddian stenosis, large duodenal papilla stenosis, oddian dyskinesia,
biliary -digestive anastomosis stenosis (anastomosis choledoc hoduodenal and biliary -jejunal
inoperable), cystic dilatation of the inter and extrahepatic biliary tract.[8]
Of the 31 cases with extrahepatic biliary tract dilatation, in 15 cases, imaging examination
revealed the presence of duct stones, as the cause of the postcholecystectomy syndrome(table I)
Biliary stasis will favor the infection. The inflammatory infiltrates in the common bile duct will
favor enclave calculus, affecting the functionality of Oddi sphincter. Consequently, oddian
stenosis occurs.
Of the total hospitalized cases with a postcholecystectomy syndrome, in 3 cases, the imaging
revealed the presence of sclerotic oddities and in other 3 cases, oddian stenosis.
There are also described the causes related to the surgical act itself, an inadequa te surgical
technique with extrahepatic biliary tract iatrogenic lesions. In 4 cases, postcholecystectomy
cholangitis was consecutive to iatrogenic injuries of bile tracts after laparoscopic
cholecystectomy.
Ampullary enclaved calculi or repeated passage of the micro calculi or achiness by oddian
narrow pass cause bouts of acute pancreatitis.[8] In the baseline study were reported to frequent
cases in which postcholecystectomy cholangitis and choledochal stones were associated with
acute pancreatitis. Spas m and posttraumatic edema cause the increased intrapancreatic pressure,
on which can be added biliary -pancreatic reflux with potentially infected bile .
Besides the pancreatic activity, the choledochal obstruction will also affect the hepatic activity.
The degree of liver damage depends on the speed of installation, extent, duration of the
obstruction and the presence or absence of infection. In obstructive jaundice due to bile duct
stones, the liver volume increases, the surface is granular in old obstruct ions, with the possibility
of parenchymal fibrosis.
The research data revealed an association in some cases of cholangitis and duct stones with
satellite hepatitis.
The extra -biliary causes of the postcholecystectomy syndrome are diseases of the liver an d
pancreas, duodenum disease, reflux esophagitis, peptic ulcer, hiatus hernia, etc..
The prevalence of postcholecystectomy syndrome by biliary causes is higher for patients who
were associated with primary cholecystectomy surgery other surgical interve ntions, on biliary –
choledocholithotomies, sphincteroplasty, biliary -digestive anastomoses.
In the reference in the study, it was reported a cholangitis after biliary -digestive anastomosis
(choledochal -jejunal anastomosis , Roux -en-Y hepaticojejunostomy ), in 10 cases out of the 221

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hospitalized cases with a postcholecystectomy syndrome. Also, statistics showed 3 cases of
cholangitis after sphincterotomy / transduodenal sphincteroplasty
There were also hospitalized patients with cholangitis and post endosc opic sphincterotomy, a
number of 4 cases from the total of 221 hospitalized patients with the postcholecystectomy
syndrome.
The literature describes a rate of approximately 1% of endoscopic retrograde
cholangiopancreatography subsequent to Angi cholates.[9 ,10,11] In the reference study, the
prevalence of post -ERCP cholangitis is 1.80%.
The postcholecystectomy syndrome treatment may be performed by medication, surgical or
endoscopic procedures.
Of the 221 cases hospitalized in surgical wards with the postcho lecystectomy syndrome in 190
cases, the treatment was by medication. In the other 31 cases, it was endoscopic and/ or surgical.
Endoscopic retrograde cholangiopancreatography, the useful diagnostic method is also the
therapeutic methods that by sphincterot omy/sphincteroplasty allows both removal of common
bile duct stones and the solving of papillary dyskinesia. [12]
The therapeutic approach by endoscopic sphincterotomy is a modern method, which replaced
with a very high success rate, the surgery of postch olecystectomy syndrome.[13,14] Endoscopic
sphincterotomy is an effective therapeutic method that allows the extraction of residual or
recurrent stones in the common bile duct, that do not exceed 1.5 cm in diameter.
The surgical treatment performed in the choledochal lithiasis may be represented by
choledocholithotomy and Kehr drainage, for residual calculi, with a mobile and moderate
expansion of bile duct.[11,12]
If the choledochal lithiasis is complicated by the enclavation of calculus in papilla of Vate r or by
a residual oddian it is performed a choledocholithotomy stenosis and sphincterotomy/oddian
sphincteroplasty and external biliary Kehr drainage.
Choledocholithotomy associated with choledochoduodenal anastomosis or duodenal Roux -en-Y
hepaticojejunostomy is chosen as the surgical approach when there is a marked dilatation of the
main biliary tract, gritted biliary duct stones, stretched stenosis, stenosis of a biliary -digestive
anastomosis and restenosis after oddian sphincterotomy.[11 ,12]
Intrahepatic biliary tract lithiasis raises difficulties to surgical approach; to eliminate spontaneous
the calculi it is necessary to perform a duodenal anastomosis or duodenal Roux -en-Y
hepaticojejunostomy In two of the 8 cases, after the surgery, b ecause of the persistence of biliary
cause that generated the postcholecystectomy syndrome, it is performed an endoscopic
sphincterotomy; In the first case for a bile fistula and in the second case for installing a duct stent
(lower duct diverticulum)
The endoscopic treatment consisted of sphincterotomy by retrograde endoscopic
colecistopancreatography, extraction of stones and depending on the case, installing a duct stent.
When the symptoms are the result of Oddi sphincter dyskinesia, initially it is admi nistered a
pharmacological treatment represented by nitroglycerin, nifedipine, anticholinergics, amyl
nitrite.[15,16,17,18]

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This treatment continues for a period of 2 -3 months; if there is no obvious clinical improvement
it will be performed endoscopic sph incterotomy or surgical sphincteroplasty. Alternatively, it
can be used, as symptomatic: antispasmodics or analgesics for the relief of pain complaints.
The dyspeptic symptoms are treated with substituents for biliary acids (ursodeoxycholic acid) or
pancr eatic enzyme extracts.[19,20] Mild cases of cholangitis respond well to parenteral
administration of ampicillin or cephalosporin in doses of 1 gram every 4 -6 hours, or 2 g every 6
hours. It is also considered that last generation penicillins with the very broad spectrum of action
(mezlocillin, piperacillin) have good biliary excretion, being used frequently.
In severe cases of cholangitis, with an accentuated inflammatory syndrome with
hyperleukocytosis it may be initiated a microbial treatment by the com bination of several
antibiotics like gentamicin, ampicillin, clindamycin, etc..
Conservative drug treatment represents, depending on the symptoms, the generating cause, and
possibly other associated digestive disorders: proton pump inhibitors, antibiotics, prokinetics,
hepatoprotective, antispasmodic, analgesic, ursodeoxycholic acid, Creon, etc..
Pharmacological treatment has increased efficiency for patients who have a non -biliary etiology
of a postcholecystectomy syndrome.
Outpatient, to avoid repeated postcholecystectomy cholangitis flashes it is important to initiate a
hepatic a nd gastric sparing regimen, avoiding the consumption of fats, spices, alcohol.

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