A 52-year-old woman comes to the office due to intermittent right upper quadrant pain and nausea. The patient has a history of obesity and gallstones, for which she underwent elective cholecystectomy a year ago. The pain is located in the right subcostal area and generally lasts 30-60 minutes. The patient recalls that she had similar episodes before the surgery. Laboratory results after one of the episodes are as follows:
| Total bilirubin | 2.1 mg/dL |
| Direct bilirubin | 1.2 mg/dL |
| Alkaline phosphatase | 185 U/L |
| Aspartate aminotransferase (SGOT) | 84 U/L |
| Alanine aminotransferase (SGPT) | 72 U/L |
Abdominal ultrasound examination reveals mild dilation of the common bile duct. The pancreas is visualized and appears normal. Which of the following is the best next step in management of this patient?
Postcholecystectomy syndrome | |
Definition |
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Etiology |
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Common features |
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CBD = common bile duct; IBS = irritable bowel syndrome; LFT = liver function test; PUD = peptic ulcer disease; SOD = sphincter of Oddi dysfunction. | |
This patient's presentation is concerning for postcholecystectomy syndrome (PCS), recurrent or persistent abdominal pain and/or dyspepsia (eg, nausea, indigestion) that occurs in either the immediate postoperative period (early) or months to years later (late). Symptoms are characteristically similar to those experienced before cholecystectomy.
PCS, which is defined by its symptoms, may be caused by a number of conditions, both biliary and extrabiliary. Common biliary causes include retained or recurrent stone in the common bile duct (CBD) and bile leak (eg, intraoperative bile duct injury). Biliary stricture (eg, late sequala of intraoperative thermal injury) and sphincter of Oddi dysfunction (SOD) can also cause PCS.
A biliary cause should be suspected when a patient has elevations in liver function test results (eg, bilirubin, alkaline phosphatase, aminotransferases) and CBD dilation on ultrasonography. In particular, these findings suggest a CBD stone, biliary stricture, or SOD. Further evaluation of the biliary tree with MR cholangiopancreatography, endoscopic ultrasonography, or endoscopic retrograde cholangiopancreatography (ERCP) can confirm the diagnosis and guide therapy. Treatment is directed at the underlying cause.
(Choice A) Antimitochondrial antibodies are usually detected in primary biliary cholangitis (PBC). However, affected patients typically have other symptoms (eg, pruritus, fatigue, jaundice) along with abdominal pain. Although PBC can present with laboratory findings of cholestasis (eg, elevated bilirubin, elevated alkaline phosphatase), imaging typically does not show a dilated CBD.
(Choice C) Helicobacter pylori stool antigen testing is used to diagnose H pylori infection in patients with peptic ulcer disease. It is not typically associated with abnormal liver function or a dilated CBD.
(Choice D) Liver biopsy should be performed when there is evidence of liver injury (eg, elevated liver function test levels) and the initial evaluation (laboratory analysis and imaging) does not provide a definitive diagnosis. This patient may eventually require liver biopsy if ERCP and other studies are unremarkable, but it is not the best next step.
(Choice E) Ursodeoxycholic acid can treat cholesterol gallstones in patients with mild symptoms who are not candidates for cholecystectomy. It is also used to slow disease progression in PBC and primary sclerosing cholangitis. Ursodeoxycholic acid is not useful in managing PCS.
Educational objective:
Postcholecystectomy syndrome is characterized by recurrent or persistent abdominal pain and/or dyspepsia after cholecystectomy; it can have a biliary or an extrabiliary cause. If a biliary source is suspected (eg, elevated liver function test levels, dilated common bile duct), imaging to visualize the biliary tree (eg, endoscopic retrograde cholangiopancreatography) is recommended.