8 Problems After Gallbladder Removal (Years Later).

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Introduction: What is a postcholecystectomy syndrome?

About 10% of patients may suffer from persistent or re-appearance abdominal pain after gallbladder removal. In some cases, the pain may persist (or reappear) years after gallbladder removal.

This condition is called (postcholecystectomy syndrome). And it the term is used to describe biliary colic, right upper abdominal pain, or diffuse upper abdominal pain similar to the pain experienced before gallbladder removal.

Also, the postcholecystectomy syndrome may involve other abdominal symptoms such as diarrhea, bloating, etc.

So, It is a diverse disease. And it can occur in one of three patterns:

  • Temporary (for a few weeks or months after gallbladder removal).
  • Persistent (for years after the operation, but it eventually ends.
  • Lifelong (continues through the lifetime).

Also, the postcholecystectomy syndrome may be:

  • A continuation of the symptoms experienced before the gallbladder removal.
  • Development of new symptoms (either immediately or years after gallbladder removal).

Another classification of the postcholecystectomy syndrome is:

  • Early type

From my own experience as a gastroenterologist, the postcholecystectomy syndrome is a term that includes a diversity of conditions (causes) and symptom patterns.

So, I will try today to address the most common causes of the postcholecystectomy syndrome as I see it. Also, I will focus on the causes that may last or appears years after gallbladder removal.

1 . Non-biliary Conditions (commonest).

Interestingly, the most common cause of gallbladder-like pain years after the operations is unrelated to the biliary system.

Studies estimate that at least 50% of the cases of post-cholecystectomy syndrome are not related to the biliary system (reference).

The table below summarizes the most common causes of non-biliary that mimic gallbladder problems (even years after its removal) (reference).

The most common causes that can mimic gallbladder pain years after cholecystectomy are:

  • Reflux esophagitis (gastrointestinal reflux disease), especially when the cause is a hiatal hernia.
  • Peptic ulcer disease pain.
  • Irritable bowel syndrome.
  • Chronic pancreatitis (especially in patients with chronic alcoholism).

How can you figure out non-biliary causes?

The main feature of all these conditions is that the pain is not a typical gallbladder pain (biliary colic).

Gallbladder pain has characteristic features that differentiate it from other causes of abdominal pain.

The table below illustrates all the features of biliary colic (true gallbladder pain).

Biliary colic (Uncomplicated gallstone).Description
1. SiteUsually, The right upper quadrant of your abdomen.
2. Spread– The pain may spread to the back of the right shoulder.
– Also, it spreads to the epigastric area.
3. CharacterConstant builds up then disappears gradually.
4. DurationAt least 30 minutes. It may last up to 6 hours.
5. Relation to food– Triggered by foods (especially fatty food and large meals.
– However, it can start spontaneously.
6. NOT related to:Movement, bowel movements, or the passage of flatus.
7. NauseaOften Present, severe.
8- Commonly associated symptomsVomiting, sweating during the attack.
9. Unusual symptoms.– Heartburn and chest pain.
– Bloating, fullness.
– Early satiety.
– Isolated epigastric pain.
10. Symptoms NOT associated:– Fever.
– Jaundice.
– Prolonged pain for more than 6 hours.
– Extreme tenderness over the gallbladder (Murphy’s sign).
– Vomiting of blood, blackish stool (PUD).

Other conditions that may mimic gallbladder pain years after gallbladder removal:

  • Reflux esophagitis (acid reflux or GERD)
    The main symptoms are heartburn (burning chest sensation), regurgitation of food or acidic substances, nausea, vomiting, and upper abdominal pain.
  • Peptic ulcer disease pain:
    Peptic ulcer disease pain is central (epigastric), related to meals, burning, or gnawing, and it is often more prolonged than gallbladder pain.
  • Irritable bowel syndrome.
    Irritable bowel syndrome is often diffuse colicky abdominal pain that comes and goes in attacks. It can be localized in the upper abdomen. Also, the pain is often relieved by defecation and is associated with changes in bowel habits. Bloating is also common in IBS patients.
  • Chronic pancreatitis pain:
    Patients with chronic pancreatitis (often due to alcoholism) may suffer from persistent or recurrent upper abdominal pain that mimics gallbladder problems. The pain is often severe and constant in the central upper abdomen and radiates to the back.

Learn More: 5 mimics of gallbladder pain, Explained by a gastroenterologist.

2. Gallbladder or cystic duct remnants.

 

Sometimes, the surgeon doesn’t remove the gallbladder completely. A small part of the gallbladder or the cystic duct (short duct connecting the gallbladder to the main bile duct) is left in rare cases.

As a result, a stone may form years after gallbladder removal in the gallbladder remnant or cystic duct.

Patients may present years after gallbladder removal with typical gallbladder pain (as described in the table above).

Some studies estimate that up to 13.3% of laparoscopic gallbladder removal surgery leaves a gallbladder stump.

Also, the left stump may already contain a stone. In such a case, the gallbladder problems appear immediately after surgery (not after years).

Management of the condition:

The condition is easily diagnosed via abdominal ultrasound or abdominal CT.

Stone-containing gallbladder or cystic duct remnants usually require a completion surgery (reference). The remnant is removed via laparoscopic or open surgery and requires a highly skilled surgeon.

3. New (Denovo) gallstone formation.

Your gallbladder is not the only site of gallstone formation. So, you may develop a new (Denovo) gallstone years after gallbladder removal.

The new stone can form in (reference):

  • The common bile duct (commonest site).
  • Inside the gallbladder or cystic duct remnants.
  • The right or left hepatic ducts (see the illustration in the previous section).
  • Rarely, gallstones may form inside the small bile ducts inside the liver.

The risk of forming Denovo gallstones years after gallbladder removal is higher in older ages, females, pregnant women, and patients with high cholesterol levels.

Symptoms:

  • New-onset typical biliary pain (as described above) appears years after gallbladder removal.
  • The stone may obstruct the CBD (common bile duct), leading to jaundice, clay stools, and dark urine (obstructive jaundice).
  • Moreover, the stone may obstruct the pancreatic ducts giving rise to typically acute pancreatitis (severe pain in the upper central abdomen that persists for days, referred to the back, with nausea, vomiting, and jaundice.

Diagnosis and treatment:

The condition is often diagnosed by abdominal ultrasound, MRCP (a special type of MRI that visualizes the biliary system and the pancreas).

If the stone is causing an obstruction (jaundice), you may undergo a special type of endoscopy called ERCP (Endoscopic retrograde cholangiopancreatography).

This is often definitive treatment unless a gallbladder stump may require further surgery.

4. Sphincter of Oddi dysfunction/biliary dyskinesia.

The sphincter of Oddi is a ring of muscle at the end of the common bile duct. Abnormal contractions or failure of the relaxation of the sphincter of Oddi may cause gallbladder-like pain.

The sphincter of Oddi dysfunction causes biliary type pain and may continue for years after gallbladder removal.

Also, it can lead to pancreatic and liver problems (learn more).

Diagnosis:

  • Symptoms are typical for biliary colics after gallbladder removal without other evidence of other complications (gallstones, gallbladder remnants, etc.).
  • It is more common in female patients who have had their gallbladder removed.
  • A special radiological test is called (quantitative hepatobiliary scintigraphy).
  • ECRP (endoscopic retrograde cholangiopancreatography) with an injection of a contrast into the biliary ducts to assess the condition.

 

5. Secondary Bile acid diarrhea (BAD).

Bile acid diarrhea (BAD) is a common and underdiagnosed condition. Bile acid diarrhea occurs when your intestine cannot handle bile acid properly.

Your gallbladder has two main functions (reference):

  • First, it concentrates the bile secreted from the liver.
  • On-demand secretion of bile with eating.

Removing your gallbladder leads to the continuous flow of the secreted bile into your intestine regardless of eating. The secreted bile is also not concentrated