What Causes Post Gallbladder Surgery Pain?

Postoperative cholecystectomy syndrome (PCS) is a clinical syndrome associated with biliary system lesions that occurs after cholecystectomy. Also called sequelae of gallbladder removal, recurrent biliary syndrome. It is generally believed that less than a third of patients with transient symptoms after cholecystectomy can disappear quickly, and less than 10% of patients may require active treatment due to persistent symptoms.

Basic Information

nickname: Sequelae of gallbladder removal, recurrent biliary syndrome
English name: postcholecystectomysyndrome
Visiting department: General Surgery

Common causes: Injury to the bile duct during surgery, postoperative Oddi sphincter stenosis and constrictive Vater papillitis, abnormal postoperative bile salt metabolism and autonomic dysfunction
Common symptoms: Pain and discomfort in the upper abdomen and right ribs, with pressure

Causes of syndrome after cholecystectomy

The disease may be related to the following factors:

1. Injury to the bile duct during operation

The gallbladder and extrahepatic bile ducts have large anatomical variations, or the inexperienced surgeon has damaged the extrahepatic bile ducts during the operation, resulting in postoperative bile duct stenosis, and a few secondary bile duct infections that cause postoperative bile duct damage or Occlusive cholangitis.

2.Oddi sphincter stenosis and constrictive Vater papillitis

These pathological changes may be associated with common bile duct stones, especially silt-like bilirubin stones or local chronic inflammatory edema.

3. Postoperative abnormal bile salt metabolism and autonomic dysfunction

Oddi sphincter tension and common bile duct pressure affect bile excretion and may play a role in the occurrence of this disease.

Clinical manifestations of syndrome after cholecystectomy

A few weeks or months after cholecystectomy, there is pain and discomfort in the upper abdomen or right quarter of the ribs, often with dull or dull pain, and a sense of compression. In severe cases, it can spread upward due to biliary infection, and cause chills, high fever, and jaundice. Its properties are different from preoperative biliary colic, and may be accompanied by loss of appetite, nausea, bloating, etc. Occasionally, bile duct spasm is caused by colic. Related to eating, especially high-fat diets.

Syndrome examination after cholecystectomy

Biochemical examination

Can be used for white blood cell count, hematuria amylase, liver function, alanine aminotransferase, -glutamyl transpeptidase and other tests.

2. Intravenous cholangiography

Due to the effects of liver function, the bile ducts inside and outside the liver are poorly developed and have little diagnostic significance.

3.B ultrasound

Simple and fast operation, diagnostic value, can find bile duct dilatation, gallstones, biliary tract tumors, pancreatitis and so on. However, it has limitations and cannot show the whole picture of the biliary system and all symptoms.

4. Upper digestive tract construction

Diagnosing hiatal hernia, ulcer, duodenal diverticulum, etc. are very helpful.

5. Hepatobiliary CT scan

Can diagnose liver tumors, intrahepatic bile duct dilatation, gallstone disease, chronic pancreatitis and other diseases.

6. Isotope ^99m -HDA hepatobiliary scan

Simple operation, no damage, suitable for patients with jaundice, can be used to observe the expansion of bile ducts inside and outside the liver, cholelithiasis and liver disease, gallbladder function, etc.

7. Endoscopy

Including esophagoscopy, gastroscopy, duodenum and so on.

ERCP has exact diagnostic value for the syndrome after cholecystectomy, with a high diagnostic success rate. It can directly and accurately show the full picture of the biliary system and lesions, the shape, size, location and number of lesions.

8.PTC

It is suitable for the identification of severe jaundice and the location of bile duct lesions.

9. Morphine-Neostatin challenge test

Patients were injected intramuscularly with 10 mg of morphine and 1 mg of neostigmine. Blood samples were taken for serum amylase and lipase before injection, 1 hour, 2 hours, and 4 hours after injection. After injection, upper abdominal pain and serum enzymes were more than 3 times higher than normal.

Diagnosis of syndrome after cholecystectomy

Based on medical history (gallbladder, bile duct or stomach, duodenal surgery history), postoperative fever, abdominal pain and jaundice, supplemented by B-mode ultrasound, CT, endoscope, cholangiography, ERCP or PTC, fine needle aspiration (FNPTC) That is, the possibility of postoperative bile duct stones and bile duct stenosis should be considered. The morphine-nemesine challenge test can be performed on patients with suspected sphincter stenosis or dysfunction. After ERCP and FNPTC examination, there are still a few patients with unknown causes and difficult diagnosis.

Treatment of syndrome after cholecystectomy

The purpose of PCS treatment is to eliminate the cause, control the infection, and facilitate the drainage of biliary tract. Pure "symptomatic treatment" is not effective. Therefore, the cause must be explored before diagnosis and a clear diagnosis must be made. Treatment methods include non-surgical and surgical treatment.

(I) Non-surgical Therapy

Indication

The diameter of bile duct stones is less than 1cm, and there is no stenosis at the lower end of the bile duct. Bile duct infection has no obvious bile duct obstruction. Acute or chronic cholecystitis, pancreatitis. biliary ascariasis. Biliary dysfunction. Extra-biliary diseases such as hiatal hernia, peptic ulcer, and chronic pancreatitis.

2. Treatment

General therapy Including diet therapy, infusion, and correction of water, electrolyte and acid-base balance imbalance. Antibiotics, antispasmodic analgesics, antacids, H2-receptor blockers, etc. Traditional Chinese Medicine and Traditional Chinese Medicine TCM and TCM syndrome differentiation and treatment have good effects on diseases such as gallbladder, bile duct stones, biliary tract infection, pancreatitis, and biliary tapeworm. The pain, paleness, pulse strings, and liver stagnation are related to Chaihu Shugan powder; flavor, cold and fever, dry mouth and throat, jaundice, red tongue, yellow greasy, slippery pulses are the contents of damp and heat, Da Chai Hu Tang He Yin Chenhao Decoction is used to treat it; those who suffer from fierce pain, high fever, dry mouth, jaundice, yellow fur, and pulse strings that are fiery poisonous should be treated with Huanglian Jiedu Decoction plus Yin Chenhao Decoction. In addition, for pancreatitis, Qingyi Decoction (Chaihu, Muxiang, Yuanhu, Paeonia lactiflora, Scutellaria baicalensis, Rhubarb, Glauber's salt, etc.) is the main drug; Wumei Decoction can be used to treat it. Straight puncture to relieve pain and regulate biliary tract function.

(B) surgical treatment

Indication

Large recurrent bile duct stones, intrahepatic bile duct stones, ampulla incarcerated stones, bile duct stricture with bile duct stones. Recurrent bile duct stenosis and obstructive suppurative cholangitis. Oddi sphincter stenosis, chronic pancreatitis with ampulla or pancreatic duct obstruction. The gallbladder duct is too long, and a small gallbladder with inflammation is formed. Extra-biliary diseases that are difficult to cure with drugs, such as hiatal hernia and ulcer.

2. Surgery method

According to the condition of the disease, the surgical method is decided. Cholecystectomy or cholecystectomy should be performed for those who have left the gallbladder or gallbladder duct too old. Bile duct stones should be explored by common bile duct incision to remove stones and various bile-enteric anastomosis or endoscopic sphincterotomy and stone removal. Oddi sphincter stenosis is feasible for sphincterotomy. Common bile duct stricture can be repaired with common bile duct shaping or reconstruction of the biliary tract. Such as common bile duct duodenal anastomosis, bile duct jejunum Roux-y anastomosis, Longmire surgery and so on. Symptoms of extra-biliary diseases, such as hiatal hernia, ulcer, etc. should also be given corresponding drugs or surgery.

Syndrome prevention after cholecystectomy

Most post cholecystectomy syndromes are preventable and can be cured early.

1. Actively carry out the combination of Chinese and western medicine to treat biliary diseases, master the indications for surgery, reduce the emergency biliary tract surgery as much as possible, and choose a good surgical method.

2. Popularize the diagnosis method of biliary tract images and fully understand the pathological changes of biliary tract. Biliary angiography, choledochoscopy, and biliary pressure measurement can help improve the treatment effect of biliary tract surgery.

3. Intrahepatic bile duct lesions are relatively rare in our country, and the operation is difficult. Improving the skills of biliary tract surgery is very important. Various biliary tract operations should eliminate the cause, prevent biliary stenosis, establish unobstructed drainage, and reduce the chance of postoperative biliary tract syndrome.