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Post cholecystectomy syndrome
- 1. POST CHOLECYSTECTOMY SYNDROME Nuwan Gunapala Registrar wd40B/ 21
- 2. OBJECTIVES Definition Epidemiology Aetiology Pathophysiology Clinical features Investigations Management
- 3. 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.
- 4. 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
- 5. 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
- 6. 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
- 7. AETIOLOGY Hepato-biliary system Cystic duct and gall bladder remnant Residual or reformed gall bladder Stump cholelithasis Neuroma Liver Fatty liver, sclerosing cholangitis, cirrhosis
- 8. Biliary tract Cholangitis Adhesions Strictures Cyst Choledocholithiasis Fistula
- 9. Periampullary Sphincter oddi dyskinesia, spasm, hypertrophy Stricture Papilloma Pancreas Pancreatitis Pancreatic stones Pancreatic cancer
- 10. EXTRA BILIARY Oesophagus Hiatal hernia Achalasia Stomach Bile gastritis PUD Cancer Duodenum Adhesions Diverticulum
- 11. OTHER PATHOLOGIES Colon Vascular Angina Small bowel A cause can be identified in 95% of patients
- 12. CLINICAL FEATURES Colic Pain Fever Jaundice Diarrhoea, Bloating Nausea
- 13. 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
- 14. Invasive procedures UGIE ERCP
- 15. 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
- 16. 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
- 17. 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
- 18. Labs: ↑ amylase, LFT ERCP: delayed emptying of contrast medium from CBD ↑ basal sphincter pressure >40mmHg US: dilated CBD
- 19. 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
- 20. THANK YOU……………….