Postcholecystectomy Syndrome (PCS) expanded with references

“The absence of the gallbladder leads to functional biliary hypertension and increased hepatic and common bile duct . 3-5 years after cholecystectomy increases right and left hepatic ducts equity.

Functional hypertension in the common bile duct contributes to the appearance of functional and hypertension in Wirsung’s pancreatic duct with the development of the phenomena of chronic pancreatitis . At the same time period in some patients this is accompanied by the progression of chronic pancreatitis, sphincter of Oddi dysfunction and duodenogastric (Biliary / bile ) reflux.

Duodenogastric reflux of mixture of bile with pancreatic juice promotes atrophic gastritis in the antral part of stomach.

From 40% to 60% of patients after cholecystectomy dyspeptic suffering from various disorders, from 20% to 40% of pains of different localization .

Up to 70% of patients after cholecystectomy have chronic effects of “bland” cholestasis, chronic cholestatic hepatitis and chronic compensatory bile acid-dependent apoptosis of hepatocytes.

Patients undergoing cholecystectomy had an increased prevalence of metabolic risk factors for cardiovascular disease, including type 2 diabetes mellitus, high blood pressure, and high cholesterol levels.

Part of patients after cholecystectomy with increased concentration of hydrophobic hepatotoxic co-carcinogenic deoxicholic bile acid in serum and/or feces with increased risk of colon cancer”

 “Biliary Diseases Laparoscopic Cholecystectomy. Postcholecystectomy Syndrome Dr. Jacob L. Turumin (Iakov L. Tyuryumin), MD, PhD, DMSci”

 

  “The incidence of postcholecystectomy syndrome has been reported to be as high as 40% in one study, and the onset of symptoms may range from 2 days to 25 years.  There may also be gender-specific risk factors for developing symptoms after cholecystectomy. In one study, the incidence of recurrent symptoms among female patients was 43%, compared to 28% of male patients.”

 “cholecystectomy is associated with several physiological changes in the upper gastrointestinal tract which may account for the persistence of symptoms or the development of new symptoms after gallbladder removal. The cholecyst sphincter of Oddi reflex, cholecyst-antral reflex, and cholecyst-oesophagal reflexes are all disrupted and some local upper gastrointestinal hormonal changes also occur after cholecystectomy. Thus, there is an increased incidence of gastritis, alkaline duodene gastric reflux and gastro-oesophageal reflux after cholecystectomy, all of which may be the basis for postcholecystectomy symptoms.”

 Postcholecystectomy syndrome (PCS), S. Mohandas, L.M. Almond, Department of General Surgery, Worcestershire Royal Hospital, Worcester, UK

 

Up to 15-20 % of cholecystectomized patients, continue to have a variety of gastrointestinal symptoms such as fatty food intolerance, nausea and vomiting, heartburn, flatulence, indigestion, diarrhea, mild occasional abdominal pain attacks and severe RUQ pain with extreme post-cholecystectomy distress. The term used to describe this condition is post-cholecystectomy syndrome (PCS). The reported frequency of postcholecystectomypain ranged from 14% to 34% in the reviewed literature, but postoperative dyspepsia was a more frequent symptom that occurred in up to 54% of cholecystectomized patients

It is obvious that irritable bowel syndrome (IBS) may occur after cholecystectomy, and, therefore, dyspeptic symptoms in patients with PCS may be caused by altered gut motility.

Sphincter of Oddi dysfunction (SOD), accounts for 1.5 – 3% of PCS patients

The majority of PCS patients suffered from dyspepsia with mild and occasional pain attacks that caused by functional motility disturbances of the upper gut and the sphincter of Oddi (SO). 2-5% of the PCS patients with continuous severe distress, intense right upper quadrant pain and recurrent cholangitis accounted from all cholecystectomized adults.

PCS symptoms could have several pathophysiological origins. The minority of PCS is caused by an organic disease of the gastrointestinal tract. In a substantial number of patients, no organic disease can be found as a cause of biliary type pain after cholecystectomy. Many patients in whom no organic abnormality can be found suffer from motility disorders of the biliary tract and the upper gut.

 Madacsy L, Dubravcsik Z, Szepes A (2015) Postcholecystectomy Syndrome: From Pathophysiology to Differential Diagnosis – A Critical Review. Pancreat Disord Ther 5:162. doi:10.4172/2165-7092.1000162 https://www.omicsonline.org/open-access/postcholecystectomy-syndrome-from-pathophysiology-to-differentialdiagnosis–a-critical-review-2165-7092-1000162.php?aid=63731

 

 Patients with cholecystectomy had more comorbidities, particularly chronic fatigue syndrome, fibromyalgia, depression, and anxiety. Postcholecystectomy gastroparesis patients had increased health care utilization and had a worse quality of life.

Cholecystectomy and Clinical Presentations of Gastroparesis, the NIDDK Gastroparesis Clinical Research Consortium (GpCRC)*

 

 “Cholecystectomy can have nutritional and metabolic consequences in the short-term (diarrhea, abdominal pain and bloating) and in the long-term (increased Body Mass Index with metabolic syndrome, gastritis, liposoluble vitamin deficiency). Pathogenic mechanisms behind these disturbances are reviewed and the need for an early post-operative nutritional intervention based on low-lipid, high-fibers diet, is highlighted. [7]

Altomare DF, Rotelli MT, Palasciano N. Diet after cholecystectomy.  https://doi.org/10.2174/0929867324666170518100053

 

Cholecystectomy itself is associated with many physiological changes in the upper gastrointestinal tract that may account for the persistence of the symptoms or the development of new symptoms after gallbladder removal. The cholecystosphincter of the Oddi reflex, cholecysto-antral reflex, and cholecyst-esophageal reflexes are all disrupted, and some local upper gastrointestinal hormonal changes often occur after cholecystectomy. Therefore, there is an increased incidence of gastritis, alkaline duodenogastric reflux, and gastro-esophageal reflux after cholecystectomy, which may be the basis for postcholecystectomy symptoms.18,19,20

Shirah, B. H., Shirah, H. A., Zafar, S. H., & Albeladi, K. B. (2018). Clinical patterns of postcholecystectomy syndrome. Annals of hepato-biliary-pancreatic surgery, 22(1), 52-57. https://dx.doi.org/10.14701%2Fahbps.2018.22.1.52

 

Source references:

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  2. Tsai M-C, Chen C-H, Lee H-C, Lin H-C, Lee C-Z (2015) Increased Risk of Depressive Disorder following Cholecystectomy for Gallstones. PLoS ONE 10(6): e0129962. https://doi.org/10.1371/journal.pone.0129962
  3. Nudo R, Pasta V, Monti M, Vergine M, Picardi N.Correlation between post-cholecystectomy syndrome and biliary reflux gastritis. Endoscopic study. https://www.ncbi.nlm.nih.gov/pubmed/2699712
  4. Lorusso D1, Pezzolla F, Montesani C, Giorgio P, Caruso ML, Cavallini A, Guerra V, Misciagna G. Duodenogastric reflux and gastric histology after cholecystectomy with or without sphincteroplastyhttps://www.ncbi.nlm.nih.gov/pubmed/2253017
  5. Shah Gilani SN1, Bass GA1, Kharytaniuk N2, Downes MR3, Caffrey EF3, Tobbia I3, Walsh TN4. Gastroesophageal Mucosal Injury after Cholecystectomy: An Indication for Surveillance? https://doi.org/10.1016/j.jamcollsurg.2016.12.003
  6. Bistritz, L., & Bain, V. G. (2006). Sphincter of Oddi dysfunction: Managing the patient with chronic biliary pain. World Journal of Gastroenterology?: WJG, 12(24), 3793–3802. http://doi.org/10.3748/wjg.v12.i24.3793
  7. Donato F. Altomare, Maria T. Rotelli, Nicola Palasciano. Diet After Cholecystectomyhttp://www.eurekaselect.com/node/152535/article
  8. Wikipedia, Postcholecystectomy syndrome.  https://en.wikipedia.org/wiki/Postcholecystectomy_syndrome
  9. Steen W Jensen, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF Postcholecystectomy Syndrome[com]
  10. S.JaunooS MohandasL.M.Almond. Postcholecystectomy syndrome (PCS)[ScienceDirect]
  11. Sureka B, Mukund A.Review of imaging in post-laparoscopy cholecystectomy complications. Indian J Radiol Imaging 2017;27:470-81  [Indian Journal of Radiology and Imaging]
  12. Murshid KR. The postcholecystectomy syndrome: A review. Saudi J Gastroenterol [serial online] 1996 [cited 2018 Jan 15];2:124-37. Available from:  http://www.saudijgastro.com/text.asp?1996/2/3/124/34017
  13. Girometti, R., Brondani, G., Cereser, L., Como, G., Del Pin, M., Bazzocchi, M., & Zuiani, C. (2010). Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography. [The British Journal of Radiology, 83(988), 351–361]
  14. Jacob L. Turumin, Victor A. Shanturov, Helena E. Turumina. Irkutsk Institute of Surgery, Irkutsk Regional Hospital, Irkutsk 664079. The role of the gallbladder in human[ScienceDirect]
  15. Jacob L. Turumin, MD, PhD, DMSci Biliary Diseases Laparoscopic Cholecystectomy. Postcholecystectomy Syndrome. http://www.drturumin.com/en/index.html#sthash.Y35Uey8C.dpuf
  16. Martin, Walton. “RECENT CONTROVERSIAL QUESTIONS IN GALL-BLADDER SURGERY.” Annals of Surgery 79.3 (1924): 424–443. Print. [PMC]
  17. The NIDDK Gastroparesis Clinical Research Consortium (GpCRC). “Cholecystectomy and Clinical Presentations of Gastroparesis.” Digestive diseases and sciences 58.4 (2013): 1062–1073. [PMC]
  18. Yong Zhang , Hao Liu , Li Li , Min Ai , Zheng Gong, Yong He, Yunlong Dong, Shuanglan Xu, Jun Wang , Bo Jin, Jianping Liu, Zhaowei Teng Cholecystectomy can increase the risk of colorectal cancer: A meta-analysis of 10 cohort studies Published: August 3, 2017 https://doi.org/10.1371/journal.pone.0181852
  19. Mearin, F., De Ribot, X., Balboa, A. Duodenogastric bile reflux and gastrointestinal motility in pathogenesis of functional dyspepsia. Role of cholecystectomy. Digest Dis Sci (1995) 40: 1703. https://doi.org/10.1007/BF02212691
  20. Simona Manea, Georgeta & Carol, Stanciu. (2008). DUODENOGASTROESOPHAGEAL REFLUX AFTER CHOLECYSTECTOMY.Jurnalul de Chirurgie. 4 [Researchgate]
  1. A Shirah, B. H., Shirah, H. A., Zafar, S. H., & Albeladi, K. B. (2018). Clinical patterns of postcholecystectomy syndrome. Annals of hepato-biliary-pancreatic surgery, 22(1), 52-57. https://dx.doi.org/10.14701%2Fahbps.2018.22.1.52
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