- Life After Gallbladder Removal Surgery: Side Effects and Complications
- Etiologies of Long-Term Postcholecystectomy Symptoms: A Systematic Review
- 1. Introduction
- 2. Methods
- 3. Results
- 4. Persistent Symptoms
- 5. Incident Symptoms
- 6. Discussion
- 7. Conclusion
- Conflicts of Interest
- Authors’ Contributions
- Supplementary Materials
- Recurrent abdominal pain after laparoscopic cholecystectomy
- What are some complications I might have after gallbladder surgery?
- Causes of hemorrhoids
- Symptoms of hemorrhoids
- Testing for hemorrhoids
- Hemorrhoid types
- Hemorrhoid treatment
Life After Gallbladder Removal Surgery: Side Effects and Complications
Gallbladder removal is a last resort. If your doctor doesn’t feel that surgery is urgent, you may want to try lifestyle changes first.
Diet and exercise
Reaching and maintaining a healthy weight can reduce pain and complications from gallbladder disease by reducing the cholesterol and inflammation that can cause gallstones.
A diet lower in fat and higher in fiber, and full of fruits and vegetables, can also improve gallbladder health. Swap animal fats, fried foods, and oily packaged snacks for olive oil and other healthy fats. Limit or avoid sugar.
Regular exercise can help your body reduce cholesterol and prevent gallstones from forming. Magnesium deficiency can increase your risk of developing gallstones. Eat magnesium-rich foods, including dark chocolate, spinach, nuts, seeds, and beans to improve gallbladder health.
A gallbladder cleanse usually refers to avoiding food for up to 12 hours, then drinking a liquid recipe like the following: 4 tablespoons of olive oil with 1 tablespoon of lemon juice every 15 minutes for two hours.
Apple cider vinegar and turmeric both have been shown to reduce inflammation. If you mix them with warm water you can enjoy them as a tea-like drink and may experience relief of your gallbladder symptoms. Some people find the menthol in peppermint tea to be soothing as well.
Some studies have shown the benefits of turmeric on gallstone formation. However, if you have gallstones, be careful how much turmeric you ingest. One 2002 study with 12 healthy participants showed 50 percent contraction of the gallbladder due to curcumin. This increased contraction could cause pain.
In addition to magnesium, choline plays a role in gallbladder health.
According to the Harvard Health Letter, bile salts may be worth a try as well, especially if your liver has been producing thick bile. Bile acids also come in prescription strength.
Speak to a doctor or nutritionist about taking one or more of these supplements if you have gallstones or a blocked bile duct.
Acupuncture may be of potential benefit to those with gallbladder disease. It most likely works by increasing the flow of bile while also reducing spasms and pain.
It’s important to note that although diet and exercise are proven methods of reducing gallbladder complications, other methods like cleanses, tonics, and supplements haven’t been studied extensively, and side effects may occur. Be sure to discuss these options with your healthcare provider before proceeding.
Etiologies of Long-Term Postcholecystectomy Symptoms: A Systematic Review
Background. Cholecystectomy does not relieve abdominal symptoms in up to 40% of patients. With 700,000 cholecystectomies performed in the US, annually, about 280,000 patients are left with symptoms, making this a serious problem. We performed a systematic review to determine the different etiologies of long-term postcholecystectomy symptoms with the aim to provide guidance for clinicians treating these patients. Methods. A systematic search of the literature was performed using MEDLINE, EMBASE, and Web of Science. Articles describing at least one possible etiology of long-term symptoms after a laparoscopic cholecystectomy were included in this review. Long-term symptoms were defined as abdominal symptoms that were present at least four weeks after cholecystectomy, either persistent or incident. The etiologies of persistent and incident symptoms after LC and the mechanism or hypothesis behind the etiologies are provided. If available, the prevalence of the discussed etiology is provided. Results. The search strategy identified 3320 articles of which 130 articles were included. Etiologies for persistent symptoms were residual and newly formed gallstones (41 studies, prevalence ranged from 0.2 to 23%), coexistent diseases (64 studies, prevalence 1-65%), and psychological distress (13 studies, no prevalence provided). Etiologies for incident symptoms were surgical complications (21 studies, prevalence 1-3%) and physiological changes (39 studies, prevalence 16-58%). Sphincter of Oddi dysfunction (SOD) was reported as an etiology for both persistent and incident symptoms (21 studies, prevalence 3-40%). Conclusion. Long-term postcholecystectomy symptoms vary amongst patients, arise from different etiologies, and require specific diagnostic and treatment strategies. Most symptoms after cholecystectomy seem to be caused by coexistent diseases and physiological changes due to cholecystectomy. The outcome of this research is summarized in a decision tree to give clinical guidance on the treatment of patients with symptoms after cholecystectomy.
In the United States (US), approximately 1.8 million patients are diagnosed with gallstones every year . In the majority of patients, gallstones will stay asymptomatic. Approximately 20% of patients will experience symptoms, like a biliary colic, for which laparoscopic cholecystectomy (LC) is the preferred treatment . As a consequence, LC is one of the most performed elective abdominal surgeries worldwide, with approximately 700,000 LCs in the US .
Although LC is the preferred treatment to relieve symptoms, previous studies show that long-term abdominal symptoms are present in up to 40% of patients after LC . This equals a yearly growth of 280,000 cases with abdominal symptoms after LC in the US. Patients suffer from symptoms like diarrhea, gas bloating, nausea, vomiting, jaundice, or abdominal pain. These symptoms after LC are a significant burden to health care systems, as 56% of patients need additional health care for diagnosis and treatment, against direct median hospital costs of $555 per year per patient. Moreover, sick leave and production loss of employed patients add an additional $361 per year per patient for work-related costs .
Abdominal symptoms after LC are often summarized as “postcholecystectomy syndrome.” However, postcholecystectomy syndrome is an arbitrary term that loosely describes the presence of symptoms after LC and consists of many persistent and incident symptoms . In order to help patients with abdominal symptoms after LC, a specific diagnosis or etiology of the complaints is needed to provide targeted treatment. Therefore, this systematic review is aimed at providing an overview of the literature on etiologies of abdominal symptoms after LC and ultimately to assist clinicians in identifying the cause of patients’ symptoms after LC and optimize treatment.
The PRISMA guideline (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) was used to perform this systematic review .
2.1. Search Strategy
A systematic literature search was conducted in the electronic databases of MEDLINE (1946–June 2018), Web of Science (1945–June 2018), and EMBASE (1980–June 2018). The search was performed using a search strategy that included terms for “(postcholecystectomy) abdominal symptoms,” “cholecystectomy,” and “cholecystolithiasis” (the full search strategy is shown in Supplementary Table 1).
2.2. Study Selection
Two reviewers (C.L. and S.W.) independently screened the titles and abstracts of the identified articles to select potentially relevant studies. Studies on abdominal symptoms after LC in uncomplicated cholecystolithiasis years, reporting at least one potential etiology for long-term symptoms, were eligible for inclusion. Long-term symptoms after LC were defined as any type of abdominal symptoms that were present at least four weeks after LC. Case reports, case series, editorials, and studies in a language other than English, Dutch, or German were excluded. Studies including patients after open cholecystectomy were excluded, as this does not reflect current surgical practice . Discrepancies between the reviewers were resolved by discussion and consensus. In case of overlapping data, the most recent study with the largest cohort was included.
2.3. Data Extraction and Synthesis
Data were independently extracted by the two reviewers (C.L. and S.W.), using a predefined data extraction form. All described etiologies for long-term postcholecystectomy symptoms and the prevalence of these etiologies (if provided in the study) were extracted. Further extracted data included the following study characteristics: author, year of publication, country, study design, sample size, and follow-up period, and additional data on patients’ age and gender, and long-term postcholecystectomy symptoms. Again, discrepancies between reviewers were resolved by discussion and consensus.
Subsequently, all etiologies were categorized as etiology for “persistent symptoms” or “incident symptoms” after LC and reported in subgroups per category. Persistent symptoms were defined as symptoms that are similar to patients’ preoperative symptoms. Incident symptoms were defined as symptoms that were not present before LC. Primary outcomes of this review were the etiologies of persistent and incident symptoms after LC; the range in prevalence of each etiology in the included studies was reported.
3.1. Selected Studies
The search strategy identified 3320 articles. After removal of duplicates, titles and abstracts of 2226 articles were screened and 269 articles were selected for full-text evaluation. Finally, 130 articles were included in this review, as shown in Figure 1.
3.2. Study Characteristics
The included studies composed of 77 prospective cohort studies, 24 retrospective cohort studies, 20 reviews, five randomized controlled trials, and four systematic reviews. Most studies were performed in Europe and North America. The postoperative follow-up period in the included studies varied from four weeks to 18 years after LC. Full study characteristics are summarized in Table S2 in the supplementary files.
3.3. Reported Etiologies of Long-Term Symptoms after LC
The reviewed literature reported the following symptoms: biliary pain, pain attacks, continuous pain, pain related to food, functional dyspepsia, nausea, vomiting, abdominal bloating, reflux, diarrhea, constipation, functional bowel problems, fever, and jaundice.
Persistent symptoms after LC were summarized into four subgroups: “residual and newly formed gallstones,” “coexistent diseases,” “psychological distress,” and “sphincter of Oddi dysfunction.” Three subgroups for etiologies of incident symptoms after LC were established: “sphincter of Oddi dysfunction,” “surgical complications,” and “physiological changes” (Figure 2). Sphincter of Oddi dysfunction (SOD) can cause persistent symptoms; however, most often it arises after LC. The etiologies reported per included study and if provided the percentage of patients with a certain etiology as cause for symptoms after LC are summarized in Table S2.
4. Persistent Symptoms
4.1. Residual and Newly Formed Gallstones
Forty-one studies reported residual or newly formed gallstones as the etiology for long-term persistent abdominal symptoms after LC. A total of 23 studies provided the prevalence of residual and newly formed gallstones as the cause for symptoms, ranging from 0.2% to 23%. Residual stones are most commonly diagnosed as retained common bile duct stones (choledocholithiasis), stones, or sludge in a cystic duct remnant or stones within the remnant gallbladder due to a subtotal cholecystectomy in difficult surgical cases. Residual stones in the cystic duct or gallbladder remnant can result in recurrent biliary colics . Usually, these symptoms are self-limiting. Choledocholithiasis after LC is associated with epigastric pain, elevated ALT and AST levels, and sometimes jaundice . Additional abdominal ultrasound might show a dilated common bile duct . Moreover, new gallstones can be formed within the bile ducts or gallbladder remnants, after LC. Depending on the location in the biliary tract, symptoms will be similar to cystic duct or gallbladder remnant stones, or choledocholithiasis .
4.2. Coexistent Diseases
Sixty-four studies reported coexistent diseases as the etiology for long-term persistent abdominal symptoms after LC. Eighteen studies provided the prevalence of coexistent diseases after LC ranging from 1% to 65%. Coexistent diseases in patients with gallstones are common and mainly nonbiliary: gastroesophageal reflux, peptic ulcer, hiatus hernia, gastritis, constipation, IBS, Anterior Cutaneous Nerve Entrapment Syndrome (ACNES), fatty liver disease, chronic obstructive pulmonary disease, or coronary artery disease . Preoperative distinction between symptoms caused by coexistent diseases and gallstones is challenging . Misinterpretation of symptoms and suboptimal indication for LC will result in persistent symptoms after surgery . Even if the indication for LC was made correctly and the biliary symptoms are resolved, symptoms of a coexistent disease can become more prominent and considered as persistent symptoms after LC .
4.3. Psychological Distress
Thirteen studies reported psychological distress as the etiology for long-term persistent abdominal symptoms after LC. None of these studies provided prevalence for psychological distress as cause for symptoms after LC. Several hypotheses exist on why psychologically distressed patients are more likely to experience persistent symptoms after LC. First, psychologically distressed patients tend to experience more functional gastrointestinal symptoms, which are not relieved by LC . Secondly, psychological distress may induce visceral hyperalgesia that exacerbates subjective perception of pain both preoperatively and postoperatively . Third, these patients are prone to experience somatization symptoms which may cause overreporting of symptoms . Somatization symptoms are also less likely to be alleviated by surgery . Considering the different perceptions and interpretations, patients with psychological distress are more at risk for poor decision-making .
4.4. Sphincter of Oddi Dysfunction
Seventeen studies reported sphincter of Oddi dysfunction (SOD) as the etiology for long-term abdominal symptoms after LC. Prevalence of SOD after LC was reported in four studies and ranged from 3% to 40%. SOD mainly presents as right upper quadrant (biliary) pain and is not easily distinguished from symptomatic cholecystolithiasis, irritable bowel syndrome, or functional dyspepsia . If SOD symptoms have been incorrectly attributed to gallstones, symptoms will persist after LC . However, SOD most often commences after LC as incident symptoms, in which case interrupted neural pathways between the duodenum, gallbladder, and sphincter of Oddi after surgery lead to sphincter of Oddi spasms or SOD . SOD can be divided in three types: type I (biliary pain, abnormal liver tests, and dilated bile duct), type II (biliary pain and abnormal liver tests or dilated bile duct), and type III (only biliary pain) .
5. Incident Symptoms
5.1. Surgical Complications
Twenty-one studies reported surgical complications as the etiology for long-term symptoms after LC. Prevalence of long-term symptoms after LC caused by surgical complications was reported in eight studies, ranging from 1% to 3%. Bile duct injury is the most feared surgical complication . Patients can develop upper abdominal pain with jaundice, fever, and possibly sepsis . Even if the bile duct injury is treated with surgical or endoscopic intervention, strictures or leakages can result in long-term symptoms of pain and biliary obstruction .
Spillage of gallstones into the peritoneal cavity is another complication associated with long-term postoperative pain, which can lead to abscesses, general peritonitis, adhesions, and fistulae, even several years after surgery . However, the majority of dropped gallstones remain clinically silent .
Pain or discomfort due to late postoperative complications can arise from infections, wound healing problems, or a trocar site hernia .
5.2. Physiological Changes
Thirty-nine studies reported physiological changes after surgery as the etiology for incident abdominal symptoms after LC. The prevalence of physiological changes after LC was described in 17 studies, ranging from 16% to 58%. Long-term effects of LC on bile acid metabolism were reported in several studies . Prior to LC, bile acids are stored in the gallbladder and bile acids are released in the duodenum by meal-induced intermittent contractions. LC results in the loss of reservoir function of the gallbladder and an altered bile metabolism. The pathophysiology of increased bile flow has not been completely clarified. However, the continuous flow of bile acids into the duodenum attributes to increased duodenal-gastric reflux and can cause symptoms of dyspepsia and an elevated risk of gastritis . Decreased esophageal sphincter pressure after LC may further attribute to dyspepsia and gastritis symptoms .
The reduced bile salt pool after LC could also induce subclinical fat malabsorption and result in diarrhea. The constant presence of bile acids in the gut, which promotes secretion and motility, could additionally result in a shortened whole gut transit time, contributing to postoperative diarrhea and flatulence .
Fifteen studies reported various other etiologies for incident long-term abdominal symptoms after LC. Changed dietary intake, mainly waiving preoperative dietary restrictions, or physical inactivity may attribute to symptoms after LC .
This systematic review provides a qualitative overview of etiologies of long-term abdominal symptoms after LC. Most symptoms after LC seem to be caused by coexistent diseases and physiological changes due to LC. Based on the etiologies of persistent and incident symptoms after LC provided in this review, we constructed a decision tree to help clinicians identify the cause of long-term symptoms after LC and optimize treatment for these patients (Figure 3).
“Postcholecystectomy syndrome” is a collective term for all symptoms after LC. This general term is not an adequate diagnosis , as multiple etiologies requiring distinct treatments may cause “postcholecystectomy syndrome.” Moreover, some symptoms are not even related to LC itself. To establish the cause of long-term symptoms after LC and decide on the proper treatment to alleviate symptoms, the underlying etiology of symptoms should be pursued.
Previous reviews divided all causes for symptoms after LC into organ systems (e.g., biliary causes, pancreatic causes, other gastrointestinal disorders, or extraintestinal disorders) or listed all diagnoses individually (e.g., peptic ulcer disease, hiatus hernia, gastroesophageal reflux, residual stones, strictures, and SOD) . The latter is a review with a limited search reach and only 21 included articles . In this review, we categorized long-term postoperative symptoms as persistent or incident symptoms after LC, thereby providing a first step in deducting the causes for long-term symptoms. If the persistent or incident nature of the symptoms is established, the categories and subgroups presented in this review are a tool for clinicians in the assessment of long-term postcholecystectomy symptoms (Figure 3).
We established that most persisting symptoms are likely to be caused by coexisting diseases; often, these will be nonbiliary symptoms. Detailed anamnesis and tailored diagnostic tests (such as ultrasound, gastroscopy, and colonoscopy) will provide insight in the presence of (functional) abdominal disorders. Accessible therapeutic options should confirm or rule out the diagnosis, for instance, with a test treatment with antacids or laxatives .
Persisting biliary pain will mainly be caused by newly formed or residual stones or SOD. These conditions can be diagnosed using abdominal or endoscopic ultrasound. Gallstones will most often be present in the CBD and can be treated by ERCP with papillotomy and stone extraction. SOD type I and II can be distinguished from other disorders by laboratory results, imaging of the biliary tree, and elevated sphincter pressure at manometry. SOD type III is difficult to distinguish from other gastrointestinal disorders, as the only criterion is biliary pain. Some literature recommends endoscopic sphincterotomy to treat SOD ; however, recently published long-term results of the EPISOD study show that in type III SOD, endoscopic sphincterotomy was not more successful compared to sham intervention in patients with postcholecystectomy SOD type III . Another study recommends medical treatment, trimebutine, and nitrates taken sublingually, as success rates are similar with endoscopic sphincterotomy .
Newly formed symptoms will often start shortly after LC but can persist and become a long-term problem. Patients with surgical complications should therefore be monitored at the outpatient clinic to obviate persisting symptoms, and surgical, endoscopic, or medical treatment can be started timely (e.g., surgical or endoscopic intervention with a stent or dilatation for bile duct injury or antibiotics for (intra-abdominal) infections). Most incident symptoms will however be physiological. Patients with new reflux symptoms after LC (due to physiological changes in bile secretion and metabolism) can be pragmatically treated with lifestyle changes, drugs that reduce the secretion of gastric acids, prokinetic drugs, or drugs that reduce the relaxations of the esophageal sphincter, to reduce reflux and relieve symptoms. Patients with (invalidating) chronic diarrhea can be treated with a bile acid sequestrant like cholestyramine, colestipol, or colesevelam .
Although this study provides tools to establish and treat symptoms, of course, preventing postoperative symptoms is preferable. A prospective study showed that 56% of patients need additional health care and medical costs and costs for sick leave were approximately $916 per year per patients . Improved patient selection and preoperative work-up for a LC could prevent persistent abdominal symptoms and costs.
In patients with nonspecific gallstone symptoms, the preoperative diagnostic trajectory should focus on confirming or ruling out other causes of upper abdominal symptoms and considering alternative or concomitant therapeutic options. Our research group is currently performing a multicenter prospective study (Dutch Trial Register: NTR7307) to identify the prevalence of functional gastrointestinal disorders (FGID) in patients with gallstones. Current literature suggests prevalence of up to 60% . If such high prevalence is accurate, a large part of persistent symptoms after LC could be explained by coexistent FGID and treatment to prevent persistent symptoms could be initiated prior to surgery. A second prospective study (NTR7267) focuses on establishing the abdominal symptoms for appropriate indication of LC to prevent persistent symptoms caused by wrong surgical indication.
Additionally, shared decision-making and increased influence in choosing their preferred treatment may result in improved physical outcomes and less distress. This is illustrated for psychologically distressed patients but may very well apply for other patients. Furthermore, we should consider that symptoms before and after LC may be present as part of the metabolic syndrome . The metabolic syndrome is described as the underlying disorder for gallstones by abnormalities of insulin resistance, resulting in increased biliary cholesterol synthesis and gallstone formation . LC is aimed at treating the gallstone symptoms, but the lifestyle and other comorbidities associated with the metabolic problem remain untreated. Incorporation of lifestyle changes and treatment of other aspects of the metabolic syndrome could reduce postoperative symptoms in this patient category.
The present review comes with strengths and limitations. Strengthening our study are the broad search and wide inclusion criteria to identify all possible etiologies of long-term abdominal symptoms after LC. Articles on open cholecystectomy were excluded, to prevent bias by etiologies or prevalence (such as higher surgical complications) inherent to the open aspects of the surgery, not reflecting current surgical practice. Additionally, differentiation between incident and persistent symptoms and descriptions of subgroups of etiologies were made to improve clinical applicability of the results. Ultimately, a clinical guidance was provided for physicians in the diagnostics and treatments of patients with symptoms after LC.
Limitations include the large heterogeneity of the included studies and subsequent inability to perform a quality assessment. As only a limited number of included studies reported the prevalence of described etiologies, we could not provide a meta-analysis. Subsequently, we were only able to provide the range of prevalence of the different etiologies to illustrate which etiologies are more and less common.
Postcholecystectomy symptoms have multiple etiologies and can be divided into persistent and incident symptoms. Most symptoms seem to be caused by coexistent diseases and physiological changes due to LC. Although treatment is available for most causes of persistent symptoms after gallbladder removal, optimized indication for surgery remains key.
Conflicts of Interest
The authors declare that there is no conflict of interest regarding the publication of this paper.
Latenstein and Wennmacker substantially contributed to the conception and design; contributed to the acquisition, analysis, and interpretation of the data; drafted the manuscript; finally approved the version to be published; and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. de Reuver, Drenth, van Laarhoven, and de Jong interpreted the data, revised the manuscript critically for important intellectual content, finally approved the version to be published, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Table S1: search strategy. Table S2: study characteristics of included studies. (Supplementary Materials)
Recurrent abdominal pain after laparoscopic cholecystectomy
Four months after undergoing laparoscopic cholecystectomy for symptomatic gallstones, an otherwise healthy 26-year-old woman begins to have episodes of epigastric and back pain similar to what she experienced before the surgery. The surgery was without complications, and her classic biliary colic disappeared afterward. Histologic evaluation of the surgical specimen revealed chronic cholecystitis with multiple small, mixed gallstones.
Now she describes a burning pain in her epigastrium and mid to upper back, starting about 30 minutes after a meal and lasting up to 4 hours. Sometimes it awakens her at night. She avoids eating for fear of inducing the pain. She has occasional chills but no fever, nausea, vomiting, jaundice, or changes in urine or stool color.
Three years ago she was diagnosed with a gastric ulcer induced by taking a nonsteroidal anti-inflammatory drug (NSAID). The ulcer was treated with a proton pump inhibitor for 1 month. She says the ulcer pain was dull and aching, different from her current pain.
Upper endoscopy 4 months ago (ie, before her laparoscopic cholecystectomy) showed no evidence of esophagitis or peptic ulcer disease.
Apart from her gallbladder operation, she has had no other surgery. According to the surgeon’s notes, intraoperative cholangiography was not performed, and no macroscopic changes of acute cholecystitis or difficult biliary anatomy were noted.
The patient does not smoke, does not drink alcohol, is not currently taking any medications, including NSAIDs or over-the-counter medications, and has not taken any recently. Her mother also had symptomatic gallstones requiring cholecystectomy.
On physical examination, only fever
There is no jaundice or pallor. Her heart and lung examinations are normal.
Her abdomen is soft and mildly tender to palpation of the epigastrium, with no distention or hepatosplenomegaly and no rebound tenderness or guarding. The scars from her laparoscopic surgery have healed well. Her bowel sounds are normal.
No costovertebral angle or spinal tenderness can be elicited.
Her laboratory values are shown in Table 1.
1. After cholecystectomy, preoperative symptoms recur in what percentage of patients?
- 10% to 40%
Postcholecystectomy syndrome—the recurrence of symptoms similar to those before the procedure—occurs in 10% to 40% of patients. The time to the onset of symptoms can range from 2 days to up to 25 years.1–4 Women may be at higher risk, with symptoms recurring in 43% vs 28% in men.5
Postcholecystectomy syndrome can have a biliary or a nonbiliary cause. Biliary causes include strictures, retained calculi, dropped calculi, tumors, sphincter of Oddi dysfunction, and calculi in the cystic duct remnant. Nonbiliary causes include functional and organic disorders such as peptic ulcer disease, gastroesophageal reflux, pancreatic disease, hepatocellular disorders, coronary artery disease, irritable bowel syndrome, and intercostal neuritis.
WHAT IS THE NEXT STEP?
2. Which is the most appropriate next step in the workup of this patient?
- Ultrasonography of the right upper quadrant
- Magnetic resonance cholangiopancreatography (MRCP)
- Endoscopic retrograde cholangiopancreatography (ERCP)
- Observation and reassurance
- Review the operative record and consult with the surgeon
Although the patient is presenting with pain and fever, two features of the classic Charcot triad (pain, fever, jaundice) seen in cholangitis (infection of a bile duct), and although cholangitis almost confirms the diagnosis of common bile duct stones in a patient with gallstones (before or after cholecystectomy), other diagnoses to consider are bile duct injury, bile leak, and biloma.
Biloma can be detected with ultrasonography. Bile duct injuries are identified intraoperatively in up to 25% of patients. For those with an unrecognized injury, the clinical presentation is variable and depends on the type of injury. If a bile leak is present, patients present early, at a median of 3 days postoperatively. However, our patient presented with symptoms 4 months after her surgery. Patients with bile duct strictures without bile leak have a longer symptom-free interval and usually present with signs of biliary obstruction. Ultrasonography can then detect biliary dilatation.6
It would be very helpful to review the operative record and to talk to the surgeon to confirm that intraoperative cholangiography had not been done and to determine the level of difficulty of the surgery. (Intraoperative cholangiography involves the introduction of contrast dye into the biliary system by cannulation of the cystic duct or by direct injection into the common bile duct. An intraoperative cholangiogram is considered normal if the entire intrahepatic and extrahepatic biliary tree is seen to be filled with contrast.) A normal cholangiogram has a negative predictive value of 99.8% for the detection of ductal stones. Thus, a normal intraoperative cholangiogram can prevent unnecessary postoperative ECRP, since it almost always indicates a clean bile duct.7
Ultrasonography of the right upper quadrant has a low sensitivity (< 50%) for detecting common bile duct stones. However, it is highly operator-dependent, and it may be twice as sensitive if done by expert radiologists than by less experienced ones. Its limitations include poor visualization of the distal portion of the duct and low sensitivity in patients in whom the common bile duct is minimally dilated and also in patients with small stones. In most studies, however, it had a very high specificity—ie, greater than 95%.8
MRCP has a sensitivity of 82.6% and a specificity of 97.5% in detecting stones in the common bile duct.9 Therefore, normal results on abdominal ultrasonography and MRCP do not completely rule out stones.
Although this patient has a high pretest probability of having common bile duct stones, ERCP should be done only after a thorough review of the previous operative procedure.
Observation and reassurance are not appropriate in a patient with cholangitis, such as this patient, because waiting increases the risk of septicemia.
Dear Gallbladder Patient: Are you suffering the agony of chronic, unexpected diarrhea? Does liquid stool start gushing out of your rectum at the most inopportune times? People who have their gallbladder removed often experience this discomfort and social embarrassment. Here’s a description of what they suffer, why they suffer, and some common treatment options.
Diarrhea is an expected condition after gallbladder surgery as there is no gallbladder to control the flow of bile to the intestines. After a fatty meal, or consumption of irritating foods such as coffee, bile floods into the digestive tract. And now you have “the runs.”
And guess what else you often end up with (pardon the pun)? Inflamed swollen hemorrhoids. See, diarrhea exacerbates hemorrhoids in the worst way. Anal veins can’t bear up under frequent episodes of diarrhea. The extreme force of liquid stool expulsion also can lead to an anal fissure. In this case, the anus burns after elimination, and there is usually blood in the stool and on the wiping paper. The burning and itching doesn’t get better, in fact it worsens over the next week or two.
Chronic hemorrhoids and anal fissues can result due to an uneven diet which irritates hemorrhoids further, by constipating and then causing diarrhea.Of course your doctor is right when she prescribes a low-fat diet with several trivial meals every day as a substitute for three big tubby ones. You must also drink adequate clear fluids (at lest two liters per day). Excess coffee unquestionably aggravates hemorrhoids, so you must change your morning ritual. You may need instead to substitute a spoon of Metamucil to a clear fluid or weak tea for a while until your sore anus heals.
Did your doctor prescribe a prescription also? Many folks swear by the cholesterol-lowering drug Questran which binds bile acids so they can pass harmlessly through your system. But if you don’t like the common side effects of this medication, such as weakness and dizziness, or you can’t risk an adverse reaction to other meds, you might consider a natural alternative to your diarrhea induced hemorrhoid problem.
For thousands of years, people have complained of hemorrhoids. The ancient practice of soaking your bottom in a “sitz bath” is still the best way to keep that anus clean and promote healing. Herbs such as san qi, calendula, and huai hua can help by gently shrinking your sore anal veins. Even a compress filled with frozen cranberries, which you can buy at any supermarket, can be very calming while effectively shrinking those hemorrhoids. In my own case, I used a recipe contained in a marvelous new e-book, H Miracle by Holly Hayden for a few weeks and I am finally living life comfortably again. Going shopping, out to dinner, I am no longer continually aware of my hemorrhoids. As a bonus, I have changed my diet according to the principles in H Miracle and those sudden bouts of diarrhea are a distant memory. (Unless I overindulge in coffee, which is my main weakness!)
There are so many hemorrhoid treatment options to choose from. But if you want relief, you HAVE to go to the source of the problem. H Miracle offers a comprehensive strategy for ridding yourself of hemorrhoids for GOOD. The book is chock-full of causes, treatment plans, recipes for your own herbal cures, audio downloads you can listen to in the privacy of your home or car. There’s even an illustrated manual for a “secret cure” using very common ingredients that heals and cures hemorrhoids in as little as TWO DAYS. You get lasting relief with this system. I’d rather not have to endure the sorrow of hemorrhoid surgery as long as I can maintain good anal health. H Miracle puts you in control so you can take your life back from the misery of hemorrhoids.
What are some complications I might have after gallbladder surgery?
Approximately 500,000 gallbladder surgeries or cholecystectomies are performed each year in the United States. The most common reason for cholecystectomies is gallbladder pain (biliary colic) due to blockage of the cystic or bile duct by gallstones. Approximately 20 million adults in the U.S. have gallstones and an estimated one million people are newly diagnosed with gallstones each year.
The gallbladder is most commonly removed because of gallstones, but it may also be removed if the gallbladder is inflamed or infected. Gallbladder removal will relieve pain, treat infection and—in most cases—stop gallstones from coming back. The risks of not having surgery are the possibilities of worsening symptoms, infection and gangrene of the gallbladder.
Most gallbladder surgeries today are performed Laparoscopically, using small incisions through which a camera and operating instruments are inserted. The most common complications of gallbladder surgery are those which are associated with any surgery, namely wound infection and excessive bleeding. Complications specific to gallbladder removal include post-operative bile leak, injury to the main duct which transports bile from the liver to the intestine (called the common bile duct), and retained bile duct stones. There is also the possibility that the procedure cannot be completed laparoscopically and a larger incision would need to be made to take out the gallbladder.
Make sure your surgeon covers all aspects of the surgery with you prior to the procedure.
Almost everyone will get hemorrhoids at some point in their life. Most of the time, symptoms go away on their own, after a few days, even without treatment. On occasion, your hemorrhoid condition is complex and needs a doctor’s attention. That’s where we can help.
Hemorrhoids are enlarged or swollen veins in the bottom of the rectum or the anus. They do not usually cause serious health problems. But they can be annoying and uncomfortable.
Hemorrhoids are common, occurring in both men and women. They are more common in people:
- Pelvic tumors
- Pregnancy, both during or after
- Sendenaty people, or those who sit for prolonged periods of time
- Those who have diarrhea or constipation
- Who are older
Treatment consists of dietary changes and having regular bowel habits. If your hemorrhoids are large, do not go away on their own or you have many hemorrhoids, you may need surgery.
Causes of hemorrhoids
In general the cause of hemorrhoids is increased pressure on the veins in the pelvis and rectal area. The cause of this can be:
- Excessive straining found with chronic constipation
- Excessive straining found with chronic diarrhea
- Pregnancy, due to pressure in the pelvis from the baby in the uterus
- Prolonged daily sitting like with truck drivers or other sedentary professions
Symptoms of hemorrhoids
The most common symptoms of hemorrhoids include the following:
- Painless rectal bleeding, usually is a small amount
- Anal itching or pain, due to irritation of the skin surrounding the anus
- Tissue bulging around the anus, some people can see or feel hemorrhoids on the outside of the anus
- Leakage of feces or difficulty cleaning after a bowel movement
Many people with hemorrhoids notice bright red blood on the stool, in the toilet or on the tissue after a BM. The amount of blood is usually small. Yet even a small amount of blood can cause the water to appear bright red. This can be frightening.
Less common is heavy bleeding.
While hemorrhoids are one of the most common reasons for rectal bleeding, there are other, more serious causes. It is not possible to know what is causing rectal bleeding unless you have an examination. You should seek medical attention if you see bleeding after a bowel movement.
Hemorrhoids can become painful. If you develop severe pain, call your healthcare provider immediately. This may be a sign of a serious problem.
Testing for hemorrhoids
Often your doctor can determine if you have hemorrhoids by asking about your symptoms and doing a physical examination.
Your doctor will do a digitial rectal examination, an exam using a gloved finger inside your rectum. You may need to do an anoscopy. This is where your doctor inserts a short, lighted scope into your anus and exams the inside of your anal canal. You may need to have a Colonoscopy or sigmoidoscopy for further testing.
Hemorrhoids hidden inside the rectum are “internal” hemorrhoids. You cannot see them, but they can cause symptoms.
Hemorrhoids that you can see or feel are “external” hemorrhoids.
External hemorrhoids are visible on the outside of the anus and originate in the lower part of the anus. These can become inflammed and the blood inside the veins can become clotted. This is a thrombosed, or clotted, hemorrhoid.
Internal Hemorrhoids are generally not visible on the outside. This is because they originate higher up in the anal canal. Internal hemorrhoids more commonly cause bleeding after a bowel movement.
If internal hemorrhoids become large and severe, they can push out through the anus, becoming visible. This can be very painful. This is especially true if the hemorrhoid becomes trapped in the anal muscle and cannot go back inside.
Classification of Internal Hemorrhoids:
- Grade 1 (minor) – A hemorrhoid is present but only visualized by a doctor with ansocopy or colonoscopy. The hemorrhoid does not extend out the anus.
- Grade 2 – The hemorrhoid(s) extends out of the anus with a bowel movement or with straining. After your BM, the hemorrhoid goes back inside on its own.
- Grade 3 – The hemorrhoid(s) extends out of the anus with a bowel movement or with straining. You have to manually push the hemorrhoid back inside the anus. If you have this, you should seek medical attention, but it is not urgent.
- Grade 4 (severe) – A hemorrhoid(s) extends outside the anus and are not able to be manually pushed back inside. If you have this seek medical attention immediately. There are significant potential complications.
Most of the time, hemorrhoid symptoms go away after a few days even without treatment. If not, treatment focuses on relieving the pain.