Cholecystectomy syndrome (Postcholecystestomy Syndrome, PCS), also known as cholecystectomy complications, recurrent biliary syndrome (Recurrent Biliary Tract Syndrome), which is due after cholecystectomy and biliary lesions appeared on the clinical syndrome. After cholecystectomy is generally believed that about 25 to 30% may occur transient symptoms may disappear quickly, about 2% to 8% can be sustained because of symptoms, and need active treatment. Because laparoscopic widely carried out, some grass-roots hospital patients after LC often resulting differences can not be properly understood, or even that the medical errors, therefore, necessary to establish a scientific understanding of PCS. Of course, talk to the doctor before surgery LC is necessary to fully explain the possible scenarios, not a mere formality, resulting in an embarrassing situation.

First People’s Hospital Urology Li Jinhai Ruzhou

Etiology


The disease after cholecystectomy may occur with the following factors:

  1. Intraoperative injury to the bile duct, gallbladder and extrahepatic bile ducts because there are large anatomical variation, or the inexperienced surgeon, may be injured during surgery of extrahepatic bile duct, causing postoperative bile duct stenosis, a small number of secondary the bile duct after bile duct damage caused by infection or obstruction cholangitis.
  2. Oddi Vater sphincter stenosis and constrictive papillitis, after the reasons causing these pathological changes is unclear, and biliary stones may be muddy, especially bilirubin stones or chronic inflammation of local edema.
  3. Postoperative bile salt metabolism and autonomic dysfunction, may affect bile excretion, Oddi sphincter tone and pressure of the common bile duct, the incidence of this disease may play a role. There are several possible causes: â‘  Oddi sphincter dysfunction. About 2.4% of biliary problems after surgery, this disease is currently no good diagnostic method. â‘¡ preoperative misdiagnosis and treatment of diseases has been found, such as hiatal hernia, colon dysfunction, intestinal stress syndrome, peptic ulcer, etc., relying on the relevant test to confirm the diagnosis. â‘¢ many of the psychological factors that have without treatment.

Pathogenesis

First, due to biliary disease
Cholecystectomy biliary disease omissions, such as extrahepatic or intrahepatic bile duct stones, Oddi sphincter stenosis disorder; also can be caused by cholecystectomy itself, such as the cystic duct left too long, traumatic bile duct stricture.
1. Bile duct stones after cholecystectomy syndrome is the most common cause. Can be divided into residual stones and recurrent stones. Reported in the literature rate of 5% to 75% or even up to 87.8%. (1) residual stones are not removed in surgery of the stone, can be divided into: â‘  to avoid residual stones: more a result of careful intraoperative exploration or unskilled is not due. â‘¡ difficult to avoid residual stones: intraoperative exploration found hepatolithiasis, confined to technical difficulties, difficult to remove. Or because an emergency case, does not allow detailed exploration or stone. (2) recurrent stones have been removed in surgery, and later occurring stones, it is difficult to judge. Some people think that symptoms more than two years, could re-set stones.

2. Bile duct injury after injury, also known as biliary stricture stricture or bile duct stricture. More than 95% occurred in the cholecystectomy, the incidence is generally between 0.1% and 0.2%, from 100 to 200 cases per cholecystectomy bile duct injury occurs one case of stenosis. Injury of bile leakage, bile peritonitis, even if the union will continue to develop into fibrosis and stenosis, biliary poor drainage, recurrent cholangitis. Stenosis, infection and recurrence of stones on each other, forming a vicious cycle.
3. Left too long cystic duct cystic duct after cholecystectomy who left more than 1cm long as the residue. A group of 132 cases of patients with biliary tract surgery in the X-ray analysis of the residual cystic duct imaging 20 cases, 15.2%. Lack of experience as surgeon, surgical acute inflammation, anatomical abnormalities, or gallbladder neck easily separated due to severe adhesion. Generally do not cause symptoms, but if there are stones in the cystic duct or bile duct obstruction in the lower end, the poor drainage of bile, intraluminal pressure increased, the expansion of the cystic duct and left secondary infection, the formation of a small gallbladder inflammation. The main symptoms are abdominal pain, fever, a small number of jaundice. Other symptoms include indigestion, anorexia, abdominal distension, nausea and vomiting. Cholecystectomy should pay attention to the treatment of cystic duct, common bile duct is generally believed that the expansion, no stones, common bile duct exploration were not from the common bile duct ligation 0.5cm cystic duct at the cut is more reasonable. Then the expansion of common bile duct, a stone, cut without opening the common bile duct stones in the gallbladder conventional exploration, ligation of common bile duct cystic duct as close as possible, as short as possible residual cystic duct, common bile duct injury that neither treatment and avoid left too long.
4. Biliary tract surgery dysfunction more common in young women, psychological factors, or endocrine disorders can be induced. Performance of paroxysmal abdominal pain, accompanied by abdominal distension, sweating, and rapid heart rate. But no symptoms of infection, X ray or B-no positive findings.
Sugawa ERCP examination by 73% gallbladder surgery syndrome had positive findings, 27% had no positive findings, mainly biliary disorders. Bar-meirs gallbladder surgery syndrome in 29 cases, 15 cases were found in 2 cases ERCP manometry (14%) papillary sphincter dysfunction, bile duct pressure changes, Oddi sphincter spasm caused by common bile duct expansion. Tanaka that the pressure loss of bile duct after cholecystectomy buffer, directly affected by the sphincter. Sphincter contraction, cholecystectomy bile duct pressure were significantly increased. Bardley and Collins that cholecystectomy, serum cholecystokinin levels, can cause contraction of the sphincter Oddi, bile duct pressure rise to symptoms.
Second, and diseases caused by biliary
Some patients with symptoms already exist before cholecystectomy, gallbladder disease mask the symptoms. Cholecystectomy with neglected diseases, such as hiatal hernia, ulcer, chronic pancreatitis, chronic hepatitis, cholecystectomy, gallbladder disease symptoms, symptoms of biliary disease from outside.


Clinical manifestations

In cholecystectomy, more than a few weeks or months after the onset of symptoms, mainly upper abdominal discomfort or pain in right hypochondrium, often has pain or pure pain, pressure, its nature is different from preoperative biliary colic may be associated with loss of appetite, nausea, abdominal distension, cramps and occasional bile duct was colic attack. Symptoms with the consumption of fatty foods in particular, into a certain relationship. Severe biliary tract infection can spread upward, and chills high fever, jaundice.
】 【Auxiliary examination
1. Biochemical white blood cell count, urine amylase, liver function, alanine aminotransferase, γ-GT peptide enzymes useful for the diagnosis of biliary obstruction.
2. Intravenous cholangiography poor developing intrahepatic bile duct, extrahepatic bile duct is also unclear, and a lot of influence by the liver so little diagnostic value.
3.B ultrasound can be found in bile duct dilatation, stones, bile duct cancer, pancreatitis. Simple, rapid diagnosis has some value, but there are limitations, can not display picture and all the symptoms of biliary system.
4. On the digestive tract angiography in the diagnosis of esophageal hiatal hernia, ulcer, duodenal diverticulum and so helpful.
5. Hepatobiliary CT scan in the diagnosis of liver cancer, intrahepatic bile duct dilatation, cholelithiasis, chronic pancreatitis.
6. Isotope 99m Tc-HDA hepatobiliary scanning, extrahepatic bile duct dilatation, gallstone disease and liver disease, etc. The method is simple, no damage, for jaundice patients.
7. Endoscopy, including esophagoscopy, gastroscopy, duodenoscopy and so on.
ERCP after cholecystectomy syndrome the exact diagnosis, Hujia You and other reports 181 cases of ERCP, the diagnosis of biliary surgery syndrome discovery and experience. Found that the disease is as follows: to determine the cause of those 169 cases (93.4%), of which 159 cases of cholelithiasis (87.8%), biliary stricture 73 cases (40.3%), biliary tract dilatation in 106 cases (58.6%), chronic recurrent cholangitis 90 cases (49.7%). Unknown causes in 12 cases (6.6%). Diagnostic ERCP success rate was 83.3%, to directly and accurately and clearly show biliary disease picture, lesion shape, size, location and quantity.
8.PTC This method is suitable for imaging of biliary heavier direct identification of jaundice and bile duct lesions positioning.
9. Morphine – neostigmine provocation test. The methods are: intramuscular injection of morphine to patients 10mg, neostigmine 1mg, respectively, before injection, 1 hour after injection, 2 hours and 4 hours blood test serum amylase and lipase. Upper abdominal pain after injection, serum enzymes more than 3 times higher than normal for the positive.


Diagnosis

According to history (gallbladder, bile duct or stomach, duodenum surgery), postoperative fever, abdominal pain and jaundice after taking into account that bile duct stones, bile duct stricture may be. B-mode ultrasound, CT, endoscopy, cholangiography can provide help in the diagnosis; ERCP or PTC and other tests, if necessary, with the fine needle aspiration needle (FNPTC) be satisfied with the diagnosis. Suspected sphincter of Oddi dysfunction who do stenosis or morphine – neostigmine provocation test. ERCP and FNPTC check for unknown reasons after small percentage of patients, diagnosis is difficult.


Treatment

PCS treatment designed to eliminate the cause, unobstructed biliary drainage, infection control. Simple “symptomatic treatment” often Debu to good results. Therefore, the treatment must be further explored its causes, to draw definitive diagnosis. Treatment of non-surgical and surgical treatment.


First, non-surgical therapy
1. Indications ① bile duct diameter <1cm, nor the lower bile duct stenosis. ② There is no obvious bile duct obstruction infection. ③ acute or chronic cholecystitis, pancreatitis. ④ bile duct ascariasis. ⑤ biliary disorders. ⑥ outside the biliary system diseases, such as hiatal hernia, peptic ulcer, chronic pancreatitis.
2. Treatment â‘  general therapy: including diet therapy, infusion, correcting water, electrolyte and acid-base balance. â‘¡ Chinese medicine: Chinese medicine, Chinese medicine dialectical theory of governance of the gallbladder, bile duct stones, biliary tract infection, pancreatitis, biliary ascariasis and other diseases has a good effect. Hypochondriac pain, pale, pulse string, liver qi stagnation were CHSGS Modified; hypochondriac pain, chills, fever, mouth and throat pain, jaundice, red tongue, yellow greasy moss, pulse a few are damp and slippery who Dachaihu Tang YCHT rule; hypochondriac pain, high fever, dry mouth, jaundice, yellow moss, pulse a few strings were applied to fire drug flaming Huanglianjiedu Tonga YCHT treatment. In addition, as with pancreatitis medication to Qingyitang (wood Lake, woody, Yuan Hu, white peony root, skullcap, rhubarb, Glauber’s salt, etc.) based; as with roundworm may Jiawu Mei Tang rule. â‘¢ Acupuncture: to relieve pain, regulate biliary function. â‘£ Other: antibiotics, antispasmodic analgesic, antacids, H2-receptor blockers and so on.


Second, the surgical therapy
1. Indications ① large recurrent bile duct stones, intrahepatic bile duct stones, impacted stones in ampulla, bile duct stenosis and bile duct stones. ② recurrent bile duct biliary tract infection, obstructive suppurative cholangitis. ③ Oddi sphincter stenosis, chronic pancreatitis with ampullary or pancreatic duct obstruction. ④ left too long cystic duct to form a small gallbladder inflammation. ⑤ drugs outside the biliary system is difficult to cure diseases, such as hiatal hernia, ulcer disease.
2. Surgical method according to pathological changes, decided surgery. ① left gall bladder or cystic duct is too long, should cholecystectomy or excision of cystic duct. ② CBD stones in common bile duct exploration should be performed to remove stones and biliary-enteric anastomosis or a variety of endoscopic sphincterotomy, lithotomy and so on. ③ Oddi sphincter possible sphincterotomy stenosis angioplasty. ④ common bile duct stenosis was feasible molding repair, or biliary tract reconstruction. Such as the common bile duct anastomosis, bile duct jejunum Roux-y anastomosis, Longmire surgery. ⑤ biliary severe symptoms and diseases, such as hiatal hernia, ulcer disease, should also be given medicines or surgery.


Prevention

Most cholecystectomy syndrome can be prevented and can get an early cure.
1. Active in Chinese and western medicine biliary disease, have good indications for surgery, to minimize the acute biliary tract surgery, choose a good surgery.
2. Popularization of biliary imaging diagnostics, fully aware of biliary pathology. Cholangiography, biliary endoscopy, gall bladder pressure measurement and other help to improve treatment of biliary tract surgery.
3. Is a rare disease of intrahepatic bile duct, surgery is difficult, very important to improve skills in biliary tract surgery. Biliary tract surgery, such as to eliminate a variety of causes, prevention of bile duct stricture, and a patent drainage, biliary tract surgery syndrome will certainly reduce the chance.

dumping syndrome after gallbladder removal


Cited reference

China Academic Journal, if the first 10 1 Xuan Liang, Chao; subtotal gastrectomy bile acid concentration in gastric juice and intragastric microflora changes of clinical significance [J]; Chongqing Medical; 2000 01 2 Yong! 430022 Wuhan, Zhang School! 430022 Wuhan, high re-Wing! 430022 Wuhan, Chen Xianxiang! 430022 Wuhan; radionuclide gastric emptying in the proximal stomach surgery in the experimental study [J]; radiology practice; 1999 04 3 Chen recovery, ZHANG Ji new Fenghao Miao, Huang Bin; gastrectomy back to the cecum on behalf of the stomach in the treatment of gastric cardia cancer [J]; avant-garde Journal of Medicine; 1999 05 4 Chang-water, Yu Jianguo; residual gastropathy and Helicobacter pylori infection [J]; Journal of Gastroenterology and Hepatology; 2000 04 5 Dong Jingwu; 270 cases of patients after endoscopic observation and clinical analysis [J]; surgical theory and practice; 2000 01 6 Jian Miao, Pu Yongdong, Caozhi Yu, LIU Wei-ping; delayed gastric emptying after subtotal gastrectomy the diagnosis and treatment [J]; Chinese Journal of Surgery; 2003 08 7 Wang Zhongyu, Wu Rong, Yin Shuo, even when the right; fat meal on the serum of patients after distal gastrectomy cholecystokinin and its significance [J]; Chinese Journal of Surgery; 1997 01 8 Wang Renzhong, Tongrong Yuan, Shifeng Wen, Xu Zhen Zhuang; jejunum interposition of artificial cardia in the anti-reflux esophagitis on the application [J]; Chinese Journal of Clinical Oncology; 1994 02 9 He Xilin, Caogao Wu, Luo Xianfeng; total gastrectomy and jejunum interposition Reform jejunum on behalf of the stomach surgery report of 20 cases [J]; Chinese Journal of Clinical Oncology; 1995 03 10 Zhouxiang Fu! 313000, Mei Hua! 313000, Chen Lingwu! 313000, Amy in! 313000, hi! 313000, Lu Minhua! 313000, Chen Wei! 313000, Bio of! 313000, Cai Yubin! 510630 Guangzhou; to take control blind ascending colon neobladder urodynamic experimental and clinical studies [J]; Journal of Urology; 2000 02

Condition analysis:


Cholecystectomy in a series of side effects, including the following aspects:
1). Indigestion, abdominal distension and diarrhea
To current knowledge, gallbladder at least storage, concentration and systolic function. Bile secreted by liver cells into the gallbladder for storage and concentration. Gallbladder bile than in hepatic bile concentrated 30 times, eating high-fat meal, had just discharged into the intestine Road to participate in digestion. If the gallbladder is removed, then the liver bile excretion from the liver nowhere to be kept, regardless of whether the human body, had continued into the intestine; when the body need a lot of bile to help digest food when the body at this time no longer concentrated bile to help, the body had to withstand indigestion, abdominal distention diarrhea bitter.
2). Cholecystectomy duodenal fluid reflux, gastric esophageal reflux
In recent years, intestinal fluid for duodenal reflux after cholecystectomy (Duodenogastric Reflux DGR) and the many reports of gastric reflux. Walsh and other in-control study also confirmed that all markers after cholecystectomy were to gastroesophageal reflux, and accompanied by decreased lower esophageal sphincter; Chen MF, also pointed out that the DGR after cholecystectomy due to the loss of functional reserve of bile, leading to the bile and food by the intermittent excretion into the persistence into the duodenum , then the opportunity to increase reflux into the stomach, resulting in DGR. resulted in bile reflux gastritis or esophagitis.
3). Cholecystectomy increases the incidence of common bile duct stones.
In the treatment of common bile duct stones in the process, it is easy to see: the common bile duct stones in the gallbladder cases, the nature of the stones are mostly bile pigment stones, known as primary bile duct stones. Analysis of the primary reasons for stone formation One of the important doctrine is “fluid” principle. in the gallbladder excised, the gallbladder for bile duct loss of fluid pressure within the buffer effect, leading to increased pressure in the common bile duct, common bile duct caused by a compensatory expansion, which Also within the common bile duct bile flow slows down, and the occurrence of vortex or vortex, which is an important theory of the formation of gallstones.
4.) Bile duct injury after cholecystectomy caused the problem.
As we all know, in the course of cholecystectomy surgery, due to the importance of Calot’s triangle, plus the impact of local tissue adhesions, cholecystectomy complications arising and then the inevitable, there is always a certain probability (bile duct injury: 0.18 ~ 2.3 %); and there is some mortality (0.17%). These include: bile duct injury, hepatic duct injury, vascular injury, gastrointestinal injury and so on. In particular, emphasis is in the vast majority of cases of bile duct injury is cholecystectomy caused.
5). Cholecystectomy on the incidence of colon cancer.
More bile after cholecystectomy bacterial degradation cycles, the resulting secondary bile acid pool content and proportion of higher and secondary bile acids are carcinogens or co-carcinogenic effect, it is prone to colon cancer. and the kinds of cancer occur in the right colon.
6). Cholecystectomy syndrome.
“Cholecystectomy syndrome,” the term but a vague concept; Imageology With modern advances in diagnostic technology, has ruled out residual stones after biliary tract surgery, diagnosis of bile duct injury, and only occurred after biliary tract surgery Oddi `sphincter inflammation and movement disorders can only be described as” surgery syndrome “, and the clinical treatment of symptoms even difficult.
6, minimally invasive gallbladder surgery recurrence rate guarantee. Minimally invasive surgery for protection by the bile of gallbladder polyps were followed up for 1-14 years, only 0.1% recurrence rate of gallstone recurrence rate of only 3.9% and the recurrence rate is safe and reliable operation. has broad prospects for development.
In summary, with the cut in the gall bladder bile between Paul, the difference in nature, endoscopic gallbladder surgery preserves preserving the physiological function of the gallbladder; and cut gall bladder surgery gallbladder is lost, the loss of the physiological function of the gallbladder can also cause a Jilie physical barriers, even posing the possibility of colon cancer; the contrary, the high-tech security bile treatment, avoiding the complications of cholecystectomy, has no serious complications, no mortality. With the development of modern medical science and technology, on the gallbladder With this important a better understanding of the digestive organs, in addition to condensation, contraction and bile duct pressure adjustment to the role of the buffer, or a complex function of chemical and adaptive immune organs. gallbladder is not an option, but a very important the digestive organs, it should not be easily repealed. Of course, gallbladder contraction, gallbladder no longer function, or gallbladder polyps were suspected cancer, cholecystectomy should be no doubt, remove the lesions.


Suggestion:


Under normal circumstances, after meals need enough of the bile secretion, to help digestion and absorption of fat, or indigestion will appear Xianxiang. To accomplish this function function main Yikao biliary and duodenal function.
Occurred after cholecystectomy biliary disorders, mainly the regulation of bile into the duodenum be obstacles, this is a manifestation of cholecystectomy.
Cholecystectomy, the gallbladder sudden interruption of the original features, resulting in a continuing inflow of bile, the duodenum, often have to wait a few months later, the bile to digest a meal with the needs of intermittently into the duodenum, to restore its normal flow. bile into the duodenum continuously, Oddi sphincter relaxation can cause the loss of tension. when duodenal peristalsis and spasm, its contents can be returned due to increased pressure on hepatic bile duct, due to loose sphincter Chi, the results of bile duct expansion. If the operation Houao Di sphincter spasm remains bound to cause tension or even expand the common bile duct. The above shows that regardless of Oddi sphincter spasm or relaxation, can lead to increased pressure within the common bile duct, and to expand , the resulting number of symptoms such as bloating gas, abdominal discomfort, and even diarrhea. Generally speaking, a functional cholecystectomy, often these symptoms within a few months, but after treatment can these symptoms disappeared or mitigation, Oddi sphincter function can be restored.

If cholecystectomy lost for many years before the Dannang function, motor function of biliary tract to adapt to this situation has already been adjusted, then resection and bile duct pressure will not be much change, there will be no noticeable symptoms.
Appear the following should be considered the performance of biliary tract dysfunction: the location and characteristics of pain as the biliary colic gallstone renvoi, but time is short, usually in a few minutes to half an hour; frequent episodes several times a day; seizures and mental factors (emotional stress, anxiety, malaise)-related; attack amyl nitrite inhalation or sublingual nitroglycerin, clothing antispasmodic drug, symptoms can be alleviated; contrast injection of morphine can induce abdominal pain; abdominal pain not associated with chills , fever and jaundice.

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