Postcholecystectomy syndrome: symptoms, treatment and classification

Surgery saves millions of lives around the world. Surgical intervention does not always have a positive result, some entail serious consequences that require long-term treatment and rehabilitation. Problems include postcholecystectomy syndrome.

PCES concept

Postcholecystectomy syndrome is a consequence of cholecystectomy, i.e. removal of the gallbladder. The gallbladder plays an important role in the body - it accumulates bile resulting from the work of the liver, concentrates it and removes it through the bile streams at the right time and in the required amount. Its removal disrupts the process, bile enters directly into the intestines, already in a smaller amount and concentration. To digest heavy food, it may not be enough, which leads to serious disturbances in the digestive system.

Causes of occurrence

PCES can arise for various reasons. Some are more common, others much less common, conventionally divided into three groups. All of them arise when the work of the sphincter of Oddi is disrupted. The sphincter of Oddi is a smooth circular muscle of the duodenum that regulates the supply of bile. Dysfunction is biliary and pancreatic.

Not related to cholecystectomy

Cholecystectomy syndrome does not always occur after resection of the gallbladder. It can be the result of a late diagnosis of the disease, an error in the examination, when the patient incorrectly describes the symptoms. Main reasons:

• poor quality examination;
• chronic gastrointestinal diseases (colitis, gastritis, pancreatitis, hepatitis, peptic ulcer);
• regular indigestion (nausea, vomiting, diarrhea);
• serious violations of the intestinal microflora;
• other pathologies that interfere with the normal secretion of bile.

Postoperative reasons

More often, the functional syndrome occurs in the postoperative period, when stones remain in the ducts when the bladder is removed, mistakes are made during the operation.

Classification of medical errors:

• the formation of granulomas - inflammation in the seam area;
• damaged bile duct;
• too large a cystic duct stump;
• pancreatitis that appears after surgery.

Causes both before and after surgery

Regardless of whether a cholecystectomy was performed, disorders of the motility of the gastrointestinal tract may occur:

• irritable bowel syndrome;
• duodenal ulcer;
• duodeno-gastric reflux - ingestion of the contents of the duodenum into the stomach cavity;
• gastroesophageal reflux disease - the release of acid from the stomach into the esophagus;
• chronic pancreatitis.

Symptoms

The clinical manifestations of the syndrome directly depend on the causes of its manifestation. Experts often confuse these symptoms with other gastrointestinal diseases, such as gastritis, since the manifestations of both are similar.

Distinguishing signs of symptoms

To make the correct diagnosis, the patient is checked for the presence of characteristic manifestations:

• Severe pain at night and immediately after eating.
• Short-term vomiting and nausea.
• The duration of the pain is at least 20 minutes.

Varieties of symptoms

After resection, the patient is most often disturbed by the following unpleasant manifestations:

• Diarrhea.
• Excessive gassing.
• Change in body weight.
• Pain and heaviness in the left hypochondrium.
• Nausea.
• Bitterness in the mouth.
• Itchy skin.
• Paleness and weakness.

In addition to the main symptoms, signs of exacerbation of diseases sometimes appear:

• Inflammation of the bile ducts. It is accompanied by an increase in body temperature.
• Stagnation of bile in the liver, turning into jaundice.

If at least one symptom manifests itself, you should immediately consult a specialist in order to avoid complications.

Diagnostics

Postcholecystectomy syndrome does not have a clear definition, it is characterized by the presence of a large number of different symptoms and causes. It complicates the formulation of the correct diagnosis, the choice of the method of treatment, and requires a deep investigation of the problem.

Diagnostics consists of several steps:

• Study of case histories, before and postoperative conclusions.
• Examination and questioning of the patient.
• Laboratory tests of blood, urine, feces and other indicators.
• Ultrasound procedure.
• Magnetic resonance and abdominal computed tomography.
• Endoscopy.
• Sphincter of Oddi manometry.
• Duodenal intubation.

Treatment

Before starting treatment, it is necessary to correctly determine the causes of the syndrome. If you make a mistake, the wrong therapy will be carried out, leading to a worsening of the patient's condition. The outpatient treatment period can be up to 28 days. An individual set of therapeutic measures is selected for each patient.

Drug treatment

The amount of drugs and the duration of treatment are determined based on the causes of the manifestation of the disease. The main drugs for this type of therapy:

• Pain relievers.
• Antispasmodics.
• Polyenzymes - for proper digestion.
• Nitrates that help the sphincter of Oddi work.
• Antiseptics.
• Probiotics.

Diet therapy

Patients after removal of the bladder should adhere to Pevzner's diet No. 5. Reduces the risk of PCES. When a symptom manifests itself, it facilitates its course, accelerates treatment.

Features of the diet:

• Lack of fried food.
• Control over the temperature of food.
• Fractional power system.

Products approved for use by patients with PCES:

• Vegetable soups, cereals, dairy soups.
• Rye bread, wheat grades 1 and 2, lingering biscuits, pastries, uncomfortable pastries.
• Lean boiled meat: chicken, beef, turkey, lamb.
• Dishes from low-fat fish, boiled or baked.
• Dairy and fermented milk products with a minimum percentage of fat.
• Any porridge.
• Almost all vegetables.
• Not very sweet compote, juice, jelly, tea, coffee with milk.
• Spices: dill, parsley, cinnamon.
• Berries, fruits, candy, honey, marmalade, candy without chocolate.

Forbidden to use:

• Broths based on meat, fish, mushrooms, cold soups.
• Puff pastries, baked goods, fresh bread, fried.
• Fatty meat: pork, goose, duck, semi-finished meat products, canned food.
• Fatty, canned, smoked fish.
• Milk products with a high percentage of fat.
• Garlic, onion, sorrel, radish, radish, canned vegetables.
• Iced drinks, cocoa, strong coffee.
• Pepper, ginger, mustard.
• Confectionery cream, ice cream, chocolate.

The menu should include a sufficient amount of protein, fat, carbohydrates, a lot of fiber and pectin.

Surgical intervention (if necessary)

The operative method is necessary if the postcholecystectomy syndrome has arisen as a result of a surgical error. It consists in removing the formed scars and stones left during the first operation.

Possible complications

With insufficient treatment, a violation of the diet, the following consequences arise:

• Excessive bacterial growth against a background of reduced immunity.
• Arterial diseases due to the formation of cholesterol plaques.
• Weight loss.
• Avitaminosis.
• Decreased hemoglobin.
• Erectile dysfunction in men.

Preventive actions

PCES is a group of symptoms observed after removal of the gallbladder, surgery on the bile ducts, this term is not an independent disease. Its ICD-10 code is K 91.5. Despite this, the prevention of the syndrome is of great importance.

Recommendations:

• Regular check-ups with a gastroenterologist.
• Avoiding alcohol and tobacco.
• Compliance with a diet.
• Eating 5-6 times a day.
• Taking vitamins.
• Leading a healthy lifestyle.

Postcholecystectomy syndrome does not always occur immediately after surgery, sometimes it makes itself felt after several months or even years. Timely prevention not only reduces the risk, but can also completely eliminate its occurrence.