eMedicine Specialties > Gastroenterology > Biliary

Cholelithiasis: Follow-up

Author: Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Coauthor(s): Anastasios A Mihas, MD, DMSc, FACP, FACG, Professor, Department of Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine; Consulting Staff, Virginia Commonwealth University Hospitals and Clinics; Chief of GI Clinical Research, Director of GI Outpatient Service, Associate Director of Hepatology, Hunter Holmes McGuire Veterans Affairs Medical Center; Jeff Allen, MD, Assistant Professor, Department of Surgery, University of Louisville
Contributor Information and Disclosures

Updated: Aug 25, 2009

Follow-up

Further Outpatient Care

  • Following cholecystectomy, about 5-10% of patients develop chronic diarrhea. This is usually attributed to bile salts. The frequency of enterohepatic circulation of bile salts increases after the gallbladder is removed, resulting in more bile salt reaching the colon. In the colon, bile salts stimulate mucosal secretion of salt and water. Postcholecystectomy diarrhea is usually mild and can be managed with occasional use of over-the-counter antidiarrheal agents, such as loperamide. More frequent diarrhea can be treated with daily administration of a bile acid-binding resin (eg, colestipol, cholestyramine, colesevelam).
  • Following cholecystectomy, a few individuals experience recurrent pain resembling biliary colic. The term postcholecystectomy syndrome is sometimes used for this condition.
    • Many patients with postcholecystectomy syndrome have long-term functional pain that was originally misdiagnosed as being of biliary origin. Persistence of symptoms following cholecystectomy is unsurprising. Diagnostic and therapeutic efforts should be directed at the true cause.
    • Some individuals with postcholecystectomy syndrome have an underlying motility disorder of the sphincter of Oddi, termed biliary dyskinesia, in which the sphincter fails to relax normally following ingestion of a meal. The diagnosis can be established in specialized centers by endoscopic biliary manometry. In established cases of biliary dyskinesia, endoscopic retrograde sphincterotomy is usually effective in relieving the symptoms.

Patient Education

  • Patients with asymptomatic gallstones should be educated to recognize and report the symptoms of biliary colic and acute pancreatitis.
    • Alarm symptoms include persistent epigastric pain lasting for greater than 20 minutes, especially if accompanied by nausea, vomiting, or fever.
    • If pain is severe or persists for more than an hour, the patient should seek immediate medical attention.
  • For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, see eMedicine's patient education article Gallstones.

Miscellaneous

Medicolegal Pitfalls

  • The major legal liability in the treatment of gallstones rests with the surgeon and interventional endoscopist.
  • Lawsuits against both surgeons and endoscopists have increased since the advent of laparoscopic cholecystectomy. Specific issues for the surgeon include common bile duct injury, trocar-induced bowel damage, and lost stones.
    • During laparoscopic cholecystectomy, a surgeon must retrieve stones that might escape through a perforated gallbladder. Conversion to an open procedure might be required in certain cases.
    • In patients in whom gallstones have been lost in the peritoneal cavity, the current recommendation is follow-up with ultrasonographic examinations for 12 months. Most of the complications (usually abscess formation around the stone) occur within this time frame.
  • Common bile duct injury is a recognized complication of cholecystectomy. However, in the legal community, it is often treated as medical malpractice.
    • A large proportion of lawsuits involving iatrogenic common bile duct injury are resolved in favor of plaintiffs by verdict or by settlement.
    • Routine cholangiography is only of minimal help in preventing common bile duct injury. However, good evidence indicates that it leads to intraoperative detection of such injuries.
    • When the anatomy of the biliary tree is uncertain, it is often prudent to convert the procedure to open cholecystectomy.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Alfred Cuschieri, MD, ChM, FRSE, FRCS, to the development and writing of this article.



More on Cholelithiasis

Overview: Cholelithiasis
Differential Diagnoses & Workup: Cholelithiasis
Treatment & Medication: Cholelithiasis
Follow-up: Cholelithiasis
Multimedia: Cholelithiasis
References
Further Reading
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References

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Further Reading

Related eMedicine Topics

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National Guideline Clearinghouse

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Keywords

cholelithiasis, gallstones, gallstone disease, gallbladder stones, gallbladder disease, gallbladder pain, gall bladder removal, pure cholesterol gallstones, pure pigment gallstones, mixed gallstones, biliary sludge, biliary colic, cholecystectomy, common bile duct stones, gall stones, choledocholithiasis, cholecystolithiasis

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Contributor Information and Disclosures

Author

Douglas M Heuman, MD, FACP, FACG, AGAF, Chief of Hepatology, Hunter Holmes McGuire Department of Veterans Affairs Medical Center; Professor, Department of Internal Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine
Douglas M Heuman, MD, FACP, FACG, AGAF is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Physicians, and American Gastroenterological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Anastasios A Mihas, MD, DMSc, FACP, FACG, Professor, Department of Medicine, Division of Gastroenterology, Virginia Commonwealth University School of Medicine; Consulting Staff, Virginia Commonwealth University Hospitals and Clinics; Chief of GI Clinical Research, Director of GI Outpatient Service, Associate Director of Hepatology, Hunter Holmes McGuire Veterans Affairs Medical Center
Anastasios A Mihas, MD, DMSc, FACP, FACG is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Federation for Clinical Research, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy, Gastroenterology Research Group, Sigma Xi, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

Jeff Allen, MD, Assistant Professor, Department of Surgery, University of Louisville
Disclosure: Nothing to disclose.

Medical Editor

David Eric Bernstein, MD, Chief, Section of Hepatology, North Shore University Hospital, Director, Associate Professor, Department of Internal Medicine, Division of Hepatology, New York University School of Medicine
David Eric Bernstein, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine
BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law Medicine and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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