Postcholecystectomy Syndrome Workup

Initial laboratory studies in the workup for postcholecystectomy syndrome (PCS) usually include the following:

• Complete blood count (CBC) to screen for infectious etiologies
• Basic metabolic panel (BMP) and amylase level to screen for pancreatic disease
• Hepatic function panel (HFP) and prothrombin time (PT) to screen for possible liver or biliary tract diseases
• If the patient is acutely ill, blood gas analysis

If laboratory findings are within reference ranges, consideration should be given to repeating these studies when symptoms are present.

Other laboratory studies that may be indicated are as follows:

• Lipase
• Gamma-glutamyl transpeptidase (GGT)
• Hepatitis panel
• Thyroid function
• Cardiac enzymes

Chest radiography should be performed to screen for lower-lung, diaphragmatic, and mediastinal diseases; in most cases, abdominal films should be obtained as well. In patients with a history of back problems or arthritis, a lower dorsal spine series should also be obtained.

For patients with right-upper-quadrant pain, barium swallow, upper gastrointestinal (GI), and small-bowel follow-through (SBFT) studies will evaluate the intestinal tract for evidence of esophagitis, including gastroesophageal reflux disease (GERD) and peptic ulcer disease (PUD). These studies are not always performed, because esophagogastroduodenoscopy (EGD) is more reliable at identifying these diseases and also permits direct visualization of the ampulla of Vater. When the pain is lower in the abdomen, a barium enema should be performed.

Angiography of suspected diseased vessels may lead to intervention for vascular disorders, such as coronary or intestinal angina.

An ultrasonographic study is almost always performed; it is a quick, noninvasive, and relatively inexpensive way to evaluate the liver, biliary tract, pancreas, and surrounding areas. A 10- to 12-mm dilation of the common bile duct (CBD) is commonly observed. Dilation exceeding 12 mm is often diagnostic of distal obstruction, such as a retained stone, CBD stricture, or ampullary stenosis.

In a study of 80 patients with PCS, Filip et al concluded that endoscopic ultrasonography (EUS) was a valuable tool for determining which patients require endoscopic retrograde cholangiopancreatography (ERCP). ^[15] The sensitivity and specificity of EUS were found to be 96.2% and 88.9%, respectively, in a subset of 53 patients who were ultimately diagnosed with biliary or pancreatic disease. The investigators found that the use of EUS helped to reduce the number of patients receiving ERCP by 51%.

EGD can be very helpful in the workup of PCS. It is a good procedure for evaluating the mucosa for signs of disease from the esophagus through the duodenum. EGD also allows direct visualization of the ampulla of Vater.

A total colonoscopy may reveal colitis, and biopsy of the terminal ileum may confirm Crohn disease.

ERCP is the most useful test in the diagnosis of PCS. ^{[15, 16]} It is unsurpassed in visualization of the ampulla, biliary, and pancreatic ducts. At least 50% of patients with PCS have biliary disease, and most of these patients’ conditions are functional in nature. An experienced endoscopist can confirm this diagnosis in most of these patients and can also provide additional diagnostic studies, such as biliary and ampullary manometry.

Delayed emptying can be observed during ERCP, as well as with hepatoiminodiacetic acid (HIDA) scanning. The CBD should clear of contrast within 45 minutes. Biliary manometry is performed in patients sedated without narcotics with a perfusion catheter; a pull-through technique is used for sphincter manometry. The sphincter is 5-10 mm long, and normal pressures are less than 30 mm Hg.

As technology improves, it will be easier to detect retrograde contractions or increased frequency of contractions (also called tachyoddia).

At the time of ERCP, therapeutic maneuvers, such as stone extraction, stricture dilatation, or sphincterotomy for dyskinesia or sphincter of Oddi stenosis, can be performed. Percutaneous transhepatic cholangiography (PTC) or magnetic resonance cholangiopancreatography (MRCP) may be of use in patients who are not candidates for ERCP or in whom ERCP has been unsuccessfully attempted.

Computed tomography (CT) can be helpful in identifying chronic pancreatitis or pseudocysts in patients with alcoholism or those with a history of pancreatitis. In patients who are not candidates for EGD and ERCP, a helical CT scan or MRCP may reveal the cause of PCS.

Nuclear imaging may demonstrate a postoperative bile leak. Occasionally, a HIDA scan or similar scintigraphic study may show delayed emptying or a prolonged half-time, but these studies lack the resolution necessary to identify dilation, stricture, and so on. Emptying delayed by more than 2 hours or a prolonged half-time can help identify the sphincter of Oddi as a potential cause but cannot differentiate between stenosis and dyskinesia.

In addition to the history and physical examination and review of the old record, electrocardiography (ECG) should be performed to screen for coronary disease. A stress test or Holter monitoring may be indicated by the findings from the history and physical, laboratory tests, or ECG.

Provocation tests, such as the morphine-neostigmine test for pain or the secretin stimulation test for pancreatic duct dilatation, have not been widely accepted. The author has not found either test to be particularly helpful.