Diagnosis and management of post-cholecystectomy symptoms: the place of endoscopy and retrograde choledochopancreatography

Postcholecystectomy syndrome in northern India--study on the diagnostic and therapeutic role of ERCP

One hundred and twenty two patients with postcholecystectomy syndrome were studied by endoscopic retrograde cholangiopancreatography (ERCP). The procedure was successful in 105 patients (85.3%) and it accurately detected abnormality of the pancreatico-biliary system in 71 patients (67.6%). ERCP results were abnormal in 82.6% of patients with biliary symptoms, with or without jaundice, compared with 34.7% of patients with non-biliary symptoms (P less than 0.001). Though ERCP showed abnormality in all patients with biliary symptoms and jaundice, as many as 70.4% of patients without jaundice had abnormal ERCP. The commonest abnormality was retained/recurrent stones (37/105 patients). Patients with biliary strictures presented significantly more often with jaundice compared with patients with biliary stones (74.3% vs 22.3%). In 19 of the 37 patients with retained biliary stones endoscopic sphincterotomy was performed and it was successful in 16 patients (84.2%). Our data indicates that ERCP detects the anatomical level as well as the nature of lesion accurately, and is essential and safe in the diagnosis and management of patients with postcholecystectomy syndrome.

Sphincter of Oddi dysfunction: results of treatment by endoscopic sphincterotomy

From a consecutive series of 451 patients with post-cholecystectomy symptoms referred for endoscopic retrograde cholangiopancreatography (ERCP), 40 (9 per cent) were diagnosed as having sphincter of Oddi dysfunction. Eight patients were excluded from the study because of incomplete data (n = 6) or additional diagnoses (n = 2). Thirty of the patients had successful ERCP and endoscopic sphincterotomy (ES); this failed in the remaining two because of severe papillary stenosis (6.3 per cent). Endoscopic biliary manometry was performed in 23 patients (77 per cent). Immediate post-ES complications occurred in eight patients (25 per cent). At a median follow-up of 46 months (range 10-88 months) 19 patients had a good outcome (63.3 per cent) and 11 patients had a poor outcome (36.7 per cent). Patients with a good outcome tended to have a delay of months or years following cholecystectomy before the development of symptoms (median 6 years versus 0 years, P = 0.0003). At ERCP, patients with a good outcome had greater common bile duct diameters (mean +/- s.d. mm, 12.6 +/- 3.6 versus 8.8 +/- 1.8, P = 0.0003) and delayed drainage from the biliary tree of injected contrast (13 versus 2 patients, P = 0.02). Endoscopic biliary manometry was abnormal in all 15 patients with a good outcome in whom it was performed but in only 3 out of 8 patients with a poor outcome (P = 0.003). Sphincter of Oddi dysfunction is an important, albeit uncommon, cause of post-cholecystectomy symptoms. ES provides symptomatic relief in the majority of patients but improved criteria for predicting outcome are required.

The postcholecystectomy syndrome: bile ducts as pain trigger zone

Sixty-five non-icteric patients presumed to have the postcholecystectomy syndrome (PCS) were followed up for 4-13 years after their first endoscopic retrograde cholangiopancreatography (ERCP) examination, which gave normal findings. All patients, however, experienced severe pain on injection of only 1-2 ml of contrast medium over 5-10 sec into the common bile duct (CBD). Thirty-four of the 65 patients were found to have true PCS on long-term follow-up studies, whereas 31 of them had other diseases. A second ERCP also showed normal results, and the injection-related pain was preceded by an abnormal pressure rise in the CBD at manometry. The CBD acted like a pain trigger zone, and the pain reaction might be diagnostic in everyday clinical practice. In conclusion, ultrasonography is an adequate diagnostic method in non-obstructive PCS. Medical treatment is often successful. ERCP and interventional treatment should be reserved for patients with obstructive symptoms and for patients in whom all medical treatment has failed.

Misdiagnosis using endoscopic retrograde cholangiopancreatography in a patient with postcholecystectomy pain

Endoscopic retrograde cholangiopancreatography (ERCP) has become an essential tool to investigate patients with the postcholecystectomy syndrome. A normal cholangiogram usually rules out the presence of biliary tract disease, and further investigations are directed towards other organ systems. We present a case in which a normal ERCP caused a significant delay in reassessing the biliary tree in a patient who eventually presented with choledocholithiasis. A repeat ERCP should be considered in patients with persistent biliary tract pain, even if the initial ERCP shows no abnormality.

Results of sphincteroplasty in patients with spastic sphincter of Oddi. Predictive value of operative biliary manometry and provocation tests

The predictive value of different preoperative provocation tests and operative biliary manometry was studied in a series of 22 patients undergoing sphincteroplasty for suspected spastic sphincter of Oddi (SPO). The result of the operation was good in 59%, 54%, and 71% of patients in groups with a positive codein test, a positive endoscopic retrograde cholangiopancreatography filling pain sign, and positive fentanyl test, respectively. Common bile duct pressure (CBDP) did not differ significantly between the SPO spasm group and control patients, but in the fentanyl test the CBDP elevation was significantly higher (p less than 0.01) than in controls (7.7 versus 3.3 mm Hg). It was concluded that the operative fentanyl test seems to be useful in predicting the response to surgery (sphincteroplasty) in patients with post-cholecystectomy biliary-type pain and suspected SPO spasm.

Common bile duct calculi. 1. Surgical therapy

Multiple techniques are now available for management of the patient with retained or recurrent common bile duct calculi. The goal of treatment is extraction of calculi with the lowest possible incidence of morbidity and mortality, the lowest cost and least discomfort to the patient, and the best long-term results. The choice of therapy--surgical or nonsurgical--depends on several factors, including presence or absence of the gallbladder and a T tube, type of calculi, operative risk, accompanying conditions, and expertise available at a particular institution. The decision to explore the common bile duct at the time of elective cholecystectomy is based on clinical, operative, and cholangiographic information. A rigorous technique of surgical exploration that includes duodenal mobilization, choledochoscopy, and cholangiography is necessary. In selected patients, biliary enteric anastomosis decreases the incidence of retained or recurrent calculi.

Acute pancreatitis following endoscopic retrograde cholangiopancreatography

An analysis of endoscopic retrograde cholangiopancreatography (ERCP) examinations suggests that repeated contrast injection into the pancreatic duct during attempts to cannulate the bile duct is of major importance in the aetiology of acute pancreatitis after ERCP, even in the absence of pancreatic acinar opacification. The technique of ERCP can easily be modified to avoid repeated pancreatic duct injection and, by doing so, an increase in the incidence of acute pancreatitis has been reversed.

Choledochoduodenostomy in calculous biliary tract disease

During a 14-year period ending in June 1979, 342 patients with calculous biliary disease underwent choledochoduodenostomy either as a primary procedure or during reoperation. Eighty per cent of the patients were aged 50 years or more. Follow-up was either by personal interview and physical examination or by means of a questionnaire, 90 per cent of the patients being assessed at periods ranging from 6 months to 14 years. A high incidence of common bile duct dilatation was found in older patients, in patients with a long history and in patients submitted to reoperation. There were no operative deaths. Postoperative complications occurred in 22 cases (6.4 per cent) and, in particular, no patient developed ascending cholangitis or symptoms related to the "blind segment". Choledochoduodenostomy is a valuable and safe procedure and can be used on wide indications, especially where peroperative cholangiography is not available.

British experience with duodenoscopic sphincterotomy for removal of bile duct stones

Duodenoscopic sphincterotomy is rapidly becoming popular in Britain. Representatives of 14 British centres met in January 1980 to discuss progress and problems with the technique. This report summarizes current experience, with particular reference to hazards. Duodenoscopic sphincterotomy is mainly being used in patients who have previously undergone cholecystectomy and who no longer have a T tube drain in place. Sphincterotomy was achieved in 87 per cent of 679 patients attempted, and the common duct was cleared of stones in 87 per cent of these. Immediate complications followed in 8.5 per cent; 1.6 per cent required urgent surgery and 7 patients (1 per cent) died. Centres with the greatest experience had better results and fewer complications. Those performing duodenoscopic sphincterotomy believe it to be a major advance in the management of high risk patients with common duct stones, after cholecystectomy. Its use remains controversial in high risk patients who still have gallbladders and in low risk patients after cholecystectomy; long term follow-up studies are essential.

Measurement of the endoscopic retrograde cholangiogram

The diameters of the common hepatic and bile ducts were measured in 100 endoscopic retrograde cholangiograms, and the effect of magnification was determined. Duct diameters were magnified by up to 48%. They were increased in some patients with chronic pancreatitis and after cholecystectomy, but were sometimes normal in patients with extrahepatic biliary obstruction.

Spontaneous closure of choledochoduodenostomy: diagnosis by endoscopy and ERCP

Choledochoduodenostomy has been recommended for the management of benign lower common bile duct obstruction, but opinion on this is still divided. Two cases are presented of recurrent cholangitis following choledochoduodenostomy, in which endoscopy and ERCP demonstrated closure of the choledochoduodenal anastomosis, continuing lower biliary obstruction and retained stones or debris. Persistent of recurrent symptoms following this operation may be due to stoma closure without adequate biliary drainage, and in these circumstances endoscopy with ERCP is proving most useful and in difficult cases may be the investigation of choice.

Iatrogenic choledochoduodenal fistula: an unsuspected cause of post-cholecystectomy symptoms

In the investigation of 90 patients referred with severe post-cholecystectomy problems, 8 patients were found at ERCP to have choledochoduodenal fistula. The clinical features associated with the fistula included pain with fever, jaundice or hyperamylasaemia. Reviewing the details of the original surgery and the endoscopic findings, it is suggested that most, if not all, of these fistulas are iatrogenic. Treatment by biliary bypass is recommended.

The early use of fine-needle percutaneous transhepatic cholangiography in an approach to the diagnosis of jaundice in a surgical unit

Fine-needle percutaneous transhepatic cholangiography (PTC) was performed in a series of 46 patients with jaundice or suspected biliary tract disease. The ductal system was successfully outlined in each of 20 patients with dilated intrahepatic ducts and in 19 of 26 patients with intrahepatic ducts of normal calibre. There were two episodes of septicaemia after PTC, one of them fatal. Valuable accurate diagnostic information was obtained in all cases with biliary tract obstruction. A programmed approach to diagnosis of suspected obstructive jaundice is outlined. Fine-needle PTC is an acceptably safe procedure and need not be followed by immediate laparotomy.