What is the cause and treatment of continued abdominal pain in a patient status post cholecystectomy (surgical removal of the gallbladder) with ultrasound findings of physiologic prominence of the bile ducts?

From the Guidelines

Continued abdominal pain after gallbladder removal with physiologically prominent bile ducts on ultrasound is likely due to post-cholecystectomy syndrome, and initial treatment should focus on conservative management with dietary modifications and medications. The patient's symptoms, such as continued abdominal pain, should be evaluated in the context of potential bile duct injury (BDI) or other complications post-cholecystectomy, as suggested by the 2020 WSES guidelines 1. However, the ultrasound findings of physiologic prominence of the bile ducts are likely a normal variant after cholecystectomy due to compensatory dilation and do not necessarily indicate pathology requiring intervention.

Initial Evaluation and Management

• The assessment of liver function tests, including serum levels of direct and indirect bilirubin, AST, ALT, ALP, GGT, and albumin, is suggested in patients with clinical signs and symptoms suggestive of BDI after cholecystectomy, as recommended by the guidelines 1.
• Initial treatment should include dietary modifications (low-fat diet, small frequent meals), and medications such as antispasmodics like hyoscyamine (0.125-0.25mg every 4 hours as needed) or dicyclomine (10-20mg four times daily).
• For pain management, acetaminophen (500-1000mg every 6 hours) is preferred, with NSAIDs like ibuprofen (400-600mg every 6 hours with food) as alternatives if not contraindicated.
• Proton pump inhibitors such as omeprazole (20mg daily) may help if acid reflux contributes to symptoms.

Further Management

• If these conservative measures fail after 4-6 weeks, referral to a gastroenterologist is warranted for consideration of endoscopic retrograde cholangiopancreatography (ERCP) to evaluate for retained stones or sphincter dysfunction, as suggested by the guidelines 1.
• The guidelines also recommend abdominal triphasic CT as the first-line diagnostic imaging investigation to detect intra-abdominal fluid collections and ductal dilation, which may be complemented with the addition of CE-MRCP to obtain the exact visualization, localization, and classification of BDI 1.
• The management strategy should prioritize a multidisciplinary approach, focusing on the patient's quality of life and minimizing the risk of complications, as the guidelines suggest that BDIs have a detrimental impact on health-related quality of life 1.

From the Research

Causes of Continued Abdominal Pain

• The patient's continued abdominal pain after cholecystectomy may be due to various factors, including functional postcholecystectomy syndrome, bile microlithiasis, or other gastrointestinal issues 2, 3, 4.
• Studies have shown that female gender, preoperative upper abdominal pain occurring >24h before admission, and each episode of upper abdominal pain >30min are independently associated with persistent postoperative upper abdominal pain 2.
• The presence of bile microlithiasis in the bile of patients who have undergone cholecystectomy may also be a cause of postcholecystectomy pain, and treatment with ursodeoxycholic acid (urso) may be effective in relieving such pain 4.

Treatment Recommendations

• Basic analgesic techniques, such as paracetamol + NSAID or cyclooxygenase-2 specific inhibitor + surgical site local anaesthetic infiltration, are recommended for managing pain after laparoscopic cholecystectomy 5.
• Opioid should be reserved for rescue analgesia only, and gabapentanoids, intraperitoneal local anaesthetic, and transversus abdominis plane blocks are not recommended unless basic analgesia is not possible 5.
• Choleretic medications, such as ursodeoxycholic acid, may be effective in relieving postoperative upper abdominal pain, especially in patients with bile microlithiasis 2, 4.
• Surgical techniques, such as low-pressure pneumoperitoneum, postprocedure saline lavage, and aspiration of pneumoperitoneum, may also help reduce pain after laparoscopic cholecystectomy 5.

Ultrasound Findings

• The ultrasound findings of physiologic prominence of the bile ducts postcholecystectomy should be correlated clinically to determine the cause of the patient's continued abdominal pain 2, 3, 4.
• Further evaluation, such as a microscopic examination of bile for crystals or microlithiasis, may be necessary to determine the underlying cause of the patient's pain 4.