From the Guidelines
Right upper quadrant (RUQ) pain after cholecystectomy should be promptly evaluated with diagnostic imaging, such as CT with IV contrast, to identify potential complications like biloma, intraabdominal abscess, bile duct injury, or acute cholangitis, as recommended by the 2024 clinical practice guideline update by the Infectious Diseases Society of America 1. The causes of RUQ pain after gallbladder removal can be diverse, including post-cholecystectomy syndrome, biliary strictures, retained bile duct stones, sphincter of Oddi dysfunction, and surgical complications.
- Common causes:
- Post-cholecystectomy syndrome
- Biliary strictures
- Retained bile duct stones
- Sphincter of Oddi dysfunction
- Surgical complications like bile leaks or injuries Management approaches vary depending on the underlying cause, but typically involve a combination of diagnostic tests, including liver function tests, abdominal ultrasound, MRCP, or ERCP, to guide treatment decisions.
- Diagnostic workup:
- Liver function tests
- Abdominal ultrasound
- MRCP
- ERCP For suspected acute cholangitis, diagnosis should include clinical signs, laboratory findings, and imaging findings, as outlined in the 2024 clinical practice guideline update 1.
- Diagnostic criteria for acute cholangitis:
- Clinical signs (jaundice, fever, chills, and RUQ abdominal pain)
- Laboratory findings (indicators of inflammation and biliary stasis)
- Imaging findings (biliary dilatation or evidence of an etiology) CT with IV contrast is the preferred subsequent imaging modality when complications of acute cholecystitis or acute cholangitis are suspected, as it provides detailed information on the biliary system and surrounding structures 1.
From the Research
Causes of Right Upper Quadrant (RUQ) Pain after Cholecystectomy
- Acute cholecystitis is the most common cause of acute pain in the right upper quadrant (RUQ) 2
- Biliary hyperkinesia, characterized by abnormally elevated gallbladder ejection fraction (GBEF), is a rare but possible cause of RUQ pain after cholecystectomy 3
- Symptomatic cholelithiasis of a remnant gallbladder after open cholecystectomy is an exceedingly rare etiology of RUQ pain 4
- Other causes of RUQ pain include conditions of hepatic, pancreatic, adrenal, renal, gastrointestinal, vascular, and thoracic origin 5
Management Options for RUQ Pain after Cholecystectomy
- Ultrasonography (US) is the primary imaging modality for assessment of acute RUQ pain, and can help identify various disease processes, including gallstones, biliary dilatation, and features of acute inflammatory disease 2
- Computed tomography, magnetic resonance (MR) imaging, MR cholangiopancreatography, or cholescintigraphy may be considered in certain cases, depending on the clinical situation and US findings 2, 5
- Laparoscopic cholecystectomy has been shown to provide significant symptomatic relief in patients with biliary hyperkinesia 3
- Surgical treatment should be considered as a viable option for symptom relief, particularly in cases where pain causes significant distress and impairs quality of life 3, 4
Persistence of Pain after Cholecystectomy
- Pain may persist in some patients after removal of the gallbladder, with 22% of patients experiencing postoperative pain 5 years after the operation 6
- The majority of patients with postoperative pain have nonspecific, diffuse pain, which is more common in younger women who had noncomplicated gallstone disease 6