What are the common causes of pain in a person without a gallbladder?

Common Causes of Pain in Persons Without a Gallbladder

The most common causes of pain in patients without a gallbladder include sphincter of Oddi dysfunction, retained or recurrent bile duct stones, post-cholecystectomy syndrome, and functional gastrointestinal disorders that mimic biliary pain.

Sphincter of Oddi Dysfunction (SOD)

Sphincter of Oddi dysfunction is a significant cause of persistent biliary-type pain after cholecystectomy 1:

• Typically presents 4-5 years after cholecystectomy
• Characterized by episodic right upper quadrant and/or epigastric pain similar to pre-cholecystectomy biliary pain
• Pain episodes typically:
  • Last at least 30 minutes
  • Build to a steady level
  • Are severe enough to interrupt activities
  • May be associated with nausea and vomiting
  • May radiate to the back or right infrascapular area
  • Can awaken patients from sleep 2

Diagnostic Approach

1. Rule out structural causes with liver function tests and pancreatic enzymes
2. Consider non-invasive testing with choledochoscintigraphy
3. Definitive diagnosis requires sphincter of Oddi manometry 1

Retained or Recurrent Bile Duct Stones

Without the gallbladder serving as a pressure reservoir, bile duct stones can cause significant symptoms 3:

• Presents with sudden onset of severe epigastric or right upper quadrant pain
• May be associated with jaundice, fever, or elevated liver enzymes
• Diagnostic approach:
  • Liver function tests
  • MRCP or ERCP for visualization of the biliary tree 4

Post-Cholecystectomy Syndrome

This represents a constellation of persistent symptoms after gallbladder removal:

• May include dyspeptic symptoms (indigestion, belching, bloating)
• Abdominal discomfort and food intolerance
• Often unrelated to the original gallstone disease and may persist after surgery 5
• Risk factors include:
  • Prolonged history of dyspeptic symptoms before surgery
  • Evidence of psychological distress 5

Functional Gastrointestinal Disorders

Several functional disorders can mimic biliary pain in patients without a gallbladder:

• Irritable bowel syndrome
• Functional dyspepsia
• Visceral hypersensitivity (particularly duodenal hyperalgesia) 3

Diagnostic Considerations

When evaluating a patient with post-cholecystectomy pain:

1. Imaging studies:

   • Ultrasound remains first-line for right upper quadrant pain evaluation 2
   • CT with IV contrast if complications are suspected 2
   • MRCP provides superior visualization of the biliary tree 2

2. Functional testing:

   • Cholescintigraphy for evaluation of bile flow and partial biliary obstruction 2
   • Sphincter of Oddi manometry for suspected sphincter dysfunction 1

Treatment Approaches

Treatment should target the specific cause:

1. For sphincter of Oddi dysfunction:

   • Endoscopic sphincterotomy provides long-term relief in >80% of patients with manometrically confirmed stenosis 1

2. For retained/recurrent bile duct stones:

   • ERCP with stone extraction
   • Consider ursodeoxycholic acid for small stones 4

3. For functional disorders:

   • Targeted symptomatic management
   • Consider visceral pain modulators for suspected visceral hypersensitivity 3

Important Caveats

• Biliary-type pain should be distinguished from non-specific dyspeptic symptoms, which often persist after cholecystectomy 5
• The absence of the gallbladder as a pressure reservoir makes the sphincter of Oddi the prime determinant of bile duct pressure 3
• Careful patient selection for invasive procedures is essential, as complications like post-ERCP pancreatitis can occur