What are the next steps for a patient with diffuse abdominal pain 2 weeks after gallbladder surgery?

Diffuse Abdominal Pain Two Weeks Post-Cholecystectomy

This patient requires immediate diagnostic workup with abdominal CT scan and liver function tests to rule out bile duct injury (BDI), which is a serious complication that can present with diffuse abdominal pain in the postoperative period and requires urgent intervention to prevent significant morbidity and mortality. 1

Immediate Diagnostic Workup

Clinical Assessment

• Promptly investigate any patient who does not rapidly recover after cholecystectomy, with alarm symptoms including fever, abdominal pain, distention, jaundice, nausea, and vomiting 1
• Check vital signs for tachycardia (≥110 bpm), fever (≥38°C), hypotension, or respiratory distress, as these are alarming clinical signs requiring urgent evaluation 1
• Persistent tachycardia alone (even without fever) in the setting of acute abdominal pain warrants immediate laboratory and imaging assessment 1

Laboratory Tests

• Obtain liver function tests immediately, including direct and indirect bilirubin, AST, ALT, alkaline phosphatase (ALP), GGT, and albumin 1
• In critically ill patients, add CRP, procalcitonin, and lactate to evaluate severity of inflammation and sepsis 1

Imaging Protocol

• Abdominal triphasic CT with IV contrast is the first-line imaging investigation to detect intra-abdominal fluid collections and ductal dilation 1
• Add contrast-enhanced MRCP (CE-MRCP) to obtain exact visualization, localization, and classification of any bile duct injury, which is essential for planning tailored treatment 1
• Ultrasound can be used as an adjunct but CT is preferred for comprehensive evaluation 1

Management Based on Findings

If Bile Duct Injury is Identified

Minor BDI (Strasberg A-D):

• If a drain was placed during surgery and bile leak is noted, observation with nonoperative management is an option initially 1
• If no drain was placed, percutaneous treatment with drain placement is useful 1
• If no improvement or worsening occurs after percutaneous drainage, endoscopic management with ERCP (biliary sphincterotomy and stent placement) becomes mandatory 1

Major BDI (Strasberg E1-E2) at 2 weeks post-op:

• At this timeframe (between 72 hours and 3 weeks), recommend percutaneous drainage of fluid collections, targeted antibiotics, and nutritional support 1
• ERCP with sphincterotomy (with or without stent) should be considered to reduce pressure gradient in the biliary tree 1
• PTBD may be useful for septic patients with complete common bile duct obstruction 1
• Refer to a center with expertise in hepatopancreatobiliary (HPB) procedures if local expertise is unavailable 1
• After minimum 3 weeks, once acute situation resolves, Roux-en-Y hepaticojejunostomy should be performed 1

If diffuse biliary peritonitis is present:

• Urgent abdominal cavity lavage and drainage are required as first step to achieve infection source control 1

Antibiotic Therapy for Suspected/Confirmed BDI

• Start broad-spectrum antibiotics immediately (within 1 hour) if biliary fistula, biloma, or bile peritonitis is suspected 1
• For critically ill or immunocompromised patients: Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g continuous infusion 1
• For septic shock: Meropenem 1g q6h by extended infusion, or Doripenem 500mg q8h by extended infusion, or Imipenem/cilastatin 500mg q6h by extended infusion 1
• Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 1, 2

If No BDI is Found

Consider other causes of persistent pain:

• Intercostal nerve injury from trocar placement can cause chest wall or abdominal pain persisting after laparoscopic cholecystectomy 3
• Diagnostic intercostal nerve blocks can confirm this diagnosis, with nerve resection and muscle implantation providing good to excellent results in most patients 3
• Functional postcholecystectomy syndrome may occur, particularly in younger women with longer duration and more frequent preoperative pain 4, 5
• Choleretic medications may be effective for relieving postoperative upper abdominal pain of unclear etiology 5

Critical Pitfalls to Avoid

• Do not dismiss diffuse abdominal pain at 2 weeks post-op as normal postoperative discomfort – BDI can present in a delayed fashion and has significant mortality (8.8% increased mortality compared to age-adjusted rates) 1
• Do not delay imaging – early detection and appropriate management of BDI is critical to prevent progression to sepsis and biliary peritonitis 1
• Be aware that patients on beta-blockers may not manifest tachycardia despite serious complications 1
• Do not attempt immediate surgical repair of major BDI at 2 weeks – this timeframe requires stabilization with drainage, antibiotics, and nutritional support before definitive repair at minimum 3 weeks 1