What causes gallbladder attack-like symptoms in someone who has had their gallbladder (cholecystectomy) removed?

Post-Cholecystectomy Biliary-Type Pain

Gallbladder attack-like symptoms after cholecystectomy occur in 22-27% of patients and most commonly result from retained bile duct stones, bile duct injury/stricture, sphincter of Oddi dysfunction, or spilled gallstones—requiring ultrasound as first-line imaging followed by MRCP or ERCP based on findings. 1

Primary Causes to Consider

Biliary Causes (Most Common)

• Choledocholithiasis (retained bile duct stones) is the most frequent culprit, presenting with classic biliary colic, potential jaundice, and elevated liver enzymes (particularly alkaline phosphatase and bilirubin). 1

• Bile duct injury or stricture can manifest months to years after surgery with cholestatic jaundice, dark urine, pale stools, itching, and recurrent episodes of cholangitis. 1 If untreated, this can progress to secondary biliary cirrhosis and liver failure. 1

• Spilled gallstones from the original surgery can cause delayed complications, with median symptom onset at 36 months (range 1-180 months). 2 These typically present as intra-abdominal abscesses (36.5%), abdominal wall abscesses (10.6%), or retroperitoneal abscesses (9.4%). 2 Risk factors include more than 15 spilled stones, stones larger than 1.5 cm, pigment stones, and perihepatic location. 2

• Bile leakage presents with persistent abdominal pain, distension, fever, and potential biloma formation. 1

• Sphincter of Oddi dysfunction should be considered when other structural causes are excluded, though this requires specialized testing. 2

Non-Biliary Causes

• Bile acid malabsorption occurs after cholecystectomy due to altered bile flow and increased enterohepatic cycling, typically causing diarrhea but can present with cramping pain. 1

• Functional disorders (bloating, belching, fatty food intolerance, chronic diffuse pain) are NOT attributable to gallstone disease and likely represent pre-existing functional GI disorders that persist after surgery. 1

Diagnostic Workup Algorithm

Initial Laboratory Testing

• Obtain comprehensive liver panel including AST, ALT, alkaline phosphatase, GGT, total and direct bilirubin, and albumin. 1, 3

• Calculate the R value: (ALT/ALT upper limit)/(ALP/ALP upper limit) to determine injury pattern: R ≥5 indicates hepatocellular injury, R ≤2 indicates cholestatic injury (suggesting bile duct obstruction). 3

• Add CRP, procalcitonin if infection/cholangitis is suspected. 1

Imaging Strategy

• First-line: Abdominal ultrasound with Doppler to evaluate for bile duct dilation, retained stones, fluid collections, and vascular complications. 2, 1, 3 This is the appropriate initial imaging for suspected biliary disease. 2

• Second-line: MRCP with contrast if ultrasound shows ductal dilation or is equivocal, providing exact visualization and localization of bile duct injury or retained stones. 1, 3 MRCP is superior to ultrasound for detecting stones in the gallbladder neck, cystic duct, or common bile duct. 2

• Triphasic CT abdomen if ultrasound is inadequate or to better characterize fluid collections/abscesses from spilled stones. 1, 3

• Hepatobiliary scintigraphy (HIDA scan) has 97% sensitivity and 90% specificity for detecting biliary tract abnormalities when ultrasound is equivocal. 1

• ERCP is both diagnostic and therapeutic when choledocholithiasis is confirmed or highly suspected. 4

Management Based on Etiology

For Retained Bile Duct Stones

• Endoscopic sphincterotomy with stone extraction is the treatment of choice. 2, 4

• Patients with recurrent stones have higher risk if they have cirrhosis, juxta-papillary diverticulum, CBD diameter ≥1.5 cm, or underwent endoscopic sphincterotomy alone. 4

For Bile Duct Injury/Stricture

• Requires urgent hepatology and surgical consultation once identified. 1

• MRCP with contrast is essential for planning tailored treatment based on injury classification. 1

For Spilled Gallstones with Abscess Formation

• 87% of symptomatic cases require surgical intervention for abscess drainage or stone removal. 2

• 12% can be managed with ultrasound or CT-guided drainage. 2

For Bile Leakage

• Small leaks may resolve with conservative management and drainage. 5, 6

• Persistent leaks require ERCP with sphincterotomy ± stent placement or surgical intervention. 7

Critical Red Flags Requiring Urgent Action

• Fever, jaundice, and right upper quadrant pain (Charcot's triad) suggests cholangitis requiring urgent ERCP. 1

• Bilirubin ≥2× upper limit with ALT ≥3× upper limit indicates severe hepatocellular injury requiring immediate hepatology consultation. 3

• Progressive jaundice with pale stools and dark urine suggests complete or high-grade bile duct obstruction. 1

Common Pitfalls to Avoid

• Do not dismiss symptoms as "functional" without completing structural evaluation—22-27% of post-cholecystectomy patients have legitimate biliary pathology. 1

• Do not assume mild LFT elevations are insignificant—cholestasis markers may be elevated before significant hepatic damage occurs, while aminotransferases remain normal initially. 1

• Do not forget about delayed complications from spilled stones—symptoms can appear years after surgery (median 36 months, up to 15 years). 2

• Do not order HIDA scan before ultrasound—ultrasound is always the appropriate first imaging test. 2