What are the recommended treatment and labs for a patient with right-sided pain for over a week and a history of cholecystectomy (gallbladder removal)?

Right-Sided Pain After Cholecystectomy: Diagnostic and Treatment Approach

For a patient with right-sided pain persisting over a week after cholecystectomy, immediately obtain liver function tests (bilirubin, AST, ALT, alkaline phosphatase, GGT, albumin) and perform abdominal ultrasound as the first-line imaging to evaluate for retained bile duct stones, bile duct injury, bile leak, or fluid collections. 1

Initial Laboratory Evaluation

Obtain comprehensive hepatobiliary labs immediately:

• Direct and indirect bilirubin, AST, ALT, alkaline phosphatase, GGT, and albumin are essential to detect bile duct injury or retained stones 1
• If the patient appears systemically ill with fever or signs of sepsis, add CRP, procalcitonin, and lactate to assess severity 1
• Note that aminotransferases may remain normal initially even with early bile duct injury, as cholestasis markers elevate before significant hepatic damage occurs 1

Imaging Strategy

Start with abdominal ultrasound with Doppler:

• Ultrasound is the first-line imaging test for post-cholecystectomy right-sided pain, evaluating for bile duct dilation, retained stones, fluid collections, and vascular complications 2, 1
• Ultrasound has 81% sensitivity and 83% specificity for biliary pathology and can identify alternative causes of pain 2

If ultrasound is equivocal or negative but clinical suspicion remains high:

• MRCP with contrast provides superior visualization of bile duct anatomy, retained stones (especially in the gallbladder neck, cystic duct, or common bile duct), and exact localization of bile duct injury 1
• CT abdomen with IV contrast can detect fluid collections, bilomas, and complications like abscess formation, though it has only 75% sensitivity for detecting stones 2, 1

Common Post-Cholecystectomy Causes of Right-Sided Pain

Biliary causes (22-27% of post-cholecystectomy patients):

• Retained bile duct stones (choledocholithiasis): Presents with biliary colic, jaundice, and elevated liver enzymes 1
• Bile duct injury or stricture: Manifests with cholestatic jaundice, dark urine, pale stools, pruritus, and recurrent cholangitis 1
• Bile leak: Causes persistent abdominal pain, distension, fever, and potential biloma formation 1, 3
• Residual gallbladder with stones: Rare complication of subtotal cholecystectomy presenting with recurrent pain 4
• Spilled gallstones: Can cause delayed abscesses (median onset 36 months), particularly if >15 stones spilled, stones >1.5 cm, or pigment stones 1

Non-biliary causes to consider:

• Intercostal nerve injury at trocar sites: Presents with chest wall or abdominal wall tenderness at portal sites, confirmed by relief with intercostal nerve block 5
• Sphincter of Oddi dysfunction: Consider when structural causes are excluded 1

Critical Pitfalls to Avoid

Do not attribute these symptoms to gallbladder disease:

• Belching, bloating, fatty food intolerance, and chronic diffuse pain are NOT attributable to gallstone disease and likely represent functional disorders that will not improve with further biliary intervention 1
• Mild postoperative hepatocellular enzyme elevations from CO2 pneumoperitoneum have no pathological significance 1

Treatment Based on Etiology

For retained bile duct stones:

• Endoscopic sphincterotomy with stone extraction is the treatment of choice 1

For bile duct injury:

• Requires tailored surgical repair based on exact classification from MRCP imaging 1
• Untreated bile duct injury can progress to secondary biliary cirrhosis, portal hypertension, and liver failure 1

For bile leak with biloma:

• May require percutaneous drainage combined with endoscopic biliary stenting 3

For spilled gallstones with abscess:

• 87% require surgical intervention for abscess drainage or stone removal; 12% can be managed with image-guided drainage 1

For intercostal neuroma:

• Diagnostic nerve blocks confirm diagnosis; nerve resection with muscle implantation provides good to excellent results in 88% of patients 5

When to Escalate Workup

Alarm symptoms requiring urgent investigation:

• Fever, jaundice, abdominal distension, nausea, and vomiting indicate potential bile duct injury, retained stones, or bile leak requiring immediate imaging and possible intervention 1
• Patients failing to recover normally after cholecystectomy warrant prompt triphasic CT scan followed by MRCP if biliary pathology is suspected 1