Download - Post cholecystectomy syndrome
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POST CHOLECYSTECTOMY SYNDROME
Nuwan GunapalaRegistrar wd40B/ 21
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OBJECTIVES
Definition Epidemiology Aetiology Pathophysiology Clinical features Investigations Management
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OUR EXPERIENCE……
Mrs Dhanuka perera Later found to have duodenal carcinoma
Mrs Nei Sherine Expired from caecal carcinoma
Mr H A Jyasena Has undergone emergency subtotal
cholecystectomy later found to have retained stones and underwent choledocho-jejunostomy and currently recovering from surgery.
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WHAT IS IT ?
First describe in 1947
It is persistence of symptoms following
cholecystectomy
continuation of symptoms which was thought
to be caused by gall bladder
development of new symptoms usually
attributed to gall bladder
symptoms due to absence of gall bladder
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EPIDEMIOLOGY
15% of patients develop the symptoms Incidence is high in patients who didn’t
have gallstones Also high in emergency surgery patients Pre-operative secure diagnosis reduce
incidence Functional disorders are the most common
causes Prior surgery, bile spillage or stone spillage
doesn’t increase the incidence More common in females
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PATHOPHYSIOLOGY Due to increase bile flow in to upper GI
tract bile reflux gastritis and esophagitis
Due to bile in the lower GI tract diarrhoea and lower abdominal pain
Other symptoms could be resulting from structures in biliary tree or extra biliary structures
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AETIOLOGY
Hepato-biliary system Cystic duct and gall bladder remnant
Residual or reformed gall bladder Stump cholelithasis Neuroma
Liver Fatty liver, sclerosing cholangitis, cirrhosis
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Biliary tract Cholangitis Adhesions Strictures Cyst Choledocholithiasis Fistula
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Periampullary Sphincter oddi dyskinesia, spasm,
hypertrophy Stricture Papilloma
Pancreas Pancreatitis Pancreatic stones Pancreatic cancer
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EXTRA BILIARY
Oesophagus Hiatal hernia Achalasia
Stomach Bile gastritis PUD Cancer
Duodenum Adhesions Diverticulum
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OTHER PATHOLOGIES
Colon Vascular
Angina Small bowel
A cause can be identified in 95% of patients
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CLINICAL FEATURES
Colic Pain Fever Jaundice Diarrhoea, Bloating Nausea
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INVESTIGATIONS
Aim is to exclude complication of cholecystectomy and identify other causes
Serology FBC LFT Amylase
Imaging chest x ray, abdominal x ray, barium swallow and follow through USS, MRCP
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Invasive procedures UGIE ERCP
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MANAGEMENT
If cause is identifiable manage specifically Patients with IBS – bulking agents, anti
spasmodics sedatives Antacids and H2 receptor blockers
Surgery for operable diseases If no obvious cause is identifiable
ERCP Open surgery
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OPEN SURGERY
Ex lap Look for another cause Intra op cholangiogram Dissect neuroma and scar tissue around
cystic duct If pancreatic head is normal can do
sphincteroplasty If pancreatic head has chronic pancreatitis
proceed with choledocho duodenostomy
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SPHINCTER OF ODDI DYSFUNCTION
Complex muscular structure Surrounds distal CBD, pancreatic duct, ampulla
of Vater Caused by structural or functional
abnormalities Fibrosis of sphincter from gallstone migration,
operative or endoscopic trauma, pancreatitis or nonspecific inflammatory processes
Sphincter dyskinesia or spasm ~1% of patient undergoing cholecystectomy
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Labs: ↑ amylase, LFT ERCP: delayed emptying of contrast
medium from CBD ↑ basal sphincter pressure >40mmHg US: dilated CBD
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MANAGEMENT
High-dose Ca channel blockers or nitrates, but evidence not convincing
Sphincterotomy (endoscopic or transduodenal)
Mucosa-mucosa apposition in surgical approach can minimize scarring and restenosis
60-80% successful if have documented objective evidence
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THANK YOU……………….