What is the pathophysiology of postcholecystectomy syndrome (PCS)?

Updated: Nov 28, 2018
  • Author: Steen W Jensen, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF  more...
  • Print
Answer

Bile is thought to be the cause of PCS in patients with mild gastroduodenal symptoms or diarrhea. [3] Removal of the reservoir function of the gallbladder alters bile flow and the enterohepatic circulation of bile. The pathophysiology of PCS is related to alterations in bile flow and is not yet fully understood.

Early articles on PCS focused primarily on anatomic abnormalities that were grossly or microscopically identifiable at the time of exploratory surgery. Improvements in technology and imaging studies have yielded an improved understanding of biliary tract disorders. This has affected the preoperative workup of patients with suspected gallbladder disease as well as those with PCS, making functional disorders of the biliary tract (including irritable sphincter) the most common causes of PCS (see Table 1 below).

Table 1. Etiologies of Postcholecystectomy Syndrome by Anatomic Location (Open Table in a new window)

Anatomy

Etiology

Gallbladder remnant and cystic duct

Residual or reformed gallbladder

Stump cholelithiasis

Neuroma

Liver

Fatty infiltration of liver

Hepatitis

Hydrohepatosis

Cirrhosis

Chronic idiopathic jaundice

Gilbert disease

Dubin-Johnson syndrome

Hepatolithiasis

Sclerosing cholangitis

Cyst

Biliary tract

Cholangitis

Adhesions

Strictures

Trauma

Cyst

Malignancy and cholangiocarcinoma

Obstruction

Choledocholithiasis

Dilation without obstruction

Hypertension or nonspecific dilation

Dyskinesia

Fistula

Periampullary

Sphincter of Oddi dyskinesia, spasm, or hypertrophy

Sphincter of Oddi stricture

Papilloma

Cancer

Pancreas

Pancreatitis

Pancreatic stone

Pancreatic cancer

Pancreatic cysts

Benign tumors

Esophagus

Aerophagia

Diaphragmatic hernia

Hiatal hernia

Achalasia

Stomach

Bile gastritis

Peptic ulcer disease

Gastric cancer

Duodenum

Adhesions

Duodenal diverticula

Irritable bowel disease

Small bowel

Adhesions

Incisional hernia

Irritable bowel disease

Colon [4]

Constipation

Diarrhea

Incisional hernia

Irritable bowel disease

Vascular

Intestinal angina

Coronary angina

Nerve

Neuroma

Intercostal neuralgia

Spinal nerve lesions

Sympathetic imbalance

Neurosis

Psychic tension or anxiety

Bone

Arthritis

Other

Adrenal cancer

Thyrotoxicosis

20% organ other than hepatobiliary or pancreatic

Foreign bodies, including gallstones and surgical clips

Abu Farsakh et al found gastritis to be more frequent postoperatively (30% vs 50%). [5] Preoperatively, no cases of peptic ulcer disease (PUD) occurred, but three cases developed postoperatively. It was also shown that fasting gastric bile acid concentration increased after cholecystectomy, and the increase was greater in patients with PCS.

At exploratory surgery, 8% of patients remain without a diagnosis.


Did this answer your question?
Additional feedback? (Optional)
Thank you for your feedback!