Furqaan Ahmed

Should patients with biliary-type pain after cholecystectomy be evaluated for microlithiasis?

Approximately 400,000 cholecystectomies are performed annually in the United States, but they do not lead to symptom resolution in all patients. Womack and Crider first described the postcholecystectomy syndrome, defined as the presence of biliary symptoms after cholecystectomy, which has been reported to occur in 24% to 28% of patients. The frequency of postcholecystectomy pain varies according to the likelihood of a biliary source for the pain before surgery. The incidence of persistent abdominal pain after cholecystectomy in patients with documented gallstones before surgery is 13% to 18%; in contrast, in patients without documented gallstones, the persistence of symptoms after surgery has been reported to occur in as many as 48%. Pain after cholecystectomy may be heterogeneous in nature and often stems from a nonpancreatobiliary group of disorders, such as gastroesophageal reflux disease, peptic ulceration, non-ulcer dyspepsia, and irritable bowel syndrome. Intestinal dysmotility and visceral hyperalgesia have also been described as the cause of symptoms in some patients. When evaluating patients with postcholecystectomy symptoms, other pancreatobiliary causes still need to be considered, including retained common bile duct (CBD) stones, chronic pancreatitis, and surgical postcholecystectomy complications. Sphincter of Oddi dysfunction (SOD) is a well-established cause of biliary-type pain that often presents after cholecystectomy. In two studies involving large numbers of patients with postcholecystectomy pain, the frequency of SOD was 9% to 11%. The likelihood of SOD varies according to the degree of evidence of underlying pancreatobiliary disease, including abnormal liver chemistry results, elevated pancreatic enzyme levels, and pancreatic or bile duct dilation on imaging. In a study published from our center, 115 patients with pancreatobiliary pain were evaluated for SOD by sphincter of Oddi manometry (SOM) and classified according to the Hogan-Geenen SOD system. The frequency of abnormal manometry was 86%, 55%, and 28% for patients classified as biliary type I, II, and III, respectively.

Reply to Reiss G, Ramrakhiani S. Right upper-quadrant pain and a normal abdominal ultrasound. Clin Gastroenterol Hepatol 2009;7:603.

ional Polyp Study (NPS)2 for the adenoma-bearing subgroup. owever, the small sample size of the adenoma subgroup (n 90, compared with 1418 in the NPS), and the rarity of incident ancers in the subgroup with no baseline adenomas (1 cancer) bviously precluded a robust analysis. The NPS shows how fficacious polypectomy can be, as opposed to how effective it is n the real world in which clearing exams may not be as astidiously performed, or follow-up not as intense or as comlete. Additionally, 13% of patients in the NPS underwent a econd clearing colonoscopy, which is not done in usual pracice, and patients with adenomas 3 cm were excluded. These onsiderations highlight major methodological differences beween the NPS and subsequent studies, including our own.