Recurrent abdominal pain after laparoscopic cholecystectomy

Cleveland Clinic Journal of Medicine. 2011 March;78(3):171-178 | 10.3949/ccjm.77a.09171

March 1, 2011|Cleveland Clinic Journal of Medicine

Carole Macaron, MD;Mohammed A. Qadeer, MD, MPH;John J. Vargo, MD, MPH

The patient undergoes ERCP with stone removal

Review of the operative report and discussion with the surgeon confirm that the laparoscopic procedure was uneventful and that intraoperative cholangiography was not done.

Therefore, the patient undergoes ERCP. The major papilla is normal. Cholangiography reveals nondilated common bile and intrahepatic ducts, with faint filling defects in the mid to distal common bile duct. Endoscopic sphincterotomy is performed, and three small stones are extracted from the common bile duct. Repeat balloon-occlusion cholangiography is normal.

The patient tolerates the procedure well and resumes a normal diet and normal activities.

Her pain persists, prompting an emergency room visit

Five days after her ERCP procedure, however, the same burning epigastric pain returns. As before, the pain occurs after eating and does not occur with fasting. At this time, she has no fever or chills.

The patient continues to have recurrent episodes of pain, on one occasion so severe she visits the emergency department. During this visit she reports she has no symptoms other than pain, and the examination is normal. Laboratory tests (Table 2) show that her liver function measures have normalized.

WHAT IS CAUSING HER PAIN?

3. Which is the most likely cause of her persistent pain?

Acute pancreatitis after ERCP
Peptic ulcer disease
Sphincter of Oddi dysfunction
Biliary stones

The most likely cause is persistent biliary stones. The common bile duct was recently explored and stones were removed, but she may still have stones in the intrahepatic ducts or in the cystic duct remnant, both of which were unopacified during the ERCP procedure, indicating that either the test was incomplete or a stone is obstructing the passage of contrast. Her persistent symptoms warrant repeating her liver function tests.

Acute pancreatitis is the most common and feared complication of ERCP, and it should be suspected in any patient who develops abdominal pain within 6 hours of the procedure. It is much less likely to develop after 12 hours, however. Risk factors for post-ERCP pancreatitis include patient factors (young age, female sex, history of recurrent pancreatitis), procedural factors (difficult cannulation, minor papilla sphincterotomy), and, less likely, operator-related factors.^10–13 In general, the more likely a patient is to have an abnormal and irregular common bile duct or pancreatic duct, the lower the risk of post-ERCP pancreatitis. The importance of operator-dependent factors is not yet clear.^10–13

Despite the postprandial pattern of our patient’s pain and her history of gastric ulcer, peptic ulcer disease is unlikely in view of a normal esophagogastroduodenoscopic examination done 4 months earlier, and since she has no recent exposure to NSAIDs.

Sphincter of Oddi dysfunction may explain her symptoms, but she recently underwent endoscopic sphincterotomy, which is regarded as the most definitive treatment.¹⁴

WHAT SHOULD BE DONE NEXT?

4. What would be the best next step in her management?

Repeat ERCP
MRCP
Endoscopic ultrasonography
Observation and reassurance

MRCP is the most appropriate next step, given her recurrent symptoms. Repeat ERCP is not appropriate, since there is no evidence of cholangitis, and since her liver function tests had completely normalized.

A recent systematic review of endoscopic ultrasonography and MRCP for diagnosing choledocholithiasis found both tests to be highly accurate, with no statistically significant differences in sensitivity or specificity between the two.¹⁵ However, MRCP has the advantage of being noninvasive and of being able to show intrahepatic stones.

Park et al,¹⁶ in a prospective study of 66 patients with primary intrahepatic stones, concluded that MRCP findings were comparable to those of percutaneous transhepatic cholangioscopy, the reference standard for locating intrahepatic stones. The sensitivity, specificity, and accuracy of MRCP for detecting and locating intrahepatic stones were high (97%, 99%, and 98%, respectively).¹⁶ However, after sphincterotomy, pneumobilia may create an appearance that can be mistaken for intraductal stones.

Figure 1. Magnetic resonance cholangiopancreatography shows a normal biliary tree (arrow) and pancreatic duct. The cystic duct cannot be seen.

Merely reassuring the patient is not appropriate at this point, given her level of pain.

She undergoes MRCP

Figure 2. Ultrasonography of the right upper quadrant shows a nondilated common bile duct 4 mm in diameter (arrow). No stones are visible.

MRCP shows a normal biliary tree without stones (Figure 1). Similarly, ultrasonography of the right upper quadrant shows no stones and a nondilated common bile duct (Figure 2).

The patient continues to have pain, and she has lost 5 pounds because she is still avoiding eating. At this point, she is beginning to wonder if her symptoms are psychogenic, since all the test results have been normal.

ERCP, MRCP, ULTRASONOGRAPHY?

5. What would be the best next step?

Reassurance
Referral to a psychiatrist
Referral to a pain management clinic
Endoscopic ultrasonography
Repeat ERCP

Endoscopic ultrasonography is needed to look for cystic duct stones. Although several tests have shown normal results, the patient’s pain continues as in the previous episodes, making stone disease the most likely cause.

Although no stones were seen on MRCP and ultrasonography, a detailed evaluation for stones in a cystic duct or retained gallbladder remnant was not done satisfactorily.

Reassurance and referral to a psychiatrist or pain management clinic are not appropriate, since an organic cause of her pain has not been completely ruled out.

Figure 3. Endoscopic ultrasonography from the duodenal bulb shows a 7-mm stone (arrow) in the cystic duct remnant or gallbladder remnant.

ERCP should not be used as a diagnostic test in a situation such as this.

Findings on endoscopic ultrasonography

Endoscopic ultrasonography is performed and reveals a large (7-mm) stone in the area of the cystic duct remnant or gallbladder remnant (Figure 3). The common bile duct is normal.

References

Download Article