Post cholecystectomy syndrome

Introduction to post-cholecystectomy syndrome Postcholecystectomy syndrome (PCS) is a general term for abdominal pain and dyspepsia in patients with a history of cholecystectomy. In patients with cholecystectomy, 20% to 40% of the original symptoms persist after surgery, or relapse or new symptoms after 2 to 3 months. In fact, it is not a true syndrome. There are many reasons for these symptoms. The clinical manifestations are different, including many biliary and non-biliary diseases. Many of these diseases are not related to cholecystectomy itself. This kind of "unknown pain" is used in internal medicine. The treatment is not effective. basic knowledge The proportion of illness: 0.0035% Susceptible people: no specific population Mode of infection: non-infectious Complications: jaundice

Causes of postoperative cholecystectomy syndrome

(1) Causes of the disease

Some people have divided PCS into two categories. The first category is the biliary and pancreatic diseases with clear diagnosis of the current diagnosis. The second category is the real PCS, which is not yet clear, and the cause of postoperative cholecystectomy syndrome:

1. Preoperative symptoms continue to exist

(1) Diagnostic error or incompleteness: The standard of gallbladder abnormality is incorrect, gassing, irritating colon, esophageal hiatus hernia, duodenal ulcer, coronary artery disease, intercostal neuritis.

(2) recurrent gallstones.

(3) intrahepatic stones.

(4) Lesions of adjacent organs: pancreatitis, Oddi sphincter stenosis, stenotic choledochitis or cholangitis, liver disease (cirrhosis), and tumors are neglected.

2. Symptoms caused by cholecystectomy itself

(1) Failure of surgical operation: Legions of the liver or extrahepatic bile ducts were left behind, and the tumor was ignored.

(2) surgical operation error: injury bile duct, immediate: bleeding, biliary peritonitis, abscess, fistula; late: stenosis, residual cystic duct.

(3) postoperative adhesions.

(4) Physiological disorders: removal of functional gallbladder, Oddi sphincter dyskinesia.

3. Other spiritual factors, etc.

(two) pathogenesis

"Cholecystectomy syndrome" is limited to anatomical and physiological disorders of extrahepatic bile ducts that continue to exist or occur newly after biliary tract surgery. 90% to 95% of patients with cholecystectomy after cholecystectomy can be cured, but the symptoms of a few patients It can continue to exist or relapse, and some patients have new symptoms, which are inconsistent with the preoperative complaints. It is obvious that these conditions are not caused by gallbladder resection.

The vast majority of PCS is due to preoperative diagnosis errors, that is, the symptoms are not caused by biliary diseases. In some cases, the symptoms of adjacent organs (biliary, liver, pancreas, duodenum) will be the same as before surgery. Of course, postoperative symptoms are unlikely to be alleviated.

Most of the occurrence of calculi after cholecystectomy is not careful during the operation. The small stones falling from the cystic duct into the common bile duct are not found. If intraoperative angiography and intraoperative choledochoscopy can be taken, the residual stones can be significantly reduced. Incidence; another condition is the absence of stones, the formation of stones due to metabolic disorders after cholecystectomy; the other case is due to inadvertent surgery, or the inevitable complications of the surgery itself.

Most of the common bile duct stenosis is not detected due to blunt injury to the common bile duct during surgery. It is only when PTC or ERCP occurs after symptoms appear. Duodenal papillary sclerosis, stenosis and pancreatic duct sclerosis, stenosis and pancreatitis may occur because of When the duodenum and common bile duct incision are examined, the metal probe forcibly passes through the nipple and is damaged by the Oddi sphincter. The injury can also cause cholesterol to deposit in the terminal bile duct mucosa and cause chronic inflammation.

The incidence of PCS has no significant relationship with the following factors: gallbladder function in oral gallbladder angiography; size and number of stones in the gallbladder; cholecystitis without stones, in recent years, the diagnosis of these diseases due to the accuracy and perfection of the diagnosis Can be clear.

There are many types of PCS in the second category. The reason is not clear at present. In recent years, studies have shown that the bile duct wall of patients with PCS is particularly sensitive to changes in pressure. As long as 1 to 2 ml of normal saline is injected into the common bile duct, the pressure of the biliary tract increases rapidly and severe pain occurs. In patients with bile reflux before cholecystectomy, postoperative reflux aggravation may be associated with pyloric sphincter dysfunction. In addition, persistent pain of PCS may be related to psychological factors, and sometimes intestinal adhesion or gallbladder bed should be considered. The possibility of scarring.

Prevention of postoperative cholecystectomy syndrome

As can be seen from the foregoing description, the prevention and reduction of PCS occurs firstly to establish a complete and correct diagnosis before surgery, and to exclude the lesions of tumors and adjacent organs of the gallbladder, and to have a correct estimate of the cause of the symptoms of the patient. In order to reduce or eliminate unnecessary surgery, patients should be told what symptoms may occur after surgery, which symptoms can be relieved, which symptoms are not affected by surgery, which need further treatment, and the need for postoperative diet needs to be gradually adapted The process tells the patient that the surgical operation requires relevant knowledge, skills and experience. If necessary, pathological examination or intraoperative cholangiography may be performed on the malignant lesions. Furthermore, the drainage tube should not be placed too long before the extubation. It is best to perform T-tube angiography.

Complications of postoperative cholecystectomy syndrome Complications

1. Pulmonary infection: Because the patient stays in bed for a long time, eating poorly, suffering from pain, resulting in low immunity, easy to be complicated by pulmonary infection, and secondly, cholecystectomy with diseases such as ulcer disease, chronic pancreatitis, chronic hepatitis and other diseases, Infected lesions are formed.

2. Astragalus: associated with postoperative bile duct stricture, as well as residual stones and recurrent stones, bile drainage is not smooth, leading to jaundice.

3. Cholesterol: It is the formation of bile duct injury or bile duct ligation, bile extravasation, prone to biliary peritonitis.

4. Postoperative intra-abdominal hemorrhage.

Symptoms of post-cholecystectomy syndrome Common symptoms Can not tolerate diarrhea, nausea, nausea, nausea, constipation, jaundice, abdominal pain

Half of PCS patients have abdominal pain or "dyspepsia" (upper abdomen or right upper quadrant fullness, belching, nausea, vomiting, constipation, intolerance of fat or diarrhea, etc.) appear within a few weeks after surgery, and the other half are postoperatively Symptoms appear within a few months or years. These symptoms are non-specific and vary depending on the underlying cause, but often include pain in the right upper abdomen or upper abdomen. It is more common after a meal, with sharp pain, and other symptoms may have heartburn. Hernia, vomiting and intolerance to a fatty diet, a small number of patients may have severe cholecystitis or pancreatitis, severe pain and may be associated with fever, jaundice or vomiting, compared with those with mild or no symptoms It is often easy to reveal a clear disease when the patient is examined. In addition to the obvious jaundice, the physical examination often does not have special value.

Examination of postoperative cholecystectomy syndrome

Because of the search for PCS, this process involves the differential diagnosis of many diseases. Therefore, the choice of various examinations should be based on the patient's medical history, clinical manifestations and possible causes. There is no uniform model, and the general laboratory results are usually normal. Elevation of bilirubin, alkaline phosphatase, amylase or transaminase is more common in lesions of the biliary tree.

Special examinations include various cholangiography, electrocardiogram, chest X-ray, ultrasonography, CT scan, endoscopy, gastrointestinal barium meal and even magnetic resonance examination.

1. Biochemical examination : white blood cell count, blood urease amylase, liver function, alanine aminotransferase, -glutamyl transpeptidase are helpful for the diagnosis of biliary obstruction.

2. Intravenous cholangiography : poor intrahepatic bile duct development, extrahepatic biliary tract is also not clear, and is greatly affected by liver function, so the diagnostic value is not large.

3. B-mode ultrasound : bile duct dilatation, gallstone, biliary tract tumor, pancreatitis, etc. can be found. It is simple and rapid, and has certain diagnostic value, but it has limitations and cannot show the full appearance of the biliary system and all the symptoms.

4. Upper gastrointestinal angiography : diagnosis of hiatal hernia, ulcer disease, duodenal diverticulum, etc. are very helpful.

5. Hepatobiliary CT scan : diagnosis of liver tumors, intrahepatic bile duct dilatation, cholelithiasis, chronic pancreatitis.

6. Isotope 99m-HDA hepatobiliary scan : observation of intrahepatic bile duct dilatation, cholelithiasis and liver lesions, gallbladder function, etc., simple and no damage, suitable for patients with jaundice.

7. Endoscopy : including esophagoscopy, gastroscopy, duodenoscopy and so on.

ERCP has a definite diagnostic value for postoperative cholecystectomy syndrome. Hu Jiayou et al reported 181 cases of ERCP, the diagnosis and experience of diagnosis of biliary postoperative syndrome, and the following diseases were found: 169 cases (93.4%) were able to determine the cause, including biliary tract There were 159 cases (87.8%) of stones, 73 cases (40.3%) of biliary stenosis, 106 cases (58.6%) of biliary dilatation, 90 cases (49.7%) of chronic recurrent cholangitis, and 12 cases (6.6%) of unknown causes, ERCP. The diagnostic success rate is 83.3%, which can directly and accurately display the whole biliary system and lesions, the shape, size, location and quantity of the lesion.

8. PTC: This direct cholangiography method is suitable for the identification of heavier jaundice and the location of bile duct lesions.

9. Morphine : The neostigmine challenge test is as follows: intramuscular injection of morphine 10 mg, neostigmine 1 mg, before the injection, 1 hour, 2 hours and 4 hours after injection, serum starch Enzymes and lipomas, pain in the upper abdomen after injection, serum enzymes more than 3 times higher than the normal value is positive.

Diagnosis and differentiation of postoperative cholecystectomy syndrome

1. Preoperative symptoms continue to exist

(1) Preoperative diagnosis is wrong or incomplete: Although the cure rate of patients after cholecystectomy has been considerably improved with the continuous development of surgical techniques, there are still a certain number of patients whose preoperative symptoms continue to exist after surgery. The primary reason is that the symptoms are mistakenly attributed to the gallbladder before surgery. Because patients with gallbladder disease may have symptoms such as flatulence and indigestion, it is easy to suspect gallbladder disease when patients develop these symptoms. It has been recognized that flatulence and Indigestion is not a specific symptom of gallbladder disease, and many of the symptoms that were previously attributed to the gallbladder are caused by causes other than the biliary tract.

In many cases, cholelithiasis can coexist with other diseases or abnormalities, which are the causes of symptoms. Heartburn, suffocation, early meal and flatulence after meals, migraine and changes in bowel habits are not " gallbladder syndrome". Unless there is paroxysmal biliary colic, it is often necessary to have a comprehensive examination to rule out other abnormalities. Symptoms caused by causes other than the gallbladder, even if the gallbladder is removed, these symptoms will continue to exist, and the symptoms of swallowing should be excluded. Irritating to the colon, esophageal hiatus hernia, post-balloon ulcer or penetrating ulcer, diverticulitis, renal colic, perirenal abscess, pyelonephritis, spondylitis and even gonococcal perihepatitis, due to cholelithiasis and esophageal hiatus Close, so the gallbladder should be checked before surgery to eliminate the possibility of hiatal hernia. Conversely, the gallbladder should be examined to exclude cholelithiasis during the repair of hiatal hernia. In addition, patients with cholelithiasis may also suffer from emotional frustration or mental assault. Symptoms of mental disorders and changes in the intensity of subjective feelings, a significant proportion of patients with PCS develop bone and muscle disease and Mental disorders, aerophagia plus hepatic flexure syndrome, irritable colon plus right intercostal neuralgia is a relatively common cause of this type of patient.

(2) common bile duct and intrahepatic calculi: due to missed diagnosis of common bile duct stones or intrahepatic bile duct stones can enter the pancreatic duct, so the symptoms before cholecystectomy can continue to exist after surgery, Glenn will be the common bile duct stones after cholecystectomy Grade 3 for residual, recurrent and new causes of stones:

1 common bile duct stones (missed), the most common:

A. Small stones are hidden in thick contrast agents.

B. Intrahepatic stones.

2 recurrent gallstones: caused by biliary stasis.

A. Congenital anomalies.

B. Stenosis caused by common bile duct inflammation.

C. New creatures.

D. Metabolic diseases: hypothyroidism, hypercholesterolemia, diabetes.

3 new causes of stones:

A. Hemolysis.

B. Cholangitis.

C. Inflammatory bowel disease.

D. Sclerosing cholangitis.

E. Obstructive cholestatic and infection: common bile duct cyst, duodenal diverticulum, chronic pancreatitis, tumor metastasis.

F. Parasite: amoeba, cysticercosis.

The most common of these is residual gallstone, which is the neglect of the common bile duct stones during cholecystectomy. In these patients, 35.5% of the patients will have symptoms in the first year after surgery, while recurrent stones are asymptomatic after more than one year. Patients who underwent choledocholithiasis during cholecystectomy were more likely to have recurrent stones (6% and 0.98%, respectively) within a few months to several years after choledocholithiasis.

Most of the stones found after surgery are located in the cholestasis of the pancreatic duct or intrahepatic bile duct. The causes of siltation include congenital anomalies, stenosis caused by infection and new organisms. At the same time, common bile duct stones can also be caused by metabolic diseases. Blood cholesterol levels are formed, including hypothyroidism, obesity, hypercholesterolemia, etc. In addition, coexisting diseases (such as inflammatory bowel disease, hemolysis, parasitic infections, etc.) can sometimes cause biliary stones, except for pigmentation. Outside the gallstones, it is rarely confirmed that stones can form in the pancreatic duct.

(3) Diseases of adjacent organs: when considering post-cholecystectomy syndrome, liver disease (hepatitis, cirrhosis), biliary tract disease (Oddi sphincter stenosis, choledochitis, cholangitis, neoplasm) and pancreatic disease (inflammation) , new organisms) should also be noted, and if possible, it is best to have a pathological report at the time of surgery.

In patients without cholecystitis, pancreatitis or obstructive jaundice, hepatobiliary diseases associated with gallbladder are rarely found. If these three diseases are not present during surgery and the common bile duct is not opened during surgery, these three diseases are unlikely to be Causes of PCS, after the removal of gallbladder, although the original cause of biliary obstruction does not exist, but there may still be some symptoms, such as burnout, especially easy to fatigue, occasionally low fever and increased blood bilirubin, cirrhosis in the cholecystectomy Less common after surgery, reported to be about 3%.

If jaundice or suppurative infection occurs after gallbladder removal, Oddi sphincter stenosis and stenotic cholangitis should be considered. These patients account for about 11% of postoperative patients. It is reported that about 55% of patients have fibrosis in this area, Oddi sphincter Both fibrosis and pancreaticobiliary stones are considered to be the most common organic diseases causing PCS. The causes of fibrosis include stone incarceration, probes, dilators or drainage T-tube damage to the biliary tract, etc. The end of the mud-like bile, gallstones and stones often aggravate the stenosis.

The diagnosis of common bile duct stricture can be performed by venous cholangiography. The density of bile ducts after 2 hours of contrast injection can be proved without significant reduction compared with 1 h. Laboratory tests can find that serum bilirubin and alkaline phosphatase levels are increased. During the operation, if the 3mm dilator can not pass the duodenal papilla, the nipple obstruction is suggested. Intraoperative cholangiography and pressure measurement can further confirm the end-obstruction of the bile duct and the increase of intra-biliary pressure. If the bile duct is not satisfied, it often needs to be cut. Open the duodenum, find the stone to remove, parallel sphincter angioplasty, it should be noted that chronic pancreatitis, pancreatic or bile duct tumors can compress the biliary tract to cause stenosis, only biopsy indicates chronic inflammation and fibrosis can confirm the diagnosis.

Recurrent pancreatitis can also be the cause of severe pain after cholecystectomy. Preoperative pancreatitis is caused by alcoholism, hyperparathyroidism or hyperlipidemia. Recurrent pancreatitis can be caused by residual biliary tract. Caused by diseases, such as small stones in the pancreatic duct, silt-like bile and ampullary stenosis, etc. If pancreatitis is suspected, pancreatic enzyme examination should be performed at the time of onset or shortly after the onset. However, it is not necessarily repeated for a long time. Pancreatic enzyme abnormalities can be found, but pancreatic exocrine function is often impaired. This can be shown by pancreatic exocrine function test. It can also be found in steatorrhea, weight loss, diabetes and pancreatic calcification. Pancreatitis and pancreatic cancer are sometimes difficult to identify. Secretion test, cytology, angiography, etc. may be helpful, but if the cause of persistent pancreatitis is not found after cholecystectomy, even if no abnormalities are found in the angiography, it is necessary to perform cholangiopancreatography and 12 fingers. Intestinal papilla incision exploration and so on.

(4) Missed tumors: Malignant tumors involving the biliary tree, even if the primary site is far from the biliary tree, can be the cause of the persistence of symptoms before cholecystectomy, the biliary system or tumors of adjacent organs (especially from It is not uncommon for the head of the pancreas, the duodenum, the abdomen and the biliary tract to coexist with the common bile duct stones or bile duct stones. Failure to find the coexisting stones is likely to lead to miscalculation of the cause and unnecessary Cholecystectomy, indeed, tumors in this area are easily overlooked even during surgery.

2. Symptoms caused by cholecystectomy

(1) Surgical operation failure: bile duct stones left in cholecystectomy can cause recurrent biliary colic, jaundice, fever or chills. This is the most overlooked problem in cholecystectomy, followed by surgery. The gallstones are discharged from the gallbladder or cystic duct into the common bile duct. In a few cases, the stones originate from the intrahepatic bile duct. The lower stones can cause symptoms. The stones can be left in the gallbladder or cystic duct, or the biliary or Oddi sphincter stenosis. The proximal end is formed.

After the obstruction of the bile duct, the pressure in the bile duct is increased, which sometimes causes the residual root of the cystic duct to leak, leading to biliary peritonitis and bile duct. However, most patients with residual stones can smoothly pass the postoperative rehabilitation period, and the symptoms are more in the postoperative period. Weeks, months or even years, patients may have symptoms similar to those of bile duct stones, such as the Charcot triad (colic, jaundice and fever); also three symptoms are not typical, the pain can be mild and short-lived, It can also be frequent, and occasionally, the only symptom of the patient is painless obstructive jaundice.

Bodvall and Overgaard classify the symptoms of PCS patients into the following types: Type I: mild and transient colic, accounting for approximately 23.5%; Type II: occasionally severe and persistent colic, approximately 3%; Type III: severe PCS ( 2.4%) with recurrent cholangitis (about 0.7%) or severe and persistent abdominal pain (1.7%), severe recurrent cholangitis in PCS and long-term severe abdominal pain.

There is a transient increase in serum bilirubin and alkaline phosphatase 12 to 48 hours after biliary colic and/or chills and fever. The jaundice caused by residual stones is often fluctuating and not very deep; Astragalus membranaceus is often persistent and deep. If bilirubin calcium stones or cholesterol crystals appear in the feces of patients 48 hours after pain, it may indicate that there may be common bile duct stones, such as similar crystals found in duodenal drainage. The meaning is the same, which has certain reference value when the X-ray or other tests are negative and the relevant examiners cannot be performed.

Abdominal plain film can only occasionally find opaque stones in the bile duct. Some patients who cannot be diagnosed by conventional cholangiography, if strictly according to the requirements of oral cholangiography, oral cholangiography may prompt diagnosis, showing bile duct stones, In patients without jaundice (bilirubin <34.2mol/L) or liver function (BSP<15mg%), venography is the most important method for diagnosing residual bile duct stones. If the diameter of the bile duct increases after cholecystectomy, it will prompt There is bile duct obstruction. During the progression of cholecystitis, the common bile duct can be gradually expanded. In the presence of gallstones, removal of the gallbladder does not affect the width of the pancreatic duct.

Patients with obstructive jaundice can show extrahepatic biliary tract through percutaneous transhepatic cholangiography, ERCP, CT or MRI, and may directly discover the cause of obstruction, if preoperative examination indicates surgical indications, or clinically Highly suspected to have a common bile duct stone, intraoperative cholangiography or ultrasound probe through the endoscopic exploration in the duodenum (ultrasound endoscopy) to confirm the diagnosis.

(2) Tumor neglect: In the case of gallbladder or gallstone surgery, if the tumor that has invaded the common bile duct and has caused stenosis is not found, the removal of gallbladder and stones from these patients may temporarily relieve the symptoms. However, preoperative symptoms may reappear soon after surgery. In addition to abdominal pain and other common digestive symptoms, patients with jaundice before surgery will soon develop jaundice and its corresponding symptoms. Therefore, clinical Physicians must be alert to cancers that are hidden and slowly growing in the liver or colonic liver.

(3) Wrong surgical operation: In patients with acute cholecystitis, or difficulty in operation, or inexperienced by the surgeon, the cystic duct or gallbladder remains easily in the operation. In addition, the cystic duct and pancreas are found due to cholangiography. The abnormal relationship between the bile ducts is more and more common, and the surgeon intentionally leaves a cystic duct during the operation to avoid damage to the pancreatic duct during the removal of the cystic duct. The expansion of the residual gallbladder or cystic duct may be related to its length and intra-biliary pressure. This cystic structure can be expanded to resemble a new gallbladder, which can contain stones and may become cancerous.

Oral or intravenous cholangiography, especially cholangiography, can show residual cysts or newly formed gallbladder, but it can be more significant if it shows the light in the bile duct or residue. It should be emphasized that although sometimes X-ray shows The cystic duct remains, but this does not prove that the residue itself is the cause of postoperative symptoms in the patient. Several studies have shown that the proportion of residual cystic duct in the PCS is even lower than that of the non-PCS, based solely on the length of the residue. It is also impossible to determine whether the patient has symptoms.

The proportion of symptoms caused by residual cystic ducts is unclear, but the symptoms of many patients can be relieved after resection, especially in the case of stones, and the symptoms caused by residual cystic ducts can occur in the months after surgery. In the year, the pain episodes resemble biliary colic, but to varying degrees, may be associated with nausea or vomiting, sometimes with chills, fever, and jaundice. Garlock and Hurwitt attribute the biliary colic, nausea, and vomiting of these patients to "cholecystectomy." Root syndrome", at the same time that jaundice, chills and fever suggest pancreaticobiliary calculi and cholangitis, and speculate that the biliary obstruction of patients with cystic duct or gallbladder residual is caused by stones, in any case, carefully explore the pancreatic duct to find stones It is always worthwhile. Of the 30 patients, 13 have found cholangioliths, 6 have found stones in the residual roots of the cystic duct, and 2 have found stones in two of them. In the patient, the common bile duct incision was performed several times, but it was not found until the cystic duct was removed.

Most scholars agree that if a part of the gallbladder lesion is neglected, or if the residual part of the cystic duct contains stones, or the residual root of the cystic duct indirectly affects the flow of bile into the duodenum, the patient will have symptoms. However, these symptoms should actually be attributed. Factors other than the residual root, and only after removing these factors will relieve the symptoms, including residual stones (missing or newly formed), pancreaticobiliary stones (missing or from residual sites), chronic inflammation with Fibrosis and kinking adhesions, common bile duct or Oddi sphincter stenosis, etc. In short, the gallbladder and cystic duct residuals themselves have no significant clinical significance, but rather are sites of complication, including inflammation and stone formation.

Patients with PCS with residual gallbladder or cystic duct have higher erythrocyte sedimentation rate, abnormal liver function, cholangitis and excessive bacterial hyperplasia. It is speculated that two residues can cause recurrence of cholangitis (Table 1), 92% The symptoms of PCS patients disappeared after removal of the gallbladder or cystic duct, and therefore consistent with the above inference.

It has also been suspected that neuroma in the residual cystic duct is a cause of symptoms caused by residues. Significant inflammatory changes and fibrosis occur in the cystic duct residual and adjacent pancreatic duct, adhesions and neuroma have been reported many times, but due to In other cystic duct residuals with abnormalities, the symptoms of the patients after resection of the residual and neuroma were not alleviated, and there is no evidence that such neuroma in PCS patients is more common than postoperative asymptomatic patients, so further research is needed.

(4) Postoperative adhesions: Even if there is severe inflammation of the gallbladder during surgery, or there is biliary peritonitis, even adhesions are inevitable. The symptoms after cholecystectomy are rarely caused by adhesions. The pyloric duodenum can be The site of cholecystectomy occurs under the liver, resulting in angulation and distortion of the pyloric end of the stomach, but only in rare cases, partial obstruction of the pyloric duodenum occurs, occasionally in the case of binge eating, symptoms may occur. In cases, symptoms similar to ulcer disease may occur, that is, abdominal discomfort is aggravated after eating. These symptoms can be attributed to pyloric duodenal adhesion, but lack of typical rhythm and periodicity of peptic ulcer, and short duration of upper abdominal discomfort The relationship with body position is more closely related to eating. The upper digestive tract barium meal can show the abnormal contour and position of the stomach and duodenum due to adhesion, and even the gastric peristalsis and the delay of emptying can be seen on the fluorescent screen. .

(5) Physiological disorders: Symptoms after cholecystectomy may be caused by various structural changes, but also due to physiological dysfunction of normal biliary tract.

Removal of functional gallbladder: If the gallbladder has no function months or years before resection, the symptoms of bile flow or changes in biliary pressure will not occur after surgery, and the body has adapted to the change of gallbladder function. Suddenly, the removal of a gallbladder with better function usually leads to changes in bile flow and causes subjective symptoms in some patients.

It has been experimentally observed that excision of the extrahepatic bile duct often occurs after removal of the functional gallbladder, but does not occur if the sphincter is incision, but the increase in sphincter tension is not the cause of biliary dilatation in each patient, nor is it per patient. The cause of increased intra-biliary pressure, therefore, the expansion of the bile duct sometimes occurs after the surgical elimination of the sphincter. The expansion at this time is considered to be due to duodenal pressure conduction to the bile duct, because the sphincter does not In the animal experiment, the pancreaticobiliary tube is obliquely implanted into the duodenal wall, so that the duodenum muscle layer replaces the sphincter, which can prevent the bile duct of the animal from expanding after the sphincter incision. However, the current bile duct dilatation The meaning and incidence are still unclear.

After the gallbladder is removed, because there is not enough concentrated bile to enter the duodenum in a certain period of time, in order to exert the best effect of digesting fat, it can not achieve the best absorption effect, so it can cause symptoms of indigestion. May be associated with flatulence and mild discomfort, and often lasts for several months.

3. Mental factors

Patients with abdominal pain after cholecystectomy but no anatomical abnormalities of the bile duct tree or other abdominal diseases (such as reflux esophagitis, peptic ulcer, irritating colon, etc.) often have psychological disorders, some patients have a history of long-term abdominal pain, gallbladder No function or function is very poor, or the gallbladder has stones but no inflammation. I hope to eliminate the pain by removing the gallbladder. The result is often frustrated. Most of the patients are female, and sometimes there are other abnormalities, which are considered to be the cause of abdominal pain. Conventional treatment is ineffective, and large studies have shown that 43% of patients with PCS have varying degrees of mental disorder.

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