In this article, we will consider the symptoms and treatment of postcholecystectomy syndrome.
The number of surgical interventions performed to treat chronic calculous cholecystitis and the complications it causes is growing every year. In our country, the number of such operations annually reaches 150 thousand. Every third patient who has undergone cholecystectomy, that is, removal of the gallbladder, experiences various disorders of an organic and functional nature from the biliary tract and related organs. All these disorders in medical practice are called postcholecystectomy syndrome, or abbreviated PCES.
Varieties of PCES
PCES in the overwhelming case does not develop subject to certain rules, including a full preoperative examination of the patient, a correctly established diagnosis and indications for surgical intervention, as well as a well-performed cholecystectomy in terms of the technique.
The following types of pathology are distinguished depending on the origin of the disease:
True postcholecystectomy syndrome. Its other name is functional. Appears as a complication due to the lack of the gallbladder ability to perform its functions.
Conditional, or organic. This is a set of symptoms that arise as a result of technical errors made during the operation or incomplete examination of the patient in preparation for cholecystectomy. Sometimes, at the stage of preparation for surgery, some complications of calculous cholecystitis are ignored.
Organic forms of PCES are much more than functional.
Causes
Factors that provoke the development of postcholecystectomy syndrome directly depend on its variety. So, the main causes of true PCES are considered:
1. Dysfunctional disorder of the sphincter of Oddi, which is responsible for regulating the flow of bile and pancreatic secretion into the duodenum.
2. Duodenal obstruction syndrome in a chronic form of the course, which causes an increase in pressure in the duodenum in the compensated stage, its decrease and expansion in decompensated.
Conditional form reasons
The conditional form of postcholecystectomy syndrome (code according to ICD-10 - K91.5) can cause the following disorders:
1. Narrowing of the common bile duct.
2. An elongated and inflamed stump of the duct of the gallbladder.
3. Granuloma or neurinoma around the surgical suture.
4. The formation of gallstone in the duct.
5. The appearance of adhesions under the liver, which causes narrowing and deformation of the common bile duct.
6. Damage to the large duodenal papilla by trauma during surgery.
7. Partial removal of the gallbladder, when another similar organ may arise from a wider stump.
8. Disease of the biliary tract of an infectious nature.
9. Herniated formation of the esophageal opening of the diaphragm.
10. Duodenal ulcer.
11. Secondary pancreatitis in a chronic form of the course.
12. Papillostenosis.
13. The diverticulum of the duodenum in the region of the large papilla.
14. A cyst in the common bile duct with a complication in the form of its dilatation.
15. Miritzi syndrome.
16. Chronic fistula formed after surgery.
17. Fibrosis, reactive hepatitis , liver steatosis.
Symptoms of postcholecystectomy syndrome
In the postoperative period, the patient may experience severity and pain in the right hypochondrium. There are a large number of clinical manifestations of postcholecystectomy syndrome, but all of them are specific. Symptoms develop both immediately after the operation, and after some time, called the light gap.
Depending on the factors that triggered the appearance of postcholecystectomy syndrome, the following symptoms are distinguished:
1. Severely severe pain in the right hypochondrium. These are the so-called biliary colic.
2. Similar pancreatic pains, characterized as shingles and extending to the back.
3. Yellow tint of the skin, mucous membranes and sclera, itching.
4. A feeling of heaviness in the region of the right hypochondrium and stomach.
5. Bitterness in the mouth, nausea, biliary vomiting, belching.
6. A tendency to intestinal disorders, manifested by frequent constipation or diarrhea. This is usually due to non-compliance with dietary recommendations after surgery.
7. Regular flatulence.
8. Psycho-emotional disorders expressed by tension, discomfort, anxiety, etc.
9. Chills and fever.
10. Increased sweating.
Diagnostics
Based on the patient's complaints and the collected history, the specialist can conclude that there is a postcholecystectomy syndrome. To confirm or exclude postcholecystectomy syndrome (ICD-10 - K91.5), a survey is prescribed that includes both instrumental and laboratory methods.
Clinical Research Methods
Clinical research methods include a biochemical blood test, which includes indicators such as total, free and bound bilirubin, AlAt, AsAT, LDH, alkaline phosphatase, amylase, etc.
Important in the process of diagnosing postcholecystectomy syndrome (code) are instrumental methods. The main ones are:
- Oral and intravenous cholegraphy. It provides for the introduction into the biliary tract of a special substance (contrast) with the subsequent conduct of fluoroscopy or radiography.
- A special type of ultrasound called transabdominal ultrasonography.
- Endoscopic variety of ultrasonography.
- Ultrasonic tests of a functional nature, with a fatty test breakfast or nitroglycerin.
- Esophagogastroduodenoscopy. It involves the study of the digestive tract in the upper section through an endoscope.
- Sphincteromanometry and cholangiography with an endoscope.
- Computer hepatobiliscintigraphy.
- Retrograde endoscopic cholangiopancreatography .
- Magnetic resonance cholangiopancreatography.
What is the treatment for postcholecystectomy syndrome?
Drug treatment
The disease in its true form is treated by conservative methods. The main recommendation of a specialist will be the adjustment of lifestyle, which implies the rejection of bad habits like drinking alcohol and smoking.
Another important point is the observance of a special therapeutic diet, which assumes nutrition on table No. 5. This diet provides for a fractional diet, which improves the outflow of bile and does not allow it to stagnate in the bile ducts.
Differentiated approach
Any appointments for postcholecystectomy syndrome of the ICD, including drugs, suggest a differentiated approach, which assumes the following:
1. Increased tone or spasm of the sphincter of Oddi suggest taking myotropic antispasmodics, such as "Spasmomen", "No-shpa", "Duspatalin." In addition, doctors prescribe peripheral M-anticholinergics, such as Gastrocepin, Buscopan, etc. After hypertension is eliminated, cholekinetics are taken, as well as drugs that accelerate the process of excretion of bile, such as sorbitol, xylitol, or magnesium sulfate.
2. If the tone of the sphincter of Oddi is reduced, prokinetics are prescribed to the patient. This group of drugs includes Ganaton, Domperidone, Tegaserod, Metoclopramide, etc.
3. To eliminate duodenal obstruction in a chronic form of the course, prokinetics are used, namely Motilium, etc. When the disease goes into a decompensated stage, repeated washing of the duodenum with disinfectant solutions is introduced into the therapy. Further, antiseptics such as Dependal-M, Intetrix, etc., as well as antibiotics from the category of fluoroquinolones are introduced into the intestinal cavity.
4. With insufficient production of cholecystokinin, its synthetic analogue, ceruletide, is introduced into the body.
5. With a deficiency of somatostatin, the administration of its analogue of octreotide is prescribed.
6. For signs of intestinal dysbiosis, pre- and probiotics are used, such as Dufalac, Bifiform, etc.
7. In case of secondary biliary-dependent pancreatitis, it is recommended to take polyenzyme preparations like Creon, Mezim-forte, etc., as well as analgesics and myotropic antispasmodics.
8. If a somatized variety of a depressive state or autonomic dystonia of the nervous system is diagnosed, it is considered effective to take tranquilizers and drugs such as Coaxil, Grandaxin, and Eglonil.
9. To prevent the formation of new stones, it is recommended to take bile acids, which are contained in drugs such as Ursosan and Ursofalk.
Organic forms of the disease are not amenable to conservative methods of therapy. The treatment of postcholecystectomy syndrome is carried out surgically.
Physiotherapeutic methods
Experts highly appreciate the effectiveness of physiotherapeutic treatment of PCES. In order to accelerate tissue regeneration, the following procedures are prescribed to the patient:
1. Ultrasound therapy. It is carried out by exposing the affected area to oscillations with a frequency of 880 kHz. The procedure is repeated once every two days. Duration of 10-12 procedures.
2. Low-frequency magnetotherapy.
3. Decimeter microwave therapy. The emitter in the form of a cylinder or a rectangle is placed in contact or a few centimeters above the skin in the area of the projection of the liver. The procedure lasts 8-12 minutes and is performed every other day up to 12 sessions.
4. Infrared laser therapy.
5. Radon or carbon baths.
Recommendations for postcholecystectomy syndrome should be strictly followed.
Methodologies
To help the patient deal with pain, the following methods are used:
1. Diadynamic therapy.
2. Amplipulse therapy.
3. Electrophoresis using analgesics.
4. Galvanization.
To reduce biliary tract spasms, the following procedures are used:
1. Electrophoresis using antispasmodics.
2. Galvanization.
3. High-frequency magnetotherapy.
4. Paraffin therapy.
5. Ozokerite applications.
The excretion of bile in the intestine is facilitated by such physiotherapy methods as:
1. Electrical stimulation.
2. Tubing or blind sounding.
3. Mineral waters.
Physiotherapeutic procedures are prescribed not only to patients with postcholecystectomy syndrome (ICD-10 - K91.5), but also as a preventive measure after cholecystectomy.
Prevention
Two weeks after the operation to remove the gallbladder, the patient can be sent for further recovery in the conditions of spa treatment. The conditions for this direction is the assessment of the patient's condition as satisfactory and good condition of the postoperative scar.
To prevent the development of the postcholecystectomy syndrome of the patient, it is necessary to examine both before and during the surgical intervention, as this will help in time to identify complications that can subsequently significantly disrupt the patient's life, causing the postcholecystectomy syndrome (ICD code - K91.5) of the organic type.
An equally important role is played by the qualification of the surgeon performing the operation, as well as the amount of tissue injury in the process of performing cholecystectomy.
Conclusion
The patient needs to be aware of the need to maintain the right lifestyle after surgery. This involves the rejection of bad habits, a balanced diet, regular monitoring in a dispensary and compliance with all the instructions of the attending physician.
PCES is an unpleasant consequence of cholecystectomy. However, timely detection and treatment will help minimize the risk of further complications.
The article examined the symptoms and treatment of postcholecystectomy syndrome.