Post cholecystectomy syndrome

Case contributed by Dr Jayanth Keshavamurthy

Presentation

Pain in the right upper quadrant in a biliary colic fashion despite cholecystectomy.

Patient Data

Age: 65 years
Gender: Male
Ultrasound

Ultrasound showing a smooth dilated CBD up to 1 cm and MRCP was performed.

MRI

MRCP confirming a dilated CBD without calculus or mass.

NM scan was recommended for post cholecystectomy syndrome.

Nuclear medicine

NM hepatobiliary scanning confirms post cholecystectomy syndrome if the scintigraphic score is >5.

Here one needs to know:

1. Time to peak liver uptake whether it is <10 minutes or more. Score 0 or 1. Patient's score is 1.

2. Time to biliary visualization whether it is >15 minutes or more. Score 0 or 1. Patient's score is 0.

3. Prominence of biliary tracts. Scored 0,1, or 2. Patient's score is 2.

4. Bowel visualization, at <15 minutes, 15-30 minutes and >30 minutes. Scored 0,1, or 2. Patient's score is 1.

5. CBD emptying fraction and Scored 0,1,2,and 3. Patient's score is 3.

6. CBD-to-liver intensity ratio at 15 and 60 minutes.Scored 0,1,2,or 3. You can see above the ROI (regions of interest) have been placed on liver and CBD. Patient's score is 2.

Here patient's total score is 9 (>5). Positive study for Sphincter of Oddi dysfunction.

Please see reference article by Sostre et al from 1992 for finer details 1.

This is an important non-invasive test which is probably underused in diagnosis of persistent pain after cholecystectomy.

Patient was referred back for possible sphincterotomy consideration.

Case Discussion

Patient is currently being investigated by gastroenterology for sphincterotomy.

Post cholecystectomy syndrome can be seen in up to 15% of patients who undergo cholecystectomy.

This non-invasive test is an important tool as manometry studies are not available everywhere. We can guide treatment based on the abnormal NM study if the patient's symptoms correlate with an abnormal study.

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