Role of endoscopic retrograde cholangiopancreatography in the investigation of pain after cholecystectomy

Abstract

Patients who continue to have or who develop abdominal pain after apparently successful cholecystectomy pose diagnostic difficulties. This study reports 384 such patients, investigated by endoscopic retrograde cholangiopancreatography (ERCP). There were 146 patients with abdominal pain alone with no previous history of common bile duct (CBD) exploration, of whom only 17 (11.6 per cent) had CBD stones on ERCP. Bile duct calculi were present in 76 of 140 patients (54.3 per cent) with abnormal biochemical findings (raised alkaline phosphatase and/or amylase level) and in 34 of 57 (60 per cent) with an abnormality detected on ultrasonography or intravenous cholangiography. A combination of biochemical and radiological abnormalities was present in 37 patients and was associated with CBD stones in 28 (76 per cent). Patients who had undergone CBD exploration represented a special group, of whom the majority (75 per cent) had common duct stones at ERCP even in the absence of biochemical and radiological abnormalities. ERCP is a useful investigation in patients with persistent postcholecystectomy symptoms. Other features in addition to pain or a history of CBD exploration may be relevant to the decision to perform ERCP in the investigation of these patients.

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain

“…The evaluation of patients with recurrent biliary symptoms will likely include endoscopic cholangiography [2,9,17]. In our experience with retained cystic duct calculi, this modality was diagnostic in four of six cases, including three patients thought to have common duct calculi based on a history of postcholecystectomy jaundice or pancreatitis.…”

Silent Myocardial Ischaemia during Endoscopic Retrograde Cholangiopancreatography

“…Myocardial ischaemia during ERCP was first reported by Rosenberg et al [3], but the pathogenesis is unclear. The risk of myocardial ischaemia appears to be higher for ERCP [5,6] than for either gastroscopy or colonoscopy. The mechanisms for this probably relate more to tachycardia, associated with a classic metabolic stress response, rather than hypoxaemia [9].…”

“…The rates for ERCP complications (pancreatitis, cholangitis, or perforation) vary from 7 % to 10 % [5,6] and procedure-related mortality ranges from 0.6 % to 0.7 % [5]. Most deaths from ERCP have occurred due to haemorrhage [5] and pancreatitis [7], al-Background and Study Aims: Myocardial ischaemia may occur during endoscopic retrograde cholangiopancreatography (ERCP) and this may predispose patients to ischaemic complications, although the incidence and risk factors for mycocardial ischaemia during ERCP have not been studied in detail.…”

Helical CT cholangiography

“…Although a cause for the symptoms may be found in up to 19% of patients with pain only, the risk of pancreatitis is approximately 5% [16,17]. Because the risk-benefit ratio in this setting is relatively low, spiral CT could be used as a diagnostic modality.…”