A 52-year-old woman comes to the office due to intermittent right upper-quadrant pain and nausea. The patient has a history of obesity and gallstones, for which she underwent elective cholecystectomy a year ago. The pain is located in the right subcostal area and generally lasts 30-60 minutes. The patient recalls that she had similar pain episodes before the surgery. Laboratory results after one of the episodes are as follows: An ultrasound of the abdomen reveals mild dilation of the common bile duct. The pancreas is visualized and appears normal. Which of the following is the best next step in management of this patient?

Question

A 52-year-old woman comes to the office due to intermittent right upper-quadrant pain and nausea.  The patient has a history of obesity and gallstones, for which she underwent elective cholecystectomy a year ago.  The pain is located in the right subcostal area and generally lasts 30-60 minutes.  The patient recalls that she had similar pain episodes before the surgery.  Laboratory results after one of the episodes are as follows:  An ultrasound of the abdomen reveals mild dilation of the common bile duct.  The pancreas is visualized and appears normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient's presentation is concerning for postcholecystectomy syndrome (PCS), persistent abdominal pain or dyspepsia (eg, nausea) that occurs either postoperatively (early) or months to years (late) after a cholecystectomy. PCS can be due to biliary (eg, retained common bile duct [CBD] stone, retained cystic duct stone, biliary dyskinesia) or extra-biliary (eg, pancreatitis, peptic ulcer disease, coronary artery disease) causes. Patients usually notice the same pain they had prior to surgery, new pain just after surgery, or the same pain that never went away. Depending on the exact cause, laboratory findings can include elevated alkaline phosphatase, mildly abnormal serum aminotransferases, and dilated CBD on abdominal ultrasound. These findings usually suggest CBD stones or biliary sphincter of Oddi dysfunction. The next step involves endoscopic ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), or magnetic resonance cholangiopancreatography for final diagnosis and guiding therapy. Treatment for PCS is directed at the causative factor. (Choice A) Antimitochondrial antibodies are usually elevated in primary biliary cholangitis (PBC). These patients typically have other symptoms (eg, pruritus, fatigue, jaundice) along with abdominal pain. Although PBC can present with laboratory findings similar to those seen in this patient, imaging typically does not show a dilated common bile duct. (Choice C) Helicobacter pylori stool antigen testing is used for diagnosing H pylori infection in patients with peptic ulcer disease. It is not typically associated with abnormal liver function tests and/or dilated common bile duct. (Choice D) Liver biopsy should be done when initial evaluation (laboratory analysis and imaging) cannot provide a definitive diagnosis or determine the severity of liver disease. This patient may require liver biopsy if ERCP and other laboratory tests for hepatitis are unremarkable. (Choice E) Ursodeoxycholic acid can treat cholesterol gallstones in patients with mild symptoms who are not candidates for cholecystectomy. It is also used to treat PBC and primary sclerosing cholangitis. Educational objective: Postcholecystectomy syndrome is persistent abdominal pain or dyspepsia either postoperatively (early) or months to years (late) after cholecystectomy. Etiologies include biliary (eg, retained common bile duct or cystic duct stone) or extra-biliary (eg, pancreatitis, peptic ulcer disease) causes. Abdominal imaging (eg, ultrasound) followed by direct visualization (eg, endoscopic retrograde cholangiopancreatography, magnetic resonance cholangiopancreatography) can establish the diagnosis and guide therapy toward the causative factor. References: Biliary causes of postcholecystectomy syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/18722735) Postcholecystectomy syndrome (PCS). (http://www.ncbi.nlm.nih.gov/pubmed/19857610)

A 52-Year-Old Woman Comes to the Office Due to Intermittent