How To Manage Postcholecystectomy Abdominal Pain

Gallstones affect 5%–25% of adults in the Western world, and each year approximately 2%–4% will develop symptoms attributable to gallstones,1 including biliary colic and epigastric pain. Complications of gallstones include acute pancreatitis, acute cholecystitis, biliary obstruction, jaundice and cholangitis. However, 80% of individuals with gallstones will never develop symptoms. Current guidelines do not recommend cholecystectomy for asymptomatic gallstones. Cholecystectomy is the most frequently performed general surgical operation, with approximately 66 660 performed annually in the UK.2 Most cases are performed for gallstone disease; however, a proportion are for presumed gallbladder dyskinesia. Internationally there are large variations within and between countries for cholecystectomy. In the USA, with a population five times that of the UK, greater than 10 times as many cholecystectomies are performed at an estimated cost of $9.9 billion. Although the majority of patients have pain relief following cholecystectomy, it is estimated that around 40% will continue to have pain postcholecystectomy,3 4 representing a significant number of individuals with morbidity. Postcholecystectomy pain (PCP) may be a persistence of the pain experienced precholecystectomy or a new pain. Patients who had elective rather than emergency surgery and those without stones or who had less typical symptoms are at higher risk to re-present with pain.5 In a recent randomised controlled trial among patients with abdominal pain and gallbladder sludge or stones,6 of a restrictive strategy versus a usual care strategy, 44% and 40% of participants, respectively, experienced PCP. This study highlights the difficulty of ascertaining whether coexisting gallstones are the cause of upper abdominal symptoms. Careful history taking, consideration of other causes and adherence to strict criteria for cholecystectomy all have a role in mitigating against persistence of symptoms postcholecystectomy. The aim of this review is to discuss the assessment and management of PCP. Acute surgical adverse events will not …