Post-cholecystectomy Biliary-like Pain

A 46 year old postal worker is referred to a gastroenterologist because of multiple episodes of severe right upper quadrant abdominal pain. On three occasions at several month intervals over the past two years the pain has required emergency room visits. Her previous medical history is negative except for a cholecystectomy performed for gallstones eight years earlier, following several episodes of uncomplicated biliary colic. Further analysis of the presenting pain by the gastroenterologist reveals that it increases to a maximum level and remains steady for more than 30 minutes (Box 1, Fig 2). At times the pain can radiate to the right subscapular region, and she has vomiting associated with the pain on some occasions. The pain has not woken her from sleep. There are no obvious precipitating factors, she has not used codeine-containing medications and the pain is not related to, or affected by, bowel movements; the pain is not relieved by antacids, posture or movement (Box 2). The pain is in fact, as far as she can remember, very similar to that which she experienced prior to her cholecystectomy. The patient does not admit to any gastrointestinal symptoms in the pain-free intervals. Physical examination is negative, including evaluation for an abdominal wall origin of pain (Box 2). The patient is not overweight.

Blood tests to assess serum liver biochemistry and pancreatic enzymes, and an abdominal ultrasound (US) scan, are performed (Box 3). The blood tests are normal. The US does not show bile duct stones (Box 4) but does show a common bile diameter of 12 mm (Box 8). At this stage, although the patient’s pain appears most consistent with a biliary origin, the gastroenterologist wishes to exclude conditions such as gastro-esophageal reflux disease and peptic ulcer (Box 7), so performs an upper GI endoscopy (Box 6); this reveals no abnormality. The gastroenterologist considers further abdominal imaging and arranges an MRCP. This also shows no abnormality except for the dilated bile duct (Box 8). CT scan of the abdomen does not reveal any other intra-abdominal abnormality (Box 9). In the absence of structural disease, the gastroenterologist suspects that the typical biliary-like pain might be due to sphincter of Oddi dysfunction (SOD) (Box 10). Records from the patient’s previous emergency room visits reveal that her liver biochemistry and pancreatic enzymes were normal on each visit. Based on the lack of any abnormality on blood tests, but the presence of a dilated bile duct, a diagnosis of biliary sphincter of Oddi dysfunction type II is made. Knowing the risks of ERCP (with or without sphincter manometry) in such cases, the gastroenterologist refers the patient to a colleague with more experience. He considers quantitative choledochoscintigraphy, but for this case is not convinced by its discriminant value, and proceeds to ERCP (Box 16). Biliary manometry is abnormal and sphincterotomy is performed. Because the pancreatic duct was injected during the cannulation process, a small temporary pancreatic stent was placed to reduce the risk of pancreatitis.