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Gastroenterology and Hepatology Item 43
A 42-year-old woman had a cholecystectomy 18 months ago for right upper quadrant pain radiating to her shoulder. No stones were found on opening the gallbladder at the operation, and the pathologic finding was chronic cholecystitis. She continues to have daily attacks of right upper quadrant pain identical to her pain before the cholecystectomy. These attacks are not associated with diet or activity.
Ultrasonography and liver tests during the attacks, as well as during asymptomatic intervals, have been normal. Trials of therapy with acid antisecretory agents and prokinetic agents have been unsuccessful. Upper intestinal endoscopy is normal.
(A) Endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy
(B) Surgical sphincteroplasty
© ERCP with biliary manometry
(D) Cholecystokinin (CCK) ultrasonography and hepato-iminodiacetic acid (HIDA) scan
(E) Symptomatic pain management
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I think A would be answer
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C. (I think so)
The pain post cholecystectomy most commonly is due to the stenosis of sphincter area (papillae Vateri) but can also due to dysfunction of the sphincter.
So to make a proper dx the manometry looks like a good choice. If it shows increased pressure than endoscopic sphincterotomy could be a curative tx.
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hi,
I would go with A....but not entirely sure about it. klmklm what is the answer?
chill
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(E) Symptomatic pain management
Educational Objective: Determine the appropriate management of postcholecystectomy biliary-type pain.
This patient has functional biliary-type pain based on her normal laboratory tests and imaging studies during pain episodes and should receive symptomatic pain management. Narcotics should be avoided, and some patients may need to be referred to pain centers for management. Endoscopic retrograde cholangiopancreatography (ERCP) with sphincter-otomy and/or biliary manometry is a morbid procedure, is unlikely to detect disease in this clinical situation, and is indicated only in patients with abnormal liver tests and/or imaging studies. Sphincterotomy or surgical sphincteroplasty is rarely effective for symptom relief in patients with normal liver tests and imaging studies and increases the morbidity of ERCP. Cholecystokinin (CCK) ultrasonography and hepatoiminodiacetic acid (HIDA) scan are not useful because they have suboptimal sensitivity and specificity for diagnosing sphincter of Oddi dysfunction.
