Continuation

Can symptoms continue after gallstones are removed?

Removal of the gallbladder (cholecystectomy) should eliminate all gallstone-related symptoms except in three situations:

1. gallstones were left in the ducts,
2. there were problems with the bile ducts in addition to gallstones, and
3. the gallstones were and are not the cause of the symptoms.
   

The possibility of gallstones in the ducts can be pursued with MRCP, endoscopic ultrasound, and ERCP. There is only one problem with the ducts that can cause gallstone-like symptoms, and that is a rare condition called sphincter of Oddi dysfunction, discussed below.

The common bile duct has a muscular wall. The last several centimeters of the common bile duct's muscle immediately before the duct joins the duodenum comprise the sphincter of Oddi. The sphincter of Oddi controls the flow of bile. Since the pancreatic duct usually joins the common bile duct shortly before it enters the duodenum, the sphincter also controls the flow of fluid from the pancreatic duct. When the muscle of the sphincter tightens, it shuts off the flow of bile and pancreatic fluid. When it relaxes, bile and pancreatic fluid flow into the duodenum, for example, after a meal. The sphincter may become scarred, and the duct is narrowed by the scarring. (The cause of the scarring is unknown.) The sphincter also may go into spasm intermittently. In either case, the flow of bile and pancreatic fluid may intermittently stop abruptly, mimicking the effects of a gallstone, particularly causing biliary colic and pancreatitis.

The diagnosis of sphincter of Oddi dysfunction can be difficult to make. The best diagnostic test requires an endoscopic procedure with the same type of endoscope as ERCP. Instead of filling the ducts with dye, however, the pressure within the sphincter is measured. If the pressure is abnormally high, scarring or spasm of the sphincter are likely. The treatment for sphincter of Oddi dysfunction is sphincterotomy. (described previously). Measurement of liver and pancreatic enzymes in the blood also may be useful for diagnosing sphincter dysfunction.

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