Brief Answer:
Possibility of post cholecystectomy syndrome

Detailed Answer:
Hi
Welcome to Healthcare-Magic
Greetings of the day

Dear Sir,

I assume you meant 9th December 2013 the date of Cholecystectomy. Going through the history and the symptoms you have provided, there could be three possibilities. Lets analyze it in detail further:
1. Recurrent Cholangitis (Inflammation and Infection of common bile duct)
2. Post Cholecsytectomy syndrome
3. Stent Infection (probably this is the reason of repeated replacement of stents)
4. Pancreatitis

I. Recurrent Cholangitis (tube carrying bile from liver to intestine) could have been one of the reason for repeat stent replacements and presence of klebsiella. However, your present complaints appears to be unlikely Recurrent Cholangitis or Pancreatitis, as the symptoms will never subside spontaneously without appropriate treatment.

Diagnosis of Cholangitis is based on typical history of pain in abdomen, fever and jaundice that can be confirmed by investigations. I would suggest you the following investigation to be done whenever you have complaints of high grade fever and abdominal pain

1. Complete Blood count: If the symptoms are due to Cholangitis , the WBC (Leucocyte ) count will definitely be elevated with raised neutrophils
2. Raised CRP
3. Liver Function test: Will show elevation of Serum Bilirubin level and other liver enzymes
4. Ultrasound of abdomen
5. Serum Amylase and Lipase: Normal levels at time of attack rules out Pancreatitis as the cause.

If the counts are normal, CRP normal and Liver function test normal during an attack it rules out Cholangitis as the cause of symptoms. Normal Serum Amylase and Lipase levels shall rule out Pancreatitis. Treatment to be done accordingly.

II. The next probability could be reinfection of stent. Stent being a foreign body acts as a nidus for infection. This explains your infection with Klebsiella too. The management would be removal of stent provided common bile duct is not dilated.

III. You have already undergone ERCP and everything is fine, which is very much reassuring. According to me, the cause of your recent symptoms could most likely be "Post cholecystectomy syndrome". It can produce symptoms which may mimic acute abdomen. It requires symptomatic treatment.

I would suggest you the following which will definitely help
1. Fat free or reduced fat diet
2. Plenty of oral fluids
3. High fiber diet
4. Vitamin Supplements
5. Combination of Proton pump inhibitor and anti-emetic : Suppressing the gastric acid by Pantoprozole and stomach motility increasing drug like Domperidone will provide much needed relief
6. Regularize food intake
7. Liquid antacid: Antacid containing Simethicone will be helpful.
8. Avoid caffeinated /carbonated / alcoholic beverages

Do get back to me for further information. Keep me updated about your progress.

Wishing you great health!

Take Care

Best Regards
Dr Deepak Kishore
MBBS,MS,MCH
Consultant Surgeon

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Brief Answer:
Possibly past episodes Cholangitis

Detailed Answer:
Hi
Greetings,

Liver enzymes in range of 400 and Bilirubin(total) in range of 4 with predominant direct (Conjugated ) Hyperbilirubinemia along with associated fever and pain definitely point towards diagnosis of Cholangitis. I hope Stones in CBD and sphincter stenosis have been ruled out during ERCP.
Stomach soreness and cramping, I would also like to rule out Gastritis as the cause. Has Helicobacteria Pylori infection been suspected anytime? During ERCP was there any pathology in Stomach which was detected?
In my clinical practise when I see patients presenting with such symptoms Cholangitis and Pancreatitis has been ruled out, I put them on empirical H Pylori eradication kit.

Do get back to me with the reports. Also kindly keep me updated about the progress. I always follow up all the individuals.

Wishing you great health!

Take Care

Best Regards
Deepak

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