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What Causes Severe Abdominal Pain After Cholecystectomy?

Posted on Tue, 19 May 2015

Question: I am a 68 year old male caucasian. About 4 years ago I had a gall bladder removal due to stones and sludge. I was having moderate to severe pain. It was a laproscopic procedure with no complications.
Three weeks after the surgery I started having moderate pain in my abdomen. The pain seemed to be located in the lower center area near the upper part of my small intestin. I went back to my surgeon who referred me to a gastro Doctor. The new Doctor did some tests and found nothing that would be causing the pain. Ths first six months after the cholecystectomy I lost from 198 pounds to 162 pounds.
After almost four years I'm now at 146 pounds. The pain never did go away and has become much worse. My blood work is normal except the alkaline phosphatase remains slightly elevated. The level of the pain varies some, sending me to the emergency room two times in the last year. Doctors found nothing. A few months after the first episode of pain, my gastroenterologist did find sludge and small stones in the bile duct in my liver, placed a temporary stint in the bile duct but removed it 6 weeks later. The pain now comes everyday and is usually so intense it completely puts a stop to any activies I have. I have been to 4 different Gastroenterologists. All have told me they have no answers. Is there any help for me? Other than this I have been a healthy working man all my life. Any suggestions of where to go now would be a blessing. Thank you. XXXXXXX C.

Answered by Dr. T Chandrakant (2 hours later)

Brief Answer:
Please give details

Detailed Answer:
Hi.
Thanks for your query.
I can understand the plight you must be going through.

To recapitulate: Male/68 - Cholecystectomy 4 yrs - pain started 3 weeks after surgery - lower center area near the upper part - lost from 198 pounds to 162 to 146 now -**alkaline phosphatase remains slightly elevated - found sludge and small stones in the bile duct - stent for **6 weeks - pain now comes everyday - so intense that it completely puts a stop to any activities - 4 different Gastroenterologist - no answers - camera endo - upper GI with 4 procedures - *PPI worsens the pain - TURP 12 years - impotent - current medications noted

My thoughts and few details requested from your side before we go ahead with discussion:
- *alkaline phosphatase remains slightly elevated > indicates the cause is obstructive.
- *stent for 6 weeks > Was this period without pain or at least some alterations in pain intensity or pattern ?
- *PPI worsens the pain > I have to find the cause.

**Please tell me in details about pain:
- Type > spasmodic / burning / twisting / throbbing or anything you can explain the best as you perceive.
- Relation to food / beverages
- Any aggravating factors?
- Any relieving factors?
- Any reference to the back or any other site?
- Please tell me the exact site of pain.
- Relief with 6 weeks of stent (said above)
- Any other points you would like to add to my knowledge that can help us both, may be related or not related.
- Any other procedures like ERCP, MRCP, Endoscopic Ultrasonography done, please post reports if available with you.

All these points may help us to get to the diagnosis. Once the diagnosis is done, treatment may be easy.

Awaiting for your feedback.
Thanks you.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. T Chandrakant (24 hours later)

I will do my best to give you more information about the pain I have.
1. The stent placed in liver bile duct did make slight difference in pain. It's been almost 4 years and is hard to recall. The doctor chose not to place permanent stent for reason I can't remember. The question that I had was if the bile duct was partially blocked before the stent, what would keep it from becoming blocked after the stent was removed. I don't recall what the Dr. said. So long ago and never saw this Dr. again.
2.The pain is like a cramp in the foot or calf except it doesn't go away. I have days when the pain is not as intense as others but the discomfort is always there.
3. I have noticed that body position seems to make a difference. When I wake before I get up I don't notice the pain. Within 10 minutes after I stand the pain is there. Also I can get some relief by lying on my back for a period of time.
4. No food in particular seems to be a trigger. I drink only water. I hurt whether I eat or not and my diet is strictly low fat. I have had tests for gluten/dairy sensitivity which came back negative. I never have heartburn or symptoms indicating GERD.
5. The pain seems to be coming from the lower center of the abdomen. When the pain is at its worst I get very short of breath. I have another endoscopy scheduled in a month. I have been taken to ER two times in the last 3 months with unbearable pain. Had bloodwork done showing no problems except elevated alkaline phosphatase, given pain medication and sent home. I do respond to pain relieving drugs.

Experiencing much pain now, must lie down. Please respond.

Answered by Dr. T Chandrakant (45 minutes later)

Brief Answer:
Further investigations.

Detailed Answer:
Thanks for your feedback.

Read and understood the feedback and its coherence.
- I can understand what you mean by difficult to remember, it was not possibly that effective.
- Pain like a cramp in the calf
-Pain starts after 10 minutes after standing from the bed.
- Relief on lying down on back
- No relation to food.
- Lower center of the abdomen.
- Shortness of breath when pain at its worst.
- **Another Endo >
- Elevated Alk Phos
- Responds to painkillers

I think you need a detailed work-up, which for some or the other reason is being not yet done:
- CT scan of the abdomen.
- Barium studies for the stomach and intestines.
- ERCP (Endoscopic Retrograde Cholangio-Pancreatography), need the X-ray plates for examination.
- MRCP (Magnetic Resonance Cholangiopancreatography)
These are the investigations that may complete the real investigations in such a case to find the cause.If not yet done, you may please demand for this for completion of the study, then only it is possible to get to the diagnosis.

Once the diagnosis is done, it is possible to have a plan for te treatment and alleviation from the ''pain''.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. T Chandrakant (3 hours later)

Just a shot in the dark. About a year ago my chiropractor while discussing my pain suggested the possibility that I may have an internal hernia. The fact that I get relief from the pain by lying on my back might suggest that an organ is not supported the way it should be. The fact that this started after the gall bladder procedure was of interest to my back Doctor. Is this a possibility? I mentioned this to one of my GI docs and got the -"let's change the subject" - response. Is this possible? I did this earlier today, the pain was really sharp and after lying down for 10 minutes, the edge was gone from the pain. Upon rising it slowly came back. Please talk to me about this. Thank You So Much. Also I talked to the surgeon that did the operation and he immediately told me to see a GI doctor. That was almost 4 years and 4 Doctors ago.

Answered by Dr. T Chandrakant (29 minutes later)

Brief Answer:
Diagnostic Laparoscopy

Detailed Answer:
Great.
This is what will be ruled out or confirmed by combined approach of Contrast enhanced CT scan and Barium studies. One of the differential diagnosis is internal hernia .

There is another possibility of something stuck at the internal sites of ports. But this can be diagnosed only by a Diagnostic Laparoscopy and if found, the solution is small and very result oriented; just release it.
This may be the reason of typical pain increase on standing and getting relieved on lying down.

There is not much of a role of a Gastroenterologist (Medical ones), you need to see a Surgeon. Talk about the above procedures and particularly the ''diagnostic Laparoscopy''.

I hope this helps. Let us find out the reason, correct it and get pain-free.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. T Chandrakant (15 hours later)

I am recalling more about what my last GI Doctor told me probably 2 years ago, just before I told my wife,"no more Doctors" The last test I took, a HYDASCAN as I remember indicated moderate bile reflux causing gastritus. To what degree was not discussed. I'm trying to see my regular Doctor today. Don't know where he will send me. Going to talk to him about taking another PPI. Never tried Nexium, maybe it will be the one. I'm open to suggestions. Again, thank you very much. I will take a copy of the options and suggestions you have given. He is a good Doctor and very receptive to trying new medications. One more recollection, I remember one Doctor saying something about the Pyloric Sphincter being cut, don't know quiet what this means. I live in a rural location and traveling to a Doctor is 1 hour plus.

Answered by Dr. T Chandrakant (3 hours later)

Brief Answer:
Pl give feedback about discussion with Doctor, insist on investigations

Detailed Answer:
HIDA scan showing bile reflux- bile reflux may not cause such symptoms as you have.
Let us see what your regulator Doctor has to say after the discussion about our points in discussion.

It is not the pyloric sphincter, they are most probable talking about sphincter of Oddi- the one that guards the bile and pancreatic duct entry in to the small intestine (duodenum).

I can understand the time taken to reach the Doctor.

Note: Revert back with your health reports to get further guidance on your gastric problems. Click here.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar