Cholecystectomy Complications: ED Presentations, Evaluation, and Management

Authors: Michael J. Yoo, MD (EM Resident Physician, San Antonio, TX), Rachel E. Bridwell (@rebridwell, EM Resident Physician, San Antonio, TX), Daniel J. Reschke, MD (EM Attending Physician, San Antonio, TX) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Case

A 48-year-old woman, with a history of hyperlipidemia, obesity, and acute cholecystitis presents to the emergency department on post-operative day 4 status post laparoscopic cholecystectomy.  The patient reports that she has noticed yellowing of her skin, nausea, vomiting, and a decreased appetite.  Her husband accompanies the patient, who also states that the patient’s eyes have been yellowing as well.

On exam, the patient’s vital signs include BP 147/81, HR 101, RR 16, T 39°C, SpO2 99% RA.  The patient appears jaundiced with scleral icterus and has mild right upper quadrant abdominal pain without rebound or guarding.  The remainder of her exam is unremarkable.

What are the next steps in your evaluation and treatment?

Introduction

Cholecystectomies are one of the most common procedures performed in the United States, with approximately 750,000 operations each year.¹  Indications for cholecystectomy include gallstone cholecystitis, acalculous cholecystitis, symptomatic gallstones, biliary dysfunction, gallstone pancreatitis, polyps, and concern for malignancy.^1,2  Since the 1990s, a laparoscopic approach has replaced the open approach as the gold standard, though approximately 5% of laparoscopic procedures are converted to an open technique.³  In the laparoscopic technique, small abdominal incisions are made, allowing ports for insufflation, cameras, and surgical tools; this is in contrast to an open cholecystectomy where approximately a 6 inch incision is made near the site of the gallbladder.⁴  Per the Center for Disease Control, the rate of cholecystectomies as an outpatient has nearly matched the rate performed as an inpatient—approximately 22 in 10,000 inpatient discharges and 21 in 10,000 ambulatory surgery visits documented cholecystectomy as a coded procedure.⁵  With this high rate of cholecystectomies being performed, especially in the setting of the increasing number as an outpatient, emergency providers should understand several potential complications.

Evaluation Overview

Complaints associated with cholecystectomy are extensive, correlating with the wide range of possible complications that can present from the perioperative period to years later.  In the setting of a history of cholecystectomy, these complaints include but are not limited to: vague abdominal pain, nausea, vomiting, decreased oral intake, fever, chills, loose stools, and jaundice.  Complications include bile duct injury, biliary stricture, bowel injury, bleeding, dropped and retained stones, and infection.  While this article focuses specifically on these post-operative complications, we remind readers to always include other abdominal diagnoses such as acute appendicitis, hepatitis, cholangitis, pancreatitis, pyelonephritis, ureterolithiasis, aortic injury, and bowel ischemia.

Workup 

Pertinent findings that should lead the clinician to focus on post-cholecystectomy complications include acute anemia, persistently elevated liver enzymes, particularly bilirubin and alkaline phosphatase, jaundice, and fever, especially in the days following the procedure.  Although there are some nuances regarding the most common complications, the initial workup of the majority of post-cholecystectomy complications begin with a complete blood cell count and liver enzymes that include a differentiated bilirubin.  An abdominal ultrasound is an excellent initial imaging modality to evaluate for fluid collections, abscesses, hematomas, and retained stones.  In the emergency department, an equivocal ultrasound study should be followed with a computed tomography, which improves imaging for drop stones and intrahepatic abscesses.^6,7  If a high suspicion for biliary injury is present, a magnetic resonance cholangiopancreatography is the study of choice with 100% sensitivity for detecting and localizing biliary tree leaks.^6,7

Bile Duct Injury

As the gold-standard approach to cholecystectomies has moved from an open to laparoscopic technique, bile duct injuries and leaks have become more common, with an incidence ranging between 0.1%-0.5%.⁸  Unfortunately, as many as 90% of these injuries are not recognized during the procedure, with a median time to diagnosis varying from 1-2 weeks, though further delays as far as years has been documented.⁸  Adding to the complexity of catching bile duct injures, patients often present with non-specific symptoms, from vague abdominal pain, peritonitis, jaundice, and sepsis in the peri-operative period to cholangitis and biliary cirrhosis in latter periods.⁸  Ultimately, any patient appearing ill, especially within 48 hours of the procedure, should prompt a low threshold for bile duct injury investigation.

Workup for bile duct injuries include serum studies and several imaging modalities.  Liver function tests (LFT), especially alanine aminotransferase (ALT) and aspartate aminotransferase (AST) can be elevated following a cholecystectomy, with a mean of 1.8-fold increase and 2.2-fold increase, respectively.⁹  Although the exact etiology is unclear, these values should return to normal within 2-3 days.⁹  However, increases in bilirubin and alkaline phosphatase (ALKP) are less common, occurring in only 9% and 4% of post-operative patients, respectively.  A persistently elevated ALT or AST with concomitant elevations in bilirubin or ALKP should raise suspicion for a bile duct injury.^10,11

The initial imaging modality of choice should be an abdominal ultrasound.  Although intrafossa fluid can be seen in up to 10%-14% of patients, fluid collections outside the gallbladder fossa are not normal.⁹  In the setting of a non-diagnostic ultrasound (sensitivities of approximately 70%), a computed tomography provides improved sensitivity (approximately 96%) for detecting a fluid collection.¹²  While fluid collections are not diagnostic, in the setting of a recent cholecystectomy, they should be approached as bile duct injuries until proven otherwise.  Ultimately, magnetic resonance cholangiopancreatography is preferred for detecting bile duct leaks, which may be performed in the inpatient setting.^12,13

From the ED, initial management should focus on control of sepsis and coordinating drainage of any bile collection, with antibiotics and interventional radiology directed drainage placement.  Although immediate consultation with a surgeon should be performed, current literature demonstrates poorer outcomes if patients with peritonitis are taken for immediate surgical correction of the bile duct injury.¹⁴  Once stable, or if the presenting non-septic, patients should be evaluated for a corrective procedure with either a hepaticojejunostomy or end-to-end anastomosis.¹⁴

Biliary Stricture

Benign biliary strictures have many etiologies; however, the majority of strictures occur post-cholecystectomy. 30% of biliary strictures may present after 5 years post-cholecystectomy. ¹⁵  A biliary stricture occurs in approximately 10% of post-cholecystectomy bile duct damage repairs.¹⁶  Strictures result from intraoperative damage to the bile duct leading to inflammation, fibrotic changes, narrowing of the lumen, and ultimately post-hepatic biliary obstruction. This obstruction can be life threatening and lead to cholangitis, portal hypertension and cirrhosis.¹⁷  Excessive cautery or dissection around the bile ducts can lead to ischemia that may result in stricture formation.¹⁸  Biliary strictures present on a spectrum of mild to severe symptoms based on the amount of luminal narrowing. Presenting signs and symptoms may include nausea, vomiting, vague abdominal pain, and jaundice.

Work up is similar to other post-cholecystectomy complications and includes liver function tests and a complete blood count. Abdominal ultrasound is the first choice for imaging and can evaluate for intrahepatic bile duct dilatation. CT scan may more accurately diagnose the site of obstruction and MRCP is even more specific.

ED treatment includes antibiotics for cholangitis and supportive care. Patients may require urgent percutaneous decompression of the biliary system for severe obstruction. Definitive care may involve endoscopic stenting, percutaneous stenting, or surgical (i.e. cholangiojejunostomy).¹⁶  Prognosis is favorable with both endoscopic and surgical intervention.¹⁸

Bowel Injury

Data on bowel injury following cholecystectomy are lacking; one study showed that it comprises 4.7% of cholecystectomy complications.¹⁹  Intraoperatively, bowel can be injured during various steps: Veress needle introduction, trochar introduction, local dissection, and diathermy contact and conductive burns.²⁰  Though rare, bowel injury can be fatal due to sepsis from fecal peritonitis.  This is especially true as the injury is often not recognized at the time of surgery, and patients have a delayed presentation with severe sepsis.  Diathermy conductive burns in particular tend to present later as the injury occurs outside of the laparoscopic view.²¹  In one study patients presented a mean of 1.7 days after surgery. ²⁰   High suspicion and early detection by the emergency physician is key to decrease mortality which was reported as 35% when diagnosis of bowel injury was made after 1 day.²⁰

Bowel injury should be suspected in patients that present with severe pain, fever, vomiting, nausea, vomiting, and anorexia in the post-operative period.  Labs can be normal or show mild increases in bilirubin and amylase.  If an intraoperative drain was placed, an amylase level on the drained fluid should be sent.²⁰  A CT scan with oral contrast is highly sensitive to detect a bowel leak.  In the presence of equivocal imaging despite a high index of suspicion, exploratory laparotomy can be both diagnostic and therapeutic.  Endoscopy can also be used to detect small leaks secondary to air leak from endoscopy.²⁰

ED management involves fluid resuscitation, antibiotic coverage for enteric bacteria, and early surgical consultation.  Patients will require direct repair of injury and possible ileostomy.²⁰

Bleeding

Bleeding remains a complication of any operative procedure, whether performed laparoscopically or with an open approach.  With respect to cholecystectomies, the total reported incidence (both intraoperative and postoperative) ranges from 0.04% to 1.55%.²²  Depending on the source of the affected vessel, bleeding can be categorized into major and minor categories; bleeding from the aorta, vena cava, iliac, right hepatic artery, and portal vein are considered major while bleeding from the epigastric, mesenteric, and omental vessels are considered minor.²²  While the approach to intraoperative bleeding is well published in literature, post-operative bleeding, as a complication of cholecystectomies, is minimally described.²²  The estimated incidence of post-operative bleeding complications alone range from 0.69% to 1.05%.²⁰  Though less common, post-operative bleeding remains an important post-operative complication, with an incidence of reoperation of 0.5%.²³

Bleeding from incision sites and trochar (port) sites compose of the major sources of external bleeding.  These can present subacutely with oozing from the site or soaking through post-operative dressing.  Trochar bleeding may result from injury to abdominal wall vessels during instrument placement and subsequent hematoma development.  During the postoperative period, most of these cases are considered a minor pattern of bleeding. Bleeding can often be controlled with pressure, packing, and external suturing.²²  Less commonly, these warrant additional surgical correction, though several cases reported minimal blood loss and no need for blood transfusions even in the setting of an additional procedure.²³

The majority of internal bleeding occurs intraoperatively, at approximately 72%, and in the setting of cholecystectomies, accounts for a majority of the indications for conversion from a laparoscopic to open technique.²³  In contrast to external bleeding, internal bleeding often warrants additional wound exploration and blood transfusions.  In a major study looking at laparoscopic bleeding complications, cases of postoperative internal bleeding required blood transfusions in approximately 59% of cases and additional surgical treatment in 50.4% of cases.²³

In the post-operative period, patients who present with any vital sign abnormalities warrant further investigation for a source of bleeding.  In addition to obtaining a complete blood cell count to look at any hemoglobin and hematocrit changes, an ultrasound can be helpful in identifying heterogeneous fluid collections and especially hematomas.  If the ultrasound is equivocal, a contrasted computed tomography can be helpful in identifying the location of a hematoma, if present, or areas of active extravasation.²⁶

Dropped Gallstones

Dropped gallstones are a common complication of cholecystectomies, especially when performed laparoscopically, occurring in 0.1%-20% procedures.²⁴  This phenomenon occurs when the gallbladder perforates and the stones spill over during retrieval of the gallbladder.  The most common location for dropped stones include the subdiaphragmatic or subhepatic space.⁶  Although most lead to a benign clinical course and are asymptomatic, a small risk remains for abdominal abscess formation, local erosion, and fistula formation.⁶  Subsequently, dropped stones often take months to years after the incident depending on their clinical sequelae.^6,25  Across several publications, the recommendation for a dropped stone is immediate retrieval during the procedure.^6,25   With such an extensive range of complications from dropped gallstones, the clinical presentation of patients widely varies, to include pain, palpable mass, signs of infection, and bowel obstruction.²⁵

Though some gallstones are radiopaque, the initial workup should include ultrasound imaging and CT.²⁵  On ultrasound, gallstones appear as echogenic densities, within a cavity if there is a concomitant abscess; on CT, these can be confused with peritoneal metastasis, appearing as nodules.²⁵

Aside from typical resuscitation for infectious symptoms, management typically involves an additional procedure.  Abscesses are approached with drain placement, fistulas are dilated, and laparotomy for bowel obstruction.²⁵  Ultimately, the stone should be retrieved, either endoscopically through fistulas, or a repeat open or laparoscopic approach.²⁵

Post-cholecystectomy Syndrome

To briefly clarify, post-cholecystectomy syndrome (PCS) is an umbrella term applied to patients status post cholecystectomy who present with a wide range of symptoms to include abdominal pain, jaundice, and dyspepsia; the timing of post-cholecystectomy syndrome varies extensively.²⁶  These symptoms are similar to pre-cholecystectomy symptoms and occurs in as high as 40% of patients, with women affected more than men.²⁶  Several etiologies theorized to contribute to PCS and may contribute to an emergent condition have been discussed above.  Less emergent etiologies that will not be discussed in this article include: long cystic duct remnant, dyskinesis of the sphincter of Oddi, and gastritis.²⁶  Many symptoms are also associated with the hormonal changes associated with cholecystectomy, to include the cholecystosphincter of Oddi reflex, cholecystoantral reflex, and cholecystoesophageal reflex.²⁶  Fortunately, 90% of patients who undergo cholecystectomy eventually have significant interval improvement compared to pre-procedural symptoms.²⁶

Key Points

• Cholecystectomy is one of the most common procedures performed and can result in a variety of complications. Presenting symptoms common to most complications include anemia, fever, nausea, vomiting, and worsening pain.
• Evaluation for complications involves measuring CBC, AST/ALT, bilirubin, and alkaline phosphatase. Both ultrasound and CT are appropriate imaging studies for initial evaluation.
• Bile duct injury is often undetected at time of surgery and presentation can be delayed up to two weeks. Patients will need treatment for sepsis and surgical repair of the leak.
• Biliary stricture can present up to 5 years after surgery, and severity is based on the amount of luminal narrowing of the stricture. Patients may require emergent decompression of the bile duct system and stenting or surgical repair.
• Bowel injury is a rare complication, but associated with high mortality.
• The majority of post-operative bleeding is external and can be managed with packing, direct pressure, or suture. Post-operative internal bleeding is rare, but can be more severe.
• Patients with dropped gallstones may be asymptomatic or develop abscess, erosions, and fistulas. Patients with the complications require retrieval of the stone.
• Post cholecystectomy syndrome can be caused by a number of etiologies. Once a severe complication is ruled out, patients can be reassured that symptoms resolve for a majority of patients over time.

Case Resolution

Due to the patient’s habitus, a right upper quadrant ultrasound was difficult to obtain.  A CT of the abdomen revealed a large fluid collection near her liver, around her gallbladder fossa.  Serum studies resulted with an ALT of 240, AST of 220, ALKP of 600, and a total bilirubin of 2.6.  The patient was resuscitated in the ED with fluids and broad-spectrum antibiotics and admitted to the internal medicine service with a surgical consultation.  While an inpatient, the patient underwent an MRCP, which revealed a bile duct injury.  The patient received an interventional radiology placed percutaneous drain.  The patient continued to be treated on the wards, and a hepaticojejunostomy was scheduled with general surgery.

References/Further Reading:

¹ Stinton LM, Shaffer EA. Epidemiology of gallbladder disease: cholelithiasis and cancer. Gut Liver. 2012;6(2):172–187.

² Hassler KR, Jones MW. Laparoscopic Cholecystectomy. StatPearls [Internet]. 2017.

³ Sakpal SV, Bindra SS, Chamberlain RS. Laparoscopic cholecystectomy conversion rates two decades later. Journal of Surgical Research. 2010;158(2):476–483.

⁴ Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. The Lancet. 1998;351(9099):321–325.

⁵ Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory Surgery Data From Hospitals and Ambulatory Surgery Centers: United States, 2010. National health statistics reports. 2017;102:1–15.

⁶ Thurley PD, Dhingsa R. Laparoscopic Cholecystectomy: Postoperative Imaging. American Journal of Roentgenology. 2008;191(3):794-801.

⁷ Aduna M, Larena JA, Martín D, Martínez-Guereñu B, Aguirre I, Astigarraga E. Bile duct leaks after laparoscopic cholecystectomy: value of contrast-enhanced MRCP. Abdominal Imaging. 2005;30(4):480–487.

⁸ Halevy A, Gold-Deutch R, Negri M, Lin G, Shlamkovich N, Evans S, Cotariu D, Scapa E, Bahar M, Sackier JM. Are elevated liver enzymes and bilirubin levels significant after laparoscopic cholecystectomy in the absence of bile duct injury? Annals of Surgery. 1994;219(4):362–364.

⁹ Frilling A, Li J, Weber F, Frühauf NR, Engel J, Beckebaum S, Paul A, Zöpf T, Malago M, Broelsch CE. Major bile duct injuries after laparoscopic cholecystectomy: a tertiary center experience. Journal of Gastrointestinal Surgery. 2004;8(6):679–685.

¹⁰ Andrei VE, Schein M, Margolis M, Rucinski JC, Wise L. Liver enzymes are commonly elevated following laparoscopic cholecystectomy: is elevated intra‐abdominal pressure the cause? Digestive Surgery.1998;15(3):256–259.

¹¹ Lee CM, Stewart L, Way LW. Postcholecystectomy abdominal bile collections. Archives of Surgery. 2000;135(5):538–544.

¹² Wu JS, Peng C, Mao XH, Lv P. Bile duct injuries associated with laparoscopic and open cholecystectomy: sixteen-year experience. World Journal of Gastroenterology.  2007;13(16):2374–2378.

¹³ Sicklick JK, Camp MS, Lillemoe KD, Melton GB, Yeo CJ, Campbell KA, Talamini MA, Pitt HA, Coleman J, Sauter PA, Cameron JL. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Annals of Surgery. 2005;241(5):786–795.

¹⁴ Dadhwal US, Vipon K. Benign Bile Duct Strictures. Medical Journal Armed Forces India. 2012;68(3):399–303.

¹⁵ Sugawara G, Masato N. Response to Re: Management Strategy for Biliary Stricture Following Laparoscopic Cholecystectomy. Journal of Hepato-Biliary-Pancreatic Sciences. 2015;22(6):E36.

¹⁶ Lillemoe KD, Melton GB, Cameron JL, Pitt HA, Campbell KA, Talamini MA, Sauter PA, Coleman J, Yeo CJ. Postoperative Bile Duct Strictures: Management and Outcome in the 1990s. Annals of Surgery. 2000;232(3):430.

¹⁷ Davids PH, Tanka AK, Rauws EA, van Gulik TM, van Leeuwen DJ, de Wit LT, Verbeek PC, Huibregtse K, van der Heyde MN, Tytgat GN. Benign Biliary Strictures. Surgery or Endoscopy? Annals of Surgery. 1993;217(3):217–237.

¹⁸  Gupta V, Gupta A, Yadav TD, Mittal BR, Kochhar R. Post-Cholecystectomy Acute Injury: What Can Go Wrong? Annals of Hepato-Biliary-Pancreatic Surgery. 2019;23(2):138.

¹⁹ Machado, NO. Duodenal Injury Post Laparoscopic Cholecystectomy: Incidence, Mechanism, Management and Outcome. World Journal of Gastrointestinal Surgery. 2016;8(4):335.

²⁰ Polychronidis, A, Tsaroucha AK, Karayiannakis AJ, Perente S, Efstathiou E, Simopoulos C.  Delayed Perforation of the Large Bowel Due to Thermal Injury during Laparoscopic Cholecystectomy. Journal of International Medical Research. 2005;33(3):360–363.

²¹ Kaushik R. Bleeding complications in laparoscopic cholecystectomy: Incidence, mechanisms, prevention and management. Journal of Minimal Access Surgery. 2010;6(3):59–65.

²² Suuronen S, Kivivuori A, Tuimala J, Paajanen H. Bleeding complications in cholecystectomy: a register study of over 22,000 cholecystectomies in Finland. BMC Surgery. 2015;15:97.

²³ Schäfer M, Lauper M, Krähenbühl L. A nation’s experience of bleeding complications during laparoscopy. The American Journal of Surgery. 2000;180(1):73–77.

²⁴ Brockmann JG, Kocher T, Senninger NJ, Schürmann GM. Complications due to gallstones lost during laparoscopic cholecystectomy. Surgical Endoscopy. 2002;16:1226–1232.

 ²⁵ Jabbari NA, Hassanpour M, Jangjoo A. Consequences of Lost Gallstones During Laparoscopic Cholecystectomy. Surgical Laparoscopy Endoscopy Percutaneous Techniques. 2016;26(3):183–192.

²⁶ Jaunoo SS, Mohandas S, Almond L. Postcholecystectomy syndrome (PCS). International Journal of Surgery. 2010;8(1):15–17.