Some patients will continue to have abdominal pain following cholecystectomy. The management of these patients depends on the diagnostic test findings.


Differential diagnosis:

(1) retained stone in the common bile duct: This is minimized by performing intraoperative cholangiography.

(2) dysfunction of the Sphincter of Oddi

(3) functional pain

(4) disorder elsewhere (esophagitis, peptic ulceration, pancreatitis, irritable bowel syndrome)


Step 1: Does the patient have pain consistent with biliary origin?

(1) Yes: Perform ultrasonography and liver function tests while the patient is experiencing pain.

(2) No: Consider alternative diagnoses.


Step 2: Are the ultrasonography and liver function tests all normal?

(1) Yes: Provide symptomatic therapy, including analgesics and/or reassurance.

(2) No: Perform ERCP and consider Sphincter of Oddi manometry.



• Ultrasonography is considered abnormal if it shows dilation of the common bile duct.

• Biliary manometry should only be done in carefully selected patients with definite evidence of a common bile duct disorder.


Step 3:

(1) Are the ERCP and/or Sphincter of Oddi manometry abnormal?

(2) Yes: Perform a sphincterotomy.

(3) No: Provide symptomatic therapy, including analgesics and/or reassurance.



• Patients with a basal pressure > 30 mm Hg tend to show improvement with sphincterotomy.

• ERCP with sphincterotomy is associated with acute pancreatitis in a significant number of patients.


ERCP is usually successful in the removal of a common bile duct stone. These stones are usually small and might be retrieved or passed. However, if the stone does not pass then it might be necessary to:

(1) try lithotripsy

(2) try chemical dissolution

(3) operate in order to remove the stone if symptoms persist or recurrent infection occurs.


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