CAUSES AND MANAGEMENT OF RECURRENT BILIARY PAIN AFTER SUCCESSFUL NONOPERATIVE GALLSTONE TREATMENT

Objective: To evaluate the frequency and causes of recurrent biliary c olic after successful extracorporeal shock wave lithotripsy of gallsto nes. Methods: Follow-up of 77 patients for 2 yr (median) after complet e gallstone clearance by lithotripsy and adjuvant oral litholysis. All patients with recurrent biliary colic were examined thoroughly (labor atory data, ultrasonography, gastroscopy); the examination included ga llbladder motility testing. If the patients suffered from additional g astrointestinal complaints, further symptom-guided investigations (pH- metry, lactose absorption study, enteroclysis, colonic transit time, c olonoscopy) were performed. Patients without documented gallstone recu rrence underwent ERCP and sphincter of Oddi manometry. Cholecystectomy was advised for patients in whom gallstones recurred, and patients wi th sphincter of Oddi dysfunction underwent endoscopic sphincterotomy. If other gastrointestinal disorders were diagnosed, appropriate treatm ent was initiated. Results: Twenty-seven patients (35%) experienced bi liary colic during follow-up. Gallstone recurrence was documented in 1 7 patients, and 16 of the patients who underwent cholecystectomy becam e symptom-free again (follow-up: 12 months). Gallbladder hypomotility was revealed in seven of the 17 patients with gallstone recurrence com pared to none of the 10 patients without gallstone recurrence (p < 0.0 5). Microlithiasis was not detected in bile samples from the patients whose gallstones did not recur. Sphincter of Oddi dysfunction was foun d in four patients, and sphincterotomy cured all of them (follow-up: 9 months). Two of the remaining six patients had functional gastrointes tinal disorders (reflux, constipation) and became asymptomatic after s pecific treatment. Conclusions: Biliary colic often recurs after succe ssful gallstone lithotripsy. Recurrent gallbladder stones are the main cause, but another cause is sphincter of Oddi dysfunction. Neither ga llbladder hypomotility nor microlithiasis seems to cause biliary sympt oms in patients without recurrence of gallstones.