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Postcholecystectomy syndrome (PCS) refers the presence of symptoms after cholecystectomy (removal of the gallbladder). These symptoms can represent either the continuation of symptoms thought to be caused by the gallbladder or the development of new symptoms normally attributed to the gallbladder. Postcholecystectomy syndrome also includes the development of symptoms caused by removal of the gallbladder. Postcholecystectomy syndrome reportedly affects about 10% to 15% of patients who have had this surgery. This condition is caused by alterations in bile flow due to the loss of the reservoir function of the gallbladder. Due to this, two main groups may arise. On the one hand, because of continuously increased bile flow into the upper gastrointestinal (GI) tract, esophagitis and gastritis may result in nausea and indigestion. On the other hand, in the lower GI tract, there may be distention, flatulence, diarrhea, and colicky lower-abdominal pain. Generalized symptoms may also include fever and jaundice.

Unfortunately, Western medicine does not provide much in the way of treatment for PCS other than further surgery (endoscopic sphincterotomy to relieve recurrent pain due to sphincter of Oddi dysfunction). However, if there is postcholecystectomy pain and no objective abnormalities, then even this surgery is not indicated. Happily, Zhu An-long of the No. 1 Jin Chang Municipal People's Hospital in Gansu published an article on the Chinese medical treatment of PCS involving a protocol that, based on the research in this article, shows great promise. Zhu's article appeared on pages 630–631 of issue 10, 2008 of Shi Yong Zhong Yi Yao Za Zhi (Journal of Practical Chinese Medicine & Pharmacology). It is titled "The Treatment of 34 Cases of Postcholecystectomy Syndrome with Jia Wei Si Ni San." A summary of this article is presented below.

Cohort description:
Among the 34 cases enrolled in this cohort study, there were 18 males and 16 females 30 to 66 years old, with an average age of 49 years. Due to cholecystitis and cholelithiasis, all the patients had undergone a cholecystectomy within one month to six years of participation in this study. All these patients exhibited right upper abdominal pain. Twenty-eight of these cases also experienced pain radiating to the right shoulder and upper back. At least two times since their original surgery, all patients had been examined with ultrasonography with no positive findings. Sixteen patients had also had endoscopic retrograde cholangiopancreatography (ERCP). In three of those cases, there were small stones lodged in the common bile duct, while in one case, there was a small stone (2.5 centimeters) lodged in the gallbladder duct.

Treatment method:

Jia Wei Si Ni San (Added Flavors Four Counterflows Powder) consisted of:

• Chai Hu (Radix Bupleuri), 10g
• stir-fried Zhi Shi (Fructus Immaturus Aurantii), 10g
• Chi Shao (Radix Rubra Paeoniae), 15g
• Bai Shao (Radix Alba Paeoniae), 15g
• Yu Jin (Tuber Curcumae), 15g
• Mu Xiang (Radix Auklandiae), 10g
• Chuan Lian Zi (Fructus Toosendam), 6g
• processed Yan Hu Suo (Rhizoma Corydalis), 15g
• Dan Shen (Radix Salviae Miltiorrhizae), 30g
• Ban Xia (Rhizoma Pinelliae), 10g
• Fu Ling (Poria), 10g
• Chen Pi (Pericarpium Citri Reticulatae), 10g
• stir-fried Lai Fu Zi (Semen Raphani), 15g
• mix-fried Gan Cao (Radix Glycyrrhizae), 6g

If liver depression was severe, then 10 grams each of Xiang Fu (Rhizoma Cyperi) and Fo Shou (Fructus Citri Sacrodactylis) and 9 grams of Qing Pi (Pericarpium Citri Reticulatae Viride) were added.

If liver depression transformed fire, 9 grams each of Huang Qin (Radix Scutellariae) and scorched Zhi Zi (Fructus Gardeniae) were added.

If abdominal distention was severe, 15 grams of Hou Po (Cortex Magnoliae Officinalis), 9 grams of Bing Lang (Semen Arecae), and 8 grams of Wu Yao (Radix Linderae) were added.

If there was vomiting of bitter water (bile), 30 grams of Dai Zhe Shi (Haemititum) decocted first, and 10 grams of Zhu Ru (Caulis Bambusae In Taeniam) were added.
If rib-side pain was severe, 15 grams each of Tao Ren (Semen Persicae) and Dang Gui (Radix Angelicae Sinensis) were added.

If there was constipation, 10 grams of cooked Da Huang (Radix Et Rhizoma Rhei) and 30 grams of Huo Ma Ren (Semen Cannabis Sativae) were added.

If there was torpid intake (poor appetite) and loose stools, then Lai Fu Zi was deleted and 10 grams each of scorched Bai Zhu (Rhizoma Atractylodis Macrocephalae), Sha Ren (Fructus Amomi), and scorched San Xian (Three Immortals: Shen Qu, Massa Medica Fermentata; Shan Zha, Fructus Crataegi; and Mai Ya, Fructus Germinatus Hordei) were added.

If there were stones in the common bile duct, 30 grams of Jin Qian Cao (Herba Desmodii/Lysimachiae) and 15 grams of Ji Nei Jin (Endothelium Corneum Gigeriae Galli) were added.

One packet of these medicinals was decocted in water and administered per day, with two weeks' administration equaling one course of treatment. Results were analyzed after one such course.

Outcomes Criteria
Cure was defined as disappearance of clinical symptoms with normal ultrasound and X-ray examinations. Improvement was defined as basic improvement in clinical symptoms with improvement in ultrasound and X-ray examinations or no change. No effect was defined as partial improvement in clinical symptoms, shorter duration of symptoms when they occurred, and no improvement in either ultrasound or X-ray examination.

Study Outcomes
Based on the preceding criteria, 21 cases (61.8%) were judged cured, while 10 cases (29.4%) were judged improved. Only three cases (8.8%) experienced no effect. Therefore, the published total effectiveness rate was 91.1%.

Discussion
After reviewing the Western medical anatomy and pathophysiology of PCS, Dr. Zhu says that, based on his clinical experience, the occurrence of PCS in most cases is related to emotional stress and overeating oily, fatty foods. In Chinese medicine, the abdomen is ruled by tai yin (the spleen) and is traversed by the liver vessels. Therefore, postsurgical abdominal pain is related to liver depression and nonsmooth flow of qi resulting in a liver-spleen disharmony. This means that the liver is depressed and the spleen in vacuous. If the liver qi becomes depressed and bound, it loses its spreading and extending. This results in the liver qi counterflowing horizontally to check and assail spleen earth. If the stomach qi does not downbear, then the gallbladder qi counterflows upward, and the upbearing and downbearing of the qi mechanism or dynamic lose their normalcy. Surgery is a form of cutting damage. Therefore, postsurgery, there are blockages and obstructions in the affected area caused by adhesions. This results in the movement of the blood losing its smooth and easy flow. Instead, the vessels and network vessels become static and obstructed. In sum, Dr. Zhu believes that the disease mechanisms of PCS are a combination of three factors: 1) liver depression qi stagnation, 2) stomach loss of harmony and downbearing, and 3) static blood obstruction and stagnation. Therefore, he believes that treatment of this condition should course the liver and resolve depression, rectify the qi and harmonize the stomach, transform stasis, and stop pain.

Thus, within Jia Wei Si Ni San, Chai Hu courses the liver and resolves depression, while Zhi Shi moves the qi, disperses stagnation, and downbears turbidity. Bai Shao nourishes the blood and restrains yin, softens or emolliates the liver, and harmonizes the blood. Chi Shao cools and quickens the blood and scatters stasis. Ban Xia harmonizes the stomach and downbears counterflow, disperses glomus, and scatters binding. Fu Ling fortifies the spleen and supplements the center. It also quiets the spirit. Chen Pi rectifies the qi and harmonizes the stomach. Dan Shen quickens the blood and transforms stasis. Once stasis has been eliminating, new (tissue and/or qi and blood) can be engendered. It also disperses swelling and stops pain. Yu Jin moves the qi and resolves depression, cools the blood and transforms stasis. Mu Xiang moves the qi and disperses distention. Chuan Lian Zi courses the liver and discharges heat, resolves depression and stops pain. Processed Yan Hu Suo is acrid, scattering, and warm and frees the flow. It quickens the blood and scatters stasis, rectifies the qi and stops pain. Stir-fried Lai Fu Zi normalizes the flow of qi and opens depression, disperses food, and transforms stasis. And finally, mix-fried Gan Cao regulates and harmonizes all the other medicinals in this formula. In addition, when combined with Bai Shao, it relaxes cramping and stops pain. Hence, when all these medicinals are combined together, their effect is to course the liver and resolve depression, rectify the qi and harmonize the stomach, quicken the blood and transform stasis, free the flow of the network vessels, and stop pain. When the liver qi obtains soothing, the gallbladder (qi) follows the stomach (qi)'s downbearing, the vessels and network vessels are freely and smoothly or easily flowing, and the qi mechanism's upbearing and downbearing regain their normalcy, then all the symptoms of this condition are automatically cured.

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