Cholelithiasis occurs when stones within the gallbladder are present. Choledocholithasis is when a stone is specifically lodged into the common bile duct (CBD). This can result in an obstruction which decreases flow of bile into the duodenum. If stones are symptomatic, a cholecystectomy is performed. In the modern era, cholecystectomy is performed laparoscopically with clips placed on the cystic duct and cystic artery. The gallbladder is extracted with the help of cauterization. However, before laparoscopic technology was available, open cholecystectomies were performed. Open cholecystectomies were the standard of treatment until 1991. So it is more likely that this patient underwent an open cholecystectomy. A complication of cholecystectomy is postcholecystectomy syndrome, which is defined as heterogeneous symptoms that persist or recur despite cholecystectomy. A 88 year old female presents with nausea, vomiting, weakness and altered mental status. On exam she had right upper quadrant (RUQ) tenderness. History was significant for cholecystectomy in the 1980s and pancreatitis requiring an ERCP and stent in 2004. Since then she denies significant issues pertaining to her surgical history. CXR revealed a metal clip from cholecystectomy. RUQ ultrasound was performed and revealed common bile duct dilation and possible obstruction from stone, but absent gallbladder. Magnetic resonance cholangiopancreatography (MRCP) was performed and revealed a filling defect and dilation of 17mm within the distal common bile duct indicating a common bile duct stone. Patient needs to undergo possible intervention to prevent potential cholangitis. Patient was transferred for further testing and possible treatment with endoscopic retrograde cholangiopancreatography (ERCP).

This case has an unusually delayed presentation of choledocholithiasis status post cholecystectomy. Although extremely rare, a CBD stone found, even forty years after cholecystectomy, is a potential cause of late postcholecystectomy syndrome. The extremely late onset of symptoms make this case unique.

References

Michael Simon, Irfan Nazir Hassan, Dhanasekaran Ramasamy, David Wilson, “Primary Choledocholithiasis 15 Years Postcholecystectomy”, Case Reports in Medicine, vol. 2020, Article ID 3265010, 3 pages, 2020. https://doi.org/10.1155/2020/3265010

Laparoscopic Remnant Cholecystectomy and Transcystic Common Bile Duct Exploration for Gallbladder/Cystic Duct Remnant with Stones and Choledocholithiasis After Cholecystectomy

Zhu, Jie-gao and Zhang, Zhong-tao. “Laparoscopic Remnant Cholecystectomy and Transcystic Common Bile Duct Exploration for Gallbladder/Cystic Duct Remnant with Stones and Choledocholithiasis After Cholecystectomy,” Journal of Laparoendoscopic & Advanced Surgical Techniques, Vol 25, Issue 1. Jan 2015.7-11.http://doi.org/10.1089/lap.2014.0186

https://www.liebertpub.com/doi/10.1089/lap.2014.0186 Choledocholithiasis

McNicoll CF, Pastorino A, Farooq U, et al. Choledocholithiasis. [Updated 2022 Jul 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441961/

Open Cholecystectomy Jones MW, Guay E, Deppen JG. Open Cholecystectomy. [Updated 2022 Apr 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448176/

Laparoscopic Cholecystectomy

Ashley, S. W., & Chen, W. (2022). Laproscopic Cholecystectomy. UpToDate. Retrieved November 15, 2022, from https://www-uptodate-com.lmunet.idm.oclc.org/contents/laparoscopic-cholecystectomy?sectionName=Postcholecystectomy+syndrome&search=post+cholecystectomy+syndrome&topicRef=3681&anchor=H689178094&source=see_link#H689178094