Studies have shown that the vast majority of patients (80%) with choledocholithiasis following cholecystectomy will present within 3 years of surgery. Delayed choledocholithiasis has been reported in patients with the most common etiologies being retained or regeneration of stones within a gallbladder remnant or cystic duct. It is estimated that between 3.4 and 10% of patients have choledocholithiasis at the time of cholecystectomy. Risk factors identified for complicated choledocholithiasis are Asian descent, increasing age, and male gender. It is estimated that up to 15% of patients <60 years of age have stones in the common bile duct, whereas it can be as high as 60% in the elderly. DiscussionĬholedocholithiasis refers to the presence of bile duct stones. The patient was asked to follow-up with his gastroenterologist as an outpatient. The patient tolerated the procedure well and was successfully treated with antibiotics and discharged home. A complete sphincterotomy was performed, and multiple black pigmented stones were removed. There were multiple hyperdensities within the bile ducts particularly at the junction of the right and left hepatic ducts in addition to the distal CBD, consistent with choledocholithiasis (Figures 1– 3).ĮRCP images demonstrate multiple filling defects (green arrows) within the common bile duct with moderate dilatation of the extra- and intrahepatic biliary tree. In addition, the patient was noted to have hyperbilirubinemia to 4.5 with elevated liver enzymes (ALT 413, AST 340, and ALP 203).Ī CT scan of the abdomen and pelvis with oral and intravenous contrast demonstrated dilated intrahepatic and extrahepatic biliary ducts with the common bile duct measuring up to 12 mm. In the ED, the patient had a temperature of 102.3☏, leukocytosis with left shift, and a positive urinalysis. Afterwards, the patient developed mild, diffuse, constant abdominal pain with nausea that worsened on the day of presentation, prompting his ED visit. The patient stated that he had eaten at a fast food restaurant one day prior to presentation. The patient’s medical history included hyperlipidemia and cholecystectomy 15 years prior to presentation. CaseĪn 86-year-old male presented to the Emergency Department (ED) with complaints of abdominal pain. We report a unique case of intra- and extrahepatic choledocholithiasis 15 years following laparoscopic cholecystectomy secondary to a primary biliary stone. Most of these reports describe the presence of stones within the gallbladder/cystic duct remnant or secondary to migrating surgical clips. There have been only a few case reports of postcholecystectomy bile duct stones occurring more than 10 years following surgery in the literature. The condition is especially common within the first three years postprocedure. Postcholecystectomy syndrome can be secondary to dysfunction of the sphincter of Oddi, traumatic stricture, retained CBD stones or retained stones within a gallbladder remnant. Most patients experience relief of symptoms after LC, but a small number experience postcholecystectomy syndrome, which presents as biliary colic. For patients suspected of having CBD stones, endoscopic retrograde cholangiopancreatography (ERCP) plays an important role preoperatively. The prevalence of common bile duct (CBD) stones with concomitant gallstones increases with age from 8–15% in patients <60 years of age and up to 60% in the elderly. Gallstone disease is extremely prevalent in the western society with laparoscopic cholecystectomy (LC) being the standard treatment for patients with symptomatic gallstones. There have been only a few case reports of postcholecystectomy bile duct stones occurring more than 10 years following surgery in the literature.
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