1418 A Troublesome Remnant

Abstract

INTRODUCTION: Postcholecystectomy syndrome (PCS) is the persistence of symptoms of biliary colic after cholecystectomy. Although PCS is relatively common with multiple etiologies, a remnant cystic duct is a rare etiology accounting for only 2.5% of cases. Mirizzi's syndrome is a rare cause of PCS due to a remnant cystic duct stone. CASE DESCRIPTION/METHODS: A 34-year-old female with a history of choledocholithiasis status-post cholecystectomy 6 years prior presented with severe, constant, sharp right upper quadrant pain with nausea and vomiting for 1 day. She had abdominal tenderness with a negative Murphy sign. She was found to have elevated liver chemistries. Patient had two hospitalizations within the past year with similar presentations with the finding of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) on both occasions. Magnetic retrograde cholangiopancreatography (MRCP) showed a dilated, remnant cystic duct with filling defect indicative of obstruction caused by the stone. ERCP was done with removal of one stone followed by surgical resection of the remnant cystic duct with an endoluminal stone. DISCUSSION: The cystic duct typically measures 2-4 cm in length, and formation of stone in the structure leads to symptoms of dyspepsia, nausea, vomiting, and possibly jaundice. Cholecystectomy provides symptom relief to 85% of patients. After cholecystectomy, an incomplete surgery can leave a residual duct of greater than 1 cm in length, defined as a cystic duct or gallbladder remnant. Formation of calculi in this structure can lead to PCS. PCS can present as continuation of symptoms after the operation or after an interval of 2 days to 25 years after disease free period. PCS has been reported in 5 to 40% of patients post-cholecystectomy. Most common causes are extrabiliary, however, biliary etiologies are not uncommon. The incidence of PCS due to remnant cystic duct has been reported to be less than 2.5%. Identifying and promptly treating the underlying etiology are important to minimize morbidity. Cystic duct remnant stones may predispose a patient to postcholecystectomy Mirizzi's syndrome. While difficult to diagnose with different imaging studies, this can be effectively diagnosed with MRCP and treated with ERCP. One study showed that ERCP/MRCP failed to identify 2 out of 3 patients with a remnant cystic duct. While endoscopic therapy is an effective and safe alternative to surgery for postcholecystectomy Mirizzi's syndrome, surgical intervention is a definite treatment.