Pain in my Colic: Absent Cystic Duct With Recurrent Gallstone Pancreatitis

Abstract

Introduction: Since its introduction in 1989, laparoscopic cholecystectomy has become the most commonly used treatment for gallbladder disease. With increasing rates since its incorporation in the health care setting, it is vital for physicians and surgeons to understand the anatomy of the biliary system as well as any anomalies that they might encounter. We present a case of an absent cystic duct, arare anomaly with only 11 reported cases, which can lead to severe surgical complications. A 58-year-old female with a past medical history of hypertension, biliary colic, status post tubal ligation and salpingectomy for ectopic pregnancy, presented to the emergency department for evaluation for recurrent epigastric and right upper quadrant pain radiating to her back, described as sharp and 3 days’ duration. She also complained of malaise, tenderness in her abdomen, nausea, and vomiting. On admission, vitals were 154/85, pulse 56, respirations 17, and temperature 98.0 F. Current medications included enalapril and atenolol/HCTZ. Labs were significant for amylase 3061, lipase >400, ALP 264, CK 180, and AST 425, and ALT 545. CT abdomen showed mild peripancreatic stranding suspicious of mild pancreatitis. Abdominal ultrasound was significant for cholithiasis. She was treated conservatively, her symptoms abated, and was taken for cholecystecomy due to the presence of gallstones. Initially, the patient was taken for laproscopic cholecystectomy, which showed a thickened gallbladder with multiple adhesions and adhesiolysis was performed. With careful dissection, it appeared that the gallbladder connected to the common bile duct with no obvious evidence of a cystic duct. The common bile duct (CBD) was also very inflamed. A decision was made to perform an operative cholangiogram, which was unsuccessful due to leakage from the gallbladder. A decision was made to perform an open cholecystectomy. A retrograde cholecystectomy was performed and the anatomy was found to be exactly as thought initially. The gallbladder directly off of the CBD with no evidence of a common cystic duct. The CBD entered the liver very high up in the bed of the gallbladder. The gallbladder was excised 1 cm from the CBD. The patient tolerated the procedure well and recovered in stable condition. Congenital anomalies such as a extrahepatic bile ducts are commonly seen intraoperatively but an absence of a cystic duct is not routinely seen Unexpectedly encountering this can lead to severe surgical ramifications. When assessing patients with recurrent episodes of gallstone pancreatitis, an absent cystic duct should be kept in the differential diagnosis. Being aware of this anomaly and the preferred surgical approach as well as the importance of cholangiography for anatomic identification, can help avoid biliary injuries.