S1479 Cystic Duct Stump Stone: A Diagnostic Dilemma of Post Cholecystectomy Syndrome

Abstract

INTRODUCTION: Post-cholecystectomy syndrome (PCS) is defined as persistent dyspepsia, upper abdominal pain, pancreatitis, or jaundice after cholecystectomy. The symptoms of PCS can be caused by a wide variety of conditions, including biliary, pancreatic, or hepatic, while the rest are extra-intestinal. PCS can be described as early: occurring in the postoperative period or late: occurring months to years later. Here we will focus on endoscopic management of retained biliary stones within the cystic duct stump. CASE DESCRIPTION/METHODS: We present a 72-year-old male with new post-prandial epigastric pain with mild tenderness on deep palpation. Cholecystectomy completed six months prior. Lipase: 82, AST: 72, ALT: 47, Total Bilirubin: 0.7, Direct bilirubin: 0.2. CT Abdomen Pelvis with Contrast: Calculus in the remnant cystic duct stump without any intra or extrahepatic biliary dilation. Endoscopic retrograde cholangiopancreatography (ERCP) and fluoroscopy were performed, without visualization of stone. Therefore, Direct Visualization Cholangioscopy was performed, where an impacted stone was noted in the proximal tip of the cystic duct stump. Electrohydraulic Lithotripsy (EHL) was completed, and fragments of the stone were flushed with biliary plastic stent placement. On a three-month follow-up, the patient remained asymptomatic with the removal of the plastic stent. DISCUSSION: It has been demonstrated that ERCP is an adequate alternative to laparoscopic therapy for the diagnosis and treatment of cystic duct stump stones, causing PCS. However, without any head-to-head trials comparing surgical versus endoscopic therapies, selection of therapy becomes anecdotal and based on institutional expertise. We demonstrate a case whereby traditional fluoroscopy with ERCP could not visualize the impacted stone at the proximal tip of the cystic duct stump. Therefore, we question whether the accuracy of diagnostic biliary fluoroscopy decreases in the setting of cystic duct stump. Without cholangioscopy and lithotripsy, the stone likely would have remained, and the patient symptomatic. Therefore, gastroenterologists should recognize the difficulty of fluoroscopic diagnosis of remnant cystic duct stump stones. Additionally, cholangioscopy facilitates selective cannulation of the cystic duct in comparison to contrast fluoroscopy on its own. We are highlighting the importance of the diagnostic and therapeutic role of direct visualization cholangioscopy, in patients with PCS and a suspected cystic duct stump stones.Figure 1.: ERCP and Fluroscopy of cystic duct stump without visualization of cystic duct stump stone.Figure 2.: Direct Visualization Cholangioscopy of impacted stone at the proximal tip of the cystic duct stump.Figure 3.: Clearance of impacted cystic duct stump stone after use of Electrohydraulic Lithotripsy.