S1536 A Retained Gallstone Post-Cholecystectomy Presenting as Abdominal Pain and Bloody Diarrhea

Abstract

Introduction: Retained gallstones is a complication of cholecystectomy which can lead to the formation of intra-abdominal abscesses. In the following case, we describe a patient who developed abdominal pain and bloody stools post-cholecystectomy, found to have a retained gallstone and abscess eroding into the liver parenchyma and colon. Case Description/Methods: A 69-year-old male with a past medical history significant for prostate cancer status post radiation and hormone therapy, hypertension, hyperlipidemia, and diabetes presented to the gastroenterology clinic for evaluation of bloody diarrhea and right lower quadrant abdominal pain of three weeks duration. He described the pain as constant and endorsed decreased appetite and three-pound weight loss over the same time period. Surgical history was significant for a laparoscopic cholecystectomy five months prior for gangrenous cholecystitis. A colonoscopy performed three years prior revealed radiation colonopathy and a tubular adenoma, but no other significant findings. Physical exam was unremarkable with no abdominal tenderness. Stool cultures and giardia were negative, and calprotectin was 8 mcg/g. Computed tomography of the abdomen and pelvis was subsequently performed, revealing a 3.5 × 2 cm peritoneal abscess with a 14 mm retained gallstone and gallstone fragments eroding into the liver parenchyma and the hepatic flexure of the colon. Given these findings, the patient was advised to present to the emergency department. He subsequently underwent a diagnostic laparoscopy with removal of the stone and drainage of the surrounding abscess. A Jackson Pratt drain was placed, and fluid cultures subsequently grew Escherichia coli. The patient was discharged with antibiotics on post-operative day two. On two-week follow up, the patient reported feeling well with complete resolution of his abdominal pain. Discussion: Gallstone spillage and subsequent abscess formation is a known risk of cholecystectomy. This most frequently occurs when laparoscopic cholecystectomy is complicated by gallbladder perforation. Symptoms of retained stones can present months to years after cholecystectomy. Definitive treatment generally requires both drainage of the abscess and removal of the retained gallstone to eliminate infection and prevent future repeat infection.Figure 1.: Computed tomography of the abdomen and pelvis (coronal view) demonstrating a 3.5 x 2 cm peritoneal abscess with a 14 mm retained gallstone (arrow) and gallstone fragments eroding into the liver parenchyma.