Case 14905

Post cholecystectomy syndrome -

DOI: 10.1594/EURORAD/CASE.14905
ISSN: 1563-4086
Section: Abdominal imaging
Area of Interest: Biliary Tract / Gallbladder Liver
Procedure: Diagnostic procedure
Imaging Technique: CT
Imaging Technique: Ultrasound
Special Focus: Dilatation Case Type: Clinical Cases
Authors: Sivakami Pradheepkumar MD, DNB;RD
Patient: 39 years, female

Clinical History:

A 36-year-old female patient presented with a history of epigastric pain and nausea on-and-off for 6 months. There
was no history of vomiting/loose stools/fever. There however was a history of laproscopic cholecystectomy 4 years
before. Lab results showed evidence of obstructive jaundice.
Imaging Findings:

On ultrasound (US) abdomen, a minimal intrahepatic biliary tract dilatation (IHBRD) was seen. A well-defined
elliptical cystic lesion of 32x10mm in size was seen in GB fossa, communicating with CHD down - likely to be a
cystic duct remnant. No internal echoes/ calculi were noted within. No free fluid was seen around. The CBD was
mildly dilated, measuring 12mm. A 5mm isoechoic focus with no posterior acoustic shadow representing sludge ball/
calculus was seen in CBD. The CBD distal end was seen tapering normally. Pancreatic duct was not dilated.
The CECT abdomen showed minimal IHBRD, dilated cystic duct remnant (45x12mm), related to dilated CHD
(12mm) laterally, spiralling around it and showing lower insertion postero-medially forming the dilated CBD (14mm).
No calculi were noted in cystic duct remnant/CBD. No abnormal contrast enhancement was seen in liver/cystic duct
remnant.
MRCP confirmed the findings on US & CECT and also showed a 5mm calculus in distal CBD. The ampulla
appeared normal.
Discussion:

When a patient in status post cholecystectomy develops symptoms that are similar to the pre-cholecystectomy state
such as right hypochondrial pain, dyspepsia and jaundice, it is called post cholecystectomy syndrome (PCS).
Womack and Crider first described PCS in 1947. Incidence is found to be as high as 40% in one study, with a
female preponderance. Patients can develop this syndrome in an early or late post-operative period [1, 2].
Most common aetiology of this syndrome is of extrabiliary origin like reflux esophagitis, acid peptic disease and
chronic pancreatitis. Out of the biliary causes, most common causes in early onset include biliary tract injury,
dropped/residual/recurrent calculi, and in late onset include dilated remnant cystic duct, CBD stricture, sphincter of
oddi stricture or dysfunction [1, 2].
Radiologically PCS evaluation starts with US abdomen and if it is inconclusive followed by MRCP which has
overcome the CT in hepatobiliary evaluation. MRCP is a non-invasive and reliable alternative method to direct
cholangiography which is considered as a gold standard investigation [3, 4].
Bile tract injury can present as biliary obstruction if the injury is mild and as bile leakage if it is severe [1]. Calculi,
either in the cystic duct remnant or CBD are considered residual if they are found within two years of the post-
operative period and considered as recurrent if found after two years [3]. Calculi are seen as an echogenic structure
with posterior acoustic shadowing if the size is large on US, hyperdense foci on CT and smooth hypointense filling
defect with a surrounding rim of hyperintense bile on MRCP [3]. MRCP has high sensitivity and specificity in finding
the biliary calculi. Dropped/ slipped calculi are commonly seen in an intrahepatic/sub-diaphragmatic location/in
peritoneum or parietal wall with or without surrounding abscess formation [2, 3].
Cystic duct remnant is considered dilated if it measures > 4mm in diameter and > 2cm in length. It can present with
or without evidence of inflammation and/or calculi within [3]. Sphincter of oddi dysfunction is evaluated with
manometry. Other investigations employed are dynamic hepatobiliary scintigraphy with Tc-99M called DISIDA or
HIDA scans [2, 3].

PCS is managed based on the aetiology. Medical treatment is usually enough to treat non-biliary causes. For biliary
causes, usually laparoscopic cystic duct remnant resection, endoscopic sphincterotomy, sphincteroplasty, or stone
removal are done. In very few patients not responding to these procedures only need laparotomy [5]. Most of the
causes of PCS are treatable and imaging plays a major role in the diagnosis and treatment plan of PCS.
Differential Diagnosis List: Post cholecystectomy syndrome secondary to dilated cystic duct remnant and
recurrent CBD calculi., CBD/ampulla stricture, Biliary dyskinesia

Final Diagnosis: Post cholecystectomy syndrome secondary to dilated cystic duct remnant and recurrent CBD
calculi.

References:

S.S. Jaunoo*, S. Mohandas, L.M. Almond (2010) Postcholecystectomy syndrome (PCS). International Journal of
Surgery 8 ,15–17 (PMID: 19857610)
R Girometti, MD, G Brondani, MD, L Cereser et al (2010) Pictorial Review Post-cholecystectomy syndrome:
spectrum of biliary findings at magnetic resonance cholangiopancreatography. The British Journal of Radiology 83
,351–361
Eranga Perera, Shweta Bhatt1, Vikram S. Dogra1 (2011) Cystic Duct Remnant Syndrome. Journal of Clinical
Imaging Science Vol. 1 Issue 1
Chandrashekhar A. Sohoni (2015) Late postcholecystectomy syndrome. due to intrahepatic calculi Sahel Medical
Journal Vol 18 , Issue 1
Steen W Jensen, MD; (Dec,) Postcholecystectomy Syndrome Treatment & Management Updated:.
emedicine.medscape.com
Figure 1
a

Description: Transverse US image showing a clear cystic lesion in gall bladder bed. Origin: Diwan
Health Complex, Royal court of Diwan, Salalah, Oman
Figure 2
a

Description: Transverse US image of dilated CBD. Origin: Diwan Health Complex, Royal court of
Diwan, Salalah, Oman
Figure 3
a

Description: Transverse US image of liver showing mild central IHBRD and periporatal cuffing.Origin:
Diwan Health Complex, Royal court of Diwan, Salalah, Oman
Figure 4
a

Description: US image of distal CBD showing an echogenic filling defect with no distal shadowing.
Origin: Diwan Health Complex, Royal court of Diwan, Salalah, Oman
Figure 5
a

Description: CECT abdomen, axial section, portal venous phase showing mild IHBR dilatation.Origin:
Diwan Health Complex, Royal court of Diwan, Salalah, Oman
Figure 6
a

Description: CECT abdomen, axial section, portal venous phase at the level of porta showing dilated
CHD (white arrow) and dilated cystic duct remnant (yellow arrow) postero-lateral to CHD.Origin:
Diwan Health Complex, Royal court of Diwan, Salalah, Oman
Figure 7
a

Description: CECT abdomen, axial section, portal venous phase at the level of pancreas showing
dilated CHD (white arrow) and dilated cystic duct remnant (yellow arrow) postero-medial to it.Origin:
Diwan Health Complex, Royal court of Diwan, Salalah, Oman
Figure 8
a

Description: CECT abdomen, coronal section portal venous phase at the level of porta showing dilated
CHD (white arrow) and dilated cystic duct remnant (yellow arrow) lateral to CHD.Origin: Diwan Health
Complex, Royal court of Diwan, Salalah, Oman
Figure 9
a

Description: CECT abdomen, coronal section portal venous phase showing dilated CHD and CBD.
Origin: Diwan Health Complex, Royal court of Diwan, Salalah, Oman
Figure 10
a

Description: MRI T2 WI, coronal plane showing dilated CHD (white arrow), CBD with a small calculus
in lumen (yellow arrow). Normally tapering end of CBD and normal ampulla (red arrow) is also seen.
Origin: Diwan Health Complex, Royal court of Diwan, Salalah, Oman
Figure 11
a

Description: MRCP, coronal image showing dilated CHD (white arrow) , dilated & long cystic duct
remnant with low insertion in to CHD (yellow arrow) and dilated CBD with a small calculus (red arrow).
Origin: Diwan Health Complex, Royal court of Diwan, Salalah, Oman