|Year : 2015 | Volume
| Issue : 1 | Page : 41-43
Late postcholecystectomy syndrome due to intrahepatic calculi
Chandrashekhar A Sohoni
Department of Radiology, NM Medical, Pune, Maharashtra, India
|Date of Web Publication||26-Feb-2015|
Chandrashekhar A Sohoni
B-5, Common Wealth Hsg. Soc., Opposite Bund Garden, Pune - 411 001, Maharashtra
Biliary and nonbiliary disorders are responsible for postcholecystectomy syndrome (PCS). The most common cause of late PCS of biliopancreatic origin is calculi in the common bile duct or the cystic duct remnant. Intra-hepatic calculi causing PCS is very uncommon. We present a case of late PCS caused by intrahepatic calculi in the left intra-hepatic biliary radicles and left hepatic duct causing obstruction of the left ductal system. Endoscopic retrograde cholangiopancreaticography did not show any stricture in the ductal system. Sphincterotomy followed by stenting of the left hepatic duct was performed to relieve the obstruction.
Keywords: Computed tomography, intra-hepatic calculi, postcholecystectomy syndrome
|How to cite this article:|
Sohoni CA. Late postcholecystectomy syndrome due to intrahepatic calculi. Sahel Med J 2015;18:41-3
| Introduction|| |
Patients who have undergone cholecystectomy may sometimes present with a recurrence of symptoms such as upper abdominal pain and dyspepsia, with or without jaundice. These symptoms may occur within few weeks of surgery or many years later. Ultrasound and/or computed tomography (CT) are used in the initial evaluation of postcholecystectomy syndrome (PCS), followed by endoscopic retrograde cholangiopancreaticography (ERCP), which can be diagnostic as well as therapeutic. Recurrent or residual biliary calculi are the most common biliary cause of PCS. However, intra-hepatic calculi causing PCS is very uncommon.
| Case report|| |
A 63-year-old nondiabetic, normotensive female presented with persistent pain in the epigastric region and bloating of the abdomen for 15 days. The patient had been taking antacids without much relief during this period. She had no vomiting or diarrhea. She had undergone laparoscopic cholecystectomy 10 years ago for gallbladder calculi and had a history of similar symptoms intermittently since past few years, albeit not so severe. On examination, she was febrile (100F) and anicteric. Her pulse rate and blood pressure were normal. There was tenderness elicited in the epigastric region but no guarding or rigidity. Ultrasonography revealed dilatation of intra-hepatic biliary radicles selectively in the lateral segments of the left lobe of the liver with presence of echogenic material within the dilated ducts, suggestive of calculi. The common bile duct was normal in caliber without any intraductal calculi. CT scan confirmed presence of multiple calculi within the dilated left intra-hepatic biliary radicles [Figure 1]a-d. The calculi were located in central as well as peripheral ducts. Pneumobilia was also noted [Figure 1]a and b. In the absence of previous endoscopic biliary intervention, the air was thought to indicate either incompetence of sphincter of Oddi or infection. Postcontrast CT images did not reveal any enhancing mass lesion along the biliary tree. The liver function tests revealed total bilirubin 3.0 mg/dL, direct bilirubin 1.6 mg/dL and alkaline phosphatase 167 IU/L. The total leukocyte count (TLC) was 14,500/mm 3 . Other laboratory parameters were within normal limits, including normal CA 19-9 level (12 IU/L). ERCP revealed dilated left intra-hepatic biliary radicles with multiple intraluminal filling defects suggestive of obstructive calculi. A calculus was also noted in left hepatic duct. No evidence of a stricture was seen. Sphincterotomy was performed, and a plastic stent was successfully placed in the left hepatic duct. Levofloxacin 250 mg twice daily was prescribed for 7 days, following 3 days of periprocedural intravenous therapy with the same antibiotic. The brush cytology did not reveal any malignant cells. The patient was afebrile and symptomatically better at follow-up 15 days later. The laboratory parameters also showed improvement with total bilirubin 1.9 mg/dL, alkaline phosphatase 92 IU/L and TLC 8000/mm 3 . Considering the multiplicity of calculi and their location, the option of surgical treatment in the form of left lateral lobectomy was discussed with the patient. She declined surgical intervention.
|Figure 1: (a-d) The computed tomography images reveal multiple intra-hepatic calculi in the lateral segments of the left lobe of liver causing obstruction of the left biliary ductal system|
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| Discussion|| |
Postcholecystectomy syndrome is a commonly used term to describe abdominal complaints occurring after cholecystectomy. The symptoms may be due to biliary or nonbiliary disorders. In some patients, the symptoms occur few weeks after surgery, while in others they may occur many years later. The symptoms are variable and include upper abdominal pain, dyspepsia, nausea, vomiting, bloating, diarrhea, and jaundice with or without fever. 
The main causes of late PCS include recurrent stones in common bile duct, bile duct strictures, cystic duct remnant harboring stones and/or inflammation, gallbladder remnant harboring stones and/or inflammation, papillary stenosis and biliary dyskinesia.
The usual approach to PCS confirmatory diagnosis includes ultrasonography and/or CT scan, followed by ERCP. Postcontrast CT helps in diagnosing neoplastic lesion along the biliary tree. Magnetic resonance cholangiopancreaticography has gained popularity as a noninvasive tool for studying the biliary tract, especially for detection of biliary calculi which may be missed on CT, and also for preoperative evaluation of biliary strictures. However, ERCP remains the gold standard.
Calculi in the common bile duct and cystic duct remnant are the most common causes of PCS of bilio-pancreatic origin. In a study of 5859 patients who underwent cholecystectomy, obstruction of the common bile duct was found in 1.8% patients, and of these, 80% was due to calculi.  Calculi are classified as "retained" or "recurrent," if found before or after 2 years following surgery, respectively. 
Postcholecystectomy syndrome due to intra-hepatic calculi is very uncommon. Primary intra-hepatic stones are formed de novo within the liver, whereas secondary intra-hepatic calculi are formed due to biliary stasis, mostly caused by strictures. In our patient, no stricture was found on ERCP. Intra-hepatic lithiasis may lead to recurrent cholangitis, chronic sepsis and even cholangiocarcinoma. The basic principles of treating intra-hepatic calculi include clearance of stones, correction of strictures and restoration of bile drainage. The modalities to achieve the same vary from case to case, depending upon the size, number and distribution of stones, presence or absence of extra-/intra-hepatic strictures and any associated lesions. Both retrograde and percutaneous approaches for stone removal and biliary drainage have been described.  In the presence of jaundice and nonfeasibility of retrograde endoscopic approach, percutaneous access for introduction of choldechoscope, stents, balloon catheters, baskets and/or lithotripters has been used with variable success rate. ,, Though a more difficult technique with higher failure rates, retrograde endoscopic approach has also been used in the treatment of intra-hepatic calculi, particularly in presence of additional extra-hepatic calculi.  Partial hepatectomy is thought to be a curative approach for localized hepatolithiasis.  In a study of 115 patients with primary intra-hepatic calculi, the stones were removed by four different methods: Common duct exploration, transhepatic intubation, hepatotomy, and hepatic resection.  The method of choice was guided by the location of stones and the condition of the bile ducts and the liver. Hepatic resection was found to have the lowest failure rate.  Resection of the segment or lobe containing calculi, strictures or atrophy has been reported to be effective in reducing stone recurrence.  Thus, surgery continues to have a primary role in the treatment of intra-hepatic lithiasis.
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