Sabat, Nestor, Westcott, Adrian, and Pretorius, Casper F. (2022) A two-decade diagnostic dilemma of a post-cholecystectomy syndrome presenting with a remnant cystic stump stone causing Mirizzi syndrome. ANZ Journal of Surgery, 92. 12. pp. 3347-3349.

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Abstract

[Extract] A 62-year-old female diagnostic dilemma has multiple presentations for over 2 years with sharp stabbing epigastric and right hypochondrial pain radiating posteriorly on the background of an open cholecystectomy for a gangrenous gallbladder in 1997. The pain was self-resolving over days with only pain relief, otherwise there was a scarcity of symptoms (Table S1). Her past medical history (Table S1), multiple normal serum lipases, and an initial Computerized Tomography (CT) completed in 2018 did not identify the cause of the pain. Physicians were consulted and excluded cardiac and respiratory as causes of pain. Two gastroscopies with biopsies over the two-year period only showed lactose intolerance and mild gastritis, but medication and dietary changes did not prevent further episodes of pain.

Presenting 2 years after the initial attack with identical pain associated with subjective fevers, dark urine, and pale stool lead to a repeated CT scan followed by a magnetic resonance cholangiopancreatography (MRCP). A large 14 mm stone was found only on the MRCP in the proximal remnant cystic duct with surrounding inflammation suggesting chronic stumpitis, (Fig. 1). The associated swelling lead to dilatation and obstruction of the upstream hepatic ducts (Figs. 1-3) reflected in the deranged bilirubin and liver function test results, Table S2. Despite multiple ERCPs and application of the SpyGlass system, the stone was not retrieved until a laparoscopic cholecystectomy was performed to remove the stone via an in incision on the remnant gallbladder pouch with subsequent complete resolution of pain and symptoms to date.

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