A 61 y.o. male presents with RUQ pain, he is sp cholecystectomy 10/2022.
What could be wrong?
something extends into the chest
and it starts behind the liver. What could it be?
Our patient had a”dropped gallstone” during laparoscopic cholecystectomy. This is a common complication of laparoscopic cholecystectomy where the stone falls behind the liver and cannot be retrieved by the scope. It is usually left in place and may result in complications like in our patient. The complications include abscesses and fistulae. While 30% of laparoscopic cholecystectomies result in dropped stones because of perforation of the gall bladder, very few result in complications
RIGHT UPPER QUADRANT PAIN AFTER CHOLECYSTECTOMY
Post-cholecystectomy syndrome- is the persistence of GI symptoms after cholecystectomy which occurs in 5-47% of patients. The causes are both biliary(common duct stone) and non biliary(adhesions,intercostal neuritis) MRCP is 95% sensitive in picking up these stones while ultracound is much less sensitive.
Bile duct injury and biliary leaks-fewer than 25% of bile duct leaks are found at surgery. Most are discovered on evaluation for persistent pain. These are usually discovered within days of the surgery.
Gallbladder and cystic duct remnants- these structures may develop stones.
Spasm of the sphincter of Oddi- up to 29% of patients with postcholecystectomy syndrome have a structural of functional abnormality of the sphincter. There is a fixed narrowing of the sphincter with elevated basal sphincter pressure. This is thought to occur because of trauma from the passage of gallstones.
Dropped gallstone with abscess- These can occur many years after the surgery.
Our patient is still in the hospital, interventional is reluctant to intervene because of the possibility of contaminating the pleural space and they see only a phlegmon not an abscess. Surgery is being contemplated.
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Ramamurthy N, Rudralingam, Martin D, et al. Out of sight but kept in mind:complications and imitations of dropped gallstones. Bastrointestinal Imaging Review AJR 2013;200:1244-53.