Post cholecystectomy cysto-hepatic duct stricture

Excerpt

A 31-year-old lady with a history of cholecystectomy five years back presented with cholestatic jaundice for one-year, increasing over the last two months with fever for one week. Examination revealed icterus and hepatomegaly. Investigations revealed leukocytosis (TLC, 15.4 × 10³/µL) and deranged liver function tests (bilirubin, 19.5 mg/dL; aspartate transaminase [AST], 98 IU/L; alanine transaminase [ALT], 50 IU/L; alkaline phosphatase [ALP], 380 IU/L). Magnetic resonance cholangiopancreatography (MRCP) showed dilated right posterior hepatic duct (Fig. 1A). On endoscopic retrograde cholangiopancreatography (ERCP), initial cholangiogram showed prominent common bile duct (CBD) with normal intra-hepatic biliary radicals. Due to discrepancy with MRCP, an occlusion cholangiogram was taken, which revealed a dilated ductal structure arising from the cystic duct area with intervening stricture (Fig. 1B–D). Attempted selective cannulation of this dilated duct was unsuccessful. On endoscopic ultrasound (EUS), aberrant dilated duct arising from cystic duct remnant and draining right posterior hepatic segments was identified. This was punctured with 19G EUS-fine-needle aspiration (FNA) needle and transmural drainage into duodenum was attained with 10F double pigtail technique (DPT) stent (Fig. 2). Fever resolved with marked improvement of liver functions (bilirubin, 3.1 mg/dL) at one-month follow-up. Feasible long-term management options include percutaneous or EUS-guided rendezvous with stricture dilatation, surgery or repeated stent exchanges every three months to keep the choledochoduodenostomy patent.

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