S3383 Two Decades Later: The Biliary Tree Strikes Back

Introduction: Cholecystectomy is the definitive treatment for symptomatic gallstone disease. While typically successful, some patients develop postcholecystectomy syndrome (PCS), marked by persistent or recurrent biliary symptoms. Retained or recurrent common bile duct (CBD) stones are a known cause of PCS, usually arising within a few years of surgery. However, CBD stone development decades later is rare, with limited data on its incidence. We present a case of choledocholithiasis causing cholangitis 20 years post-cholecystectomy, underscoring the importance of considering this diagnosis in patients with remote surgical histories presenting with biliary symptoms or abnormal liver chemistries. Case Description/Methods: A 68-year-old woman with a history of cholecystectomy 20 years prior presented with 3 days of fever and fatigue. She was febrile to 103.1°F with leukocytosis (WBC 13.46 × 10³/µL). Liver enzymes were elevated: ALT 70 U/L, AST 126 U/L, alkaline phosphatase 1367 U/L, total bilirubin 2.8 mg/dL, direct bilirubin 2.1 mg/dL. Blood cultures grew ESBL-producing Escherichia coli confirming bacteremia. Right upper quadrant ultrasound showed a 1.0 cm dilated CBD. Magnetic resonance cholangiopancreatography (MRCP) revealed a 1.7 cm stone in the distal CBD, with upstream intrahepatic and extrahepatic ductal dilation (up to 1.4 cm). The patient was diagnosed with acute cholangitis secondary to choledocholithiasis. Due to altered anatomy from a prior Roux-en-Y procedure, endoscopic ultrasound-directed transgastric endoscopic retrograde cholangiopancreatography (ERCP) was unsuccessful. After a multidisciplinary evaluation, she underwent inpatient biliary drain placement with plans for outpatient stone extraction. Discussion: CBD stones are classified as secondary, originating from the gallbladder, or primary, arising de novo within the bile duct, typically >2 years post-cholecystectomy. Primary stones are infrequent in Western populations and rarely reported beyond a decade after surgery. The 20-year interval in this case strongly suggests a primary etiology, representing an exceptionally delayed presentation of PCS. Clinicians should maintain a high index of suspicion for choledocholithiasis in patients presenting with biliary symptoms or cholestatic liver enzymes, regardless of remote cholecystectomy history. Early diagnosis is critical, given the potential for significant morbidity associated with delayed primary CBD stones.