S3428 Over Two Decades of Stones: Recurrent Choledocholithiasis Secondary to Food Reflux

Introduction: Recurrent choledocholithiasis after cholecystectomy is uncommon. It is often attributed to retained stones, stasis of bile, infection, or anatomical anomalies. An uncommon but little known cause is food reflux into the common bile duct (CBD), serving as a nidus for stone formation. We present a striking case of a patient who underwent over 25 endoscopic retrograde cholangiopancreatographies (ERCPs)s across 2 decades due to recurrent choledocholithiasis caused by food reflux into a dilated CBD. Case Description/Methods: A 68-year-old man with no significant medical history presented initially in 2006 with jaundice and right upper quadrant pain. Endoscopic retrograde cholangiopancreatography (ERCP) revealed 3 CBD stones, which were extracted and followed by laparoscopic cholecystectomy. He remained asymptomatic until 2008, then he returned with severe epigastric pain and elevated liver enzymes, including a total bilirubin of 4.5 mg/dL. Computed tomography imaging was unrevealing, but 2 small brown pigment stones and a fragment of food were found on ERCP. Food reflux into the CBD was thought to promote recurrence of stones. Twenty-three more ERCP were required for recurrent choledocholithiasis over the next 15 years. Symptoms included right upper quadrant pain occasionally accompanied by jaundice. Liver function tests were often normal at presentation, which led to diagnostic delays. His bile was lithogenic, and his CBD remained persistently dilated (>10 mm). He was treated with ursodeoxycholic acid with minimal effect, and despite losing over 70 pounds, the frequency of symptoms and stone recurrence remained unchanged. No evidence of biliary stricture, malignancy, or parasitic infection was ever found. Discussion: Food reflux into the CBD is a rare but significant contributor to recurrent stone formation, particularly in patients with dilated ducts and altered biliary dynamics. Organic debris acts as a nidus for stone formation, especially when bile is lithogenic. In this case, standard therapies including cholecystectomy, ERCP, ursodiol, and weight loss failed to prevent recurrence. Liver function tests were frequently normal, contributing to delayed recognition. We surmise that reflux of food into the CBD may contribute more to recurrent stone formation than previously realized. In patients with recurrent post-cholecystectomy choledocholithiasis and no other identifiable cause, food reflux should be considered. This case highlights the diagnostic and therapeutic challenges in managing recurrent biliary stone disease.