S3526 Delayed Presentation of Primary Choledocholithiasis 15 Years Post-Cholecystectomy

Introduction: Choledocholithiasis, or stones in the common bile duct (CBD), typically presents within a few years after cholecystectomy. However, delayed presentations—even more than a decade later—can occur. This case highlights a rare instance of primary choledocholithiasis presenting 15 years post-cholecystectomy, underscoring the importance of maintaining diagnostic suspicion in patients with biliary symptoms, regardless of surgical history timing. Case Description/Methods: A 51-year-old woman with a history of gastric sleeve surgery, adrenal insufficiency, hypothyroidism, and remote cholecystectomy presented with persistent nausea, vomiting, and epigastric pain. She had recently become non-adherent to medications due to hurricane-related displacement. Vitals were stable. Labs revealed leukocytosis with neutrophilia and significantly elevated liver enzymes: alkaline phosphatase 610 U/L, ALT 1639 U/L, AST 2883 U/L, total bilirubin 1.3 mg/dL, and GGT 468 U/L. The R factor indicated hepatocellular injury. Workup for hepatitis, acetaminophen toxicity, and alcohol use was negative; ANA was 1:80, and INR was 1.0. Ultrasound and computed tomography imaging demonstrated normal liver morphology, absent gallbladder, and CBD dilation to 9.7 mm with intrahepatic ductal dilation. Magnetic resonance cholangiopancreatography (MRCP) confirmed a CBD measuring 1.5 cm with choledocholithiasis. Blood cultures grew Klebsiella pneumoniae and Enterobacter species, raising concern for acute cholangitis. She was started on intravenous ceftriaxone and underwent endoscopic retrograde cholangiopancreatography (ERCP), which revealed and cleared CBD sludge and stones without purulent drainage. Her symptoms and liver enzymes improved, with only mild transient post-ERCP elevation. She was discharged on oral antibiotics with close outpatient follow-up. Discussion: This case underscores the importance of maintaining clinical suspicion for primary choledocholithiasis even many years after cholecystectomy. Although most retained stones present within 3 years, primary stones can form de novo much later due to biliary stasis or infection. Prompt imaging, ERCP, and antibiotic therapy remain critical in such delayed yet clinically significant presentations.