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Mucocele of the gall bladder stump: a cause of post‐cholecystectomy syndrome

A 47‐year‐old female was referred for surgical review with a 23‐ year history of intermittent right upper quadrant abdominal pain. The patient had obstructive jaundice with associated cholangitis during pregnancy 25 years prior. This was treated with an open cholecystectomy, which led to resolution of her symptoms for 18 months until similar preoperative pain returned. It was described as a throbbing and squeezing type pain in the right upper quadrant radiating to the right scapula and shoulder. The episodes of pain continued for many years, worsening in the 5 years before presentation. Opioid analgesia was required on a regular basis and there was associated nausea and vomiting. These episodes increased in severity and frequency, causing significant interference with daily activities and work. The attacks were occurring at least fortnightly, lasting several days at a time and requiring hospital admissions for analgesia and intravenous fluids. The patient's examination was unremarkable and liver function tests, inflammatory markers and full blood count were all normal. The patient had an endoscopy in 2005 and a colonoscopy in 2007, which were both normal, and yet her symptoms continued. An abdominal ultrasound in 2011 had revealed a small stone in the bile duct; however, subsequent endoscopic retrograde cholangiopancreatography and pancreatic stenting done in August failed to alleviate her symptoms. A magnetic resonance cholangiopancreatography (MRCP) done in September 2011 did report probable choledocholithiasis in the cystic stump. Her gastroenterologist performed a small bowel video capsule examination in September 2011, which showed multiple tiny, aphthous ulcers and mucosal erosion from the duodenum to the terminal ileum. She was diagnosed with Crohn's disease despite negative serology but did not receive any treatment. The patient had another MRCP in early 2013 that revealed a remnant of the gall bladder with a normal cystic duct. The stump was approximately 1 cm in length, and had an appearance consistent with its containing internal debris or a small calculus (Fig. 1) there being a filling defect within the stump. The common bile duct and pancreatic duct were normal. Laparoscopy revealed adhesions to the gall bladder fossa and a tense turgid gall bladder stump, which was mobilized. There was then found to be a mucocele of the gall bladder stump (Fig. 2) secondary to a stone in the neck. An intra‐operative cholangiogram demonstrated free flow of dye into the duodenum with no evidence of biliary duct dilatation or choledocholithiasis. Histopathology of the gall bladder stem (10 × 10 × 4 mm) revealed fibromuscular stroma within which there were several small aggregates of bile stones. Figure 3 shows the gall bladder fossa post‐resection. The patient had an uneventful post‐operative period. Seven months post‐operatively, the patient was well, and all her pain had essentially resolved. She refers to the repeat cholecystectomy as one of the best decisions she has made.