Biliary Findings on Magnetic Resonance Cholangiopancreatography in Patients with
Post Cholecystectomy Pain
Ummara Siddique*, Syed Ghulam Ghaus, Seema Gul, Shahjehan Alam, Aman Nawaz Khan, Hadia Abid, Abdullah Safi and Kalsoom Nawab
Department of Radiology, Rehman Medical Institute, Pakistan
Submission: December 19, 2018; Published: January 28, 2019
*Corresponding author: Ummara Siddique, Department of Radiology, Rehman Medical Institute, Peshawar, Pakistan
How to cite this article: Ummara S, Syed G G, Seema G, Shahjehan A, Aman N Khan, et al. Biliary Findings on Magnetic Resonance Cholangiopancreatography in Patients with Post Cholecystectomy Pain. Curr Trends Clin Med Imaging. 2019; 2(5): 555599. DOI: 10.19080/CTCMI.2019.02.555599
Purpose: To find the incidence of different causes of post cholecystectomy pain on magnetic resonance cholangiopancreatography.
Methodology: This is a prospective study of 74 patients with post-operative complain of post-cholecystectomy symptoms. Their ages ranged from 20 to 70 years. Patients with liver transplant were not included. MRCP was performed on 1.5 tesla GE machine at radiology department of our hospital. MRCP images were assessed for bile duct diameters and the presence of strictures and stones. A common bile duct (CBD) diameter of < 8mm was considered normal, whereas > or = 9mm was considered abnormal. Findings were correlated with LFTs and clinical findings.
Results: Our results showed that 86.4%cases with post cholecystectomy pain had positive findings on MRCP. The commonest finding was biliary stones in 37.8 % cases. Post-cholecystectomy biliary complications included retained CBD stones in 28 patients (9 intrahepatic, 18 extra-hepatic and 1 in cystic duct stump), biliary duct injury in 4 patients (2 cases with biliary duct ligation and 2 cases with biliary leakage. Stricture was detected in distal CBD in 9, in CHD in 4 cases, at ampulla in 2, at hilum in 9 and in 9 at anastomotic site of choledochoeneterostomy site. In 10 of our cases, MRCP was negative for any finding.
Cоnclusiоn: We conclude from our results that that 86.4%cases with post cholecystectomy pain had positive findings on MRCP and the most common cause of post cholecystectomy pain was biliary stones seen in 37.8%. The use of breath-hold 3D-SSFP MRCP is essential in evaluation of post-laparoscopic cholecystectomy biliary complications and in planning for management regimens.
Recommendation: MRCP should be performed in patients with post cholecystectomy pain. If the CBD on ultrasound is > or = 10mm and no cause is identified, MRCP is necessary. However, the availability of LFTs raises the diagnostic value of imaging.
Cholecystectomy is one of the most commonly performed operations and is mostly followed by an uneventful course . Sometimes cholecystectomy fails to relieve symptoms or new symptoms develop. When the pre-surgery symptoms persist in post-op period, it is called as post-cholecystectomy syndrome (PCS), which is now a well-recognized clinical entity . It is a misnomer as it is not a syndrome per se and defined as a complex of heterogeneous symptoms, consisting of upper abdominal pain and dyspepsia, which recur and/or persist after cholecystectomy . PCS reportedly affects about 10 - 15% of patients . Post cholecystectomy patients can present with recurring or persistent pain in epigastrium and upper abdomen. Study conducted by Guso and fellows in 2015 noted 25% rate of complications in patients undergoing imaging following cholecystectomy .
Patients can have pain due to either biliary complication (Table 1) following surgery like retained migrated calculi, inflamed Gallbladder stump or because of operative complications like biliary leakage or ductal injury. Biliary manifestations may occur early in the post-operative period, usually because of incomplete surgery (retained calculi in the cystic duct remnant or in the common bile duct) or operative complications, such as bile duct injury and/or bile leakage. A later onset is commonly caused by inflammatory scarring strictures involving the sphincter of Oddi or the common bile duct (CBD), recurrent calculi or biliary dyskinesia. Post cholecystectomy patients can have non-hepatobiliary cause like duodenogastric reflux of bile. The overall incidence of positive endoscopic and histopathological changes in the stomach of cholecystectomized patients is 20-30% especially significant is the atrophic type of gastritis . In another study, cholecystectomized patients when compared to
cholelithiasis patients and healthy patients showed much higher
duodenogastric reflux and much higher concentrations of bile
acid in gastric juice .
The traditional imaging approach for diagnosing underlying
cause for post cholecystectomy pain has involved ultrasound
and/or Computed Tomography (CT) followed by direct
cholangiography, whereas manometry of the sphincter of Oddi
and biliary scintigraphy have been reserved for cases of biliary
dyskinesia. Because of its capability to provide non-invasive
high-quality visualization of the biliary tract, MRCP has been
advocated as a reliable imaging tool for assessing patients with
post cholecystectomy pain or suspected PCS and for guiding
management decisions. The present study was carried out to find
the incidence and risk factors for post cholecystectomy pain in
patients undergoing cholecystectomy. This paper illustrates the
rationale for using MRCP, together with the main MRCP biliary
findings and diagnostic pitfalls.
This is a prospective study of 74 patients with history of
cholecystectomy (laparoscopic or open) and post-operative
complaint of pain/post-cholecystectomy symptoms. Their ages
ranged from 20 to 70 years. Patients of liver transplant were
not included. MRCP was performed on 1.5 tesla GE machine
at radiology department of our hospital. MRCP images were
assessed for bile duct diameters and the presence of strictures
and stones. Additional findings like presence of pancreatitis
or fluid collections were also assessed. A common bile duct
(CBD) diameter of <8mm was considered normal, whereas >
or = 8mm was considered abnormal. Signal void foci in biliary
ducts were considered as stones, whether obstructing or not.
Axial T2W images were also assessed for additional related
findings like presence of any neoplastic mass, pancreatitis or
fluid collections etc. Findings were correlated to LFTs. For MRCP,
we used sequences heavily T2 weighted sequences to depict the
fluid-containing biliary tree and pancreatic duct. Post processing
of the image data was performed to obtain maximum intensity
projection (MIP) images and multiplanar reformatted images.
The 3D imaging technique has potential advantages over twodimensional
imaging, including the capacity to obtain thinner
sections with no gap and a higher signal-to-noise ratio. Because
partial volume averaging effects may obscure small stones and
subtle mural irregularities, thin-section source images were
Our results showed that 86.4%cases with post
cholecystectomy pain had positive findings on MRCP. The
commonest finding was biliary stones in 37.8 % cases (Table
2). The commonest site of biliary stones was CBD in 24.3%
cases. Biliary strictures were seen in 33 patients (in distal CBD
in 9, in CHD in 4 cases, at ampulla in 2, at hilum in 9 and in 9
at anastomotic site of choledochoeneterostomy site) (Table 3)
(Figures 1-6). GB remnant was seen in 5, one of which had stones.
Other findings included biliary leak, duct injury, PSC, portal
biliopathy, cholangitis and hilar mass. In 10 of our cases, MRCP
was negative for any finding. Pancreatitis was seen in 9 patients.
Post cholecystectomy pain can be due to biliary and extrabiliary
causes. This study focuses on biliary manifestations in
patients with post cholecystectomy pain. MRCP is a non-invasive
technique and beautifully highlights the biliary tree. As compared
to ERCP, which is invasive and requires iodinated contrast, MRCP
requires no intravenous contrast. 3D primary raw datasets are
ideal for visualization of pancreatico-biliary ducts. Retained
bile duct stones after cholecystectomy is a well-recognized
postoperative complication. Biliary calculi are visualized as signal
void foci within the T2 hyperintense bile. The reported incidence
after laporoscopic cholecystectomy is 0.5-2% and after open
cholecystectomy, it varies between 5-15% . A study conducted
in Pakistan showed that the most common etiological diagnostic
finding was residual biliary stones; followed by iatrogenic bile
duct obstruction . A large proportion of MRCP findings in our
study also had retained biliary calculi i.e 37.8%(n=28).
Solitary CBD stones were detected in 18 cases, which is
comparable to study conducted by Durrani and fellows, which
showed 15 cases with isolated CBD stones. Their study showed 39% cases 8 with retained biliary calculi whereas our study
showed 37.8%, which is comparable. In their study calculi in both
intrahepatic ducts were seen in 13 cases, whereas in our study
intrahepatic duct stones were seen in 9. In our study retained
CBD calculi accounted for 24.3%% of the complications whereas
in a study conducted by Ganci-Cerrud, it was 17% . For
suspected biliary duct stones, ERCP followed by sphincterotomy
and caluli extraction is the preferred initial approach, if the
probability is high [1,4,7].
Stones smaller than 3mm can pass spontaneously if the
sphincter of oddi is not stenotic, which, may be complicated
by pancreatitis or cholangitis. In our study, pancreatitis was
seen in 9 and cholangitis in 11 of our cases, the causes might
be the same. In our study the most common finding overall
was strictures, commonest site being the CBD, CHD and hilum.
In study conducted by Duran  and fellows, the second most
common complication was iatrogenic ligature in 13% patients,
whereas in our study the iatrogenic bile duct injury was seen
in only 5.4% cases. Their study had 8 cases with post-operative
CBD stricture, whereas in our study CBD strictures were seen in
9 which is comparable. These CBD strictures can be managed by
endoscopic stenting and so ERCP was suggested.
Our results showed that 86.4% cases with post
cholecystectomy pain had positive findings on MRCP. It was noted
in our patients that the commonest site of biliary stones was
CBD, biliary strictures were commonly in distal CBD, confluence
and anastomotic site. Another finding seen was documented
as the GB remnant, seen in 5 of our cases, one of which had
stones. This GB remnant coud be either a duplicate gallbladder,
dilated cystic duct stump or partially left GB in cases of partial
cholecystectomy. The surgical details could not be obtained as
most of the patients were referred from other centers.
Biliary dilatation cannot be the only presentation of biliary
pathologies. Primary sclerosing cholangitis (PSC) is an entity with multiple small biliary strictures without any significant
biliary dilatation. Findings of PSC were seen in 4 of our cases.
Two of our patients with post cholecystectomy pain had biliary
dilatation due to portal biliopathy. Mass at hilum was diagnosed
in 7 of our cases, which were advised cytological brushings and
biopsy. Post cholecystectomy pain can be due to a number of
reasons and commonest in our study was biliary calculi. The
preoperative incidence of choledocolithiasis amongst patients
undergoing cholecystectomy is reported to be 10-15% .
However, the retention of CBD calculi after open cholecystectomy
is between 5-15%10. MRCP can identify stones as small as 2mm
that are retained in the biliary tree .