Post-cholecystectomy syndrome: spectrum of biliary findings at magnetic resonance cholangiopancreatography

Abstract

Post-cholecystectomy syndrome (PCS) is defined as a complex of heterogeneous symptoms, consisting of upper abdominal pain and dyspepsia, which recur and/or persist after cholecystectomy. Nevertheless, this term is inaccurate, as it encompasses biliary and non-biliary disorders, possibly unrelated to cholecystectomy. Biliary manifestations of PCS 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, recurrent calculi or biliary dyskinesia. The traditional imaging approach for PCS has involved ultrasound and/or 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 visualisation of the biliary tract, magnetic resonance cholangiopancreatography (MRCP) has been advocated as a reliable imaging tool for assessing patients with suspected PCS and for guiding management decisions. This paper illustrates the rationale for using MRCP, together with the main MRCP biliary findings and diagnostic pitfalls.

Figure 1

A 31-year-old female patient presenting with right upper abdominal pain 1 week after laparoscopic cholecystectomy. (a) T₂ weighted projective magnetic resonance cholangiopancreatography image shows an elongated hyperintense fluid collection proximal to the cystic duct stump, along with a small amount of subhepatic free fluid, which is well delineated in the axial T₂ weighted single-shot fast spin-echo image. (b) An aberrant right intrahepatic bile duct is visible (arrow in (a)). (c) Coronal and (d) axially reformatted T₁ weighted fat saturated three-dimensional gradient echo images obtained 20 min after intravenous injection of gadoxetic acid document the passage of contrast agent from the cystic duct stump into the fluid collection and the subhepatic space, demonstrating the presence of a bile leak. (Courtesy of Celso Matos, MD, Brussels, Belgium.)

Figure 2

A 60-year-old female patient presenting with colic pain in the abdominal right upper quadrant 3 weeks after laparoscopic cholecystectomy. (a) Maximum intensity projection reconstruction of the biliary tree shows multiple calculi in the distal portion of the common bile duct as small filling defects, surrounded by a thin rim of bile signal. Mild biliary dilation is present upstream. The redundant cystic stump inserts at the medial aspect of the common bile duct. (b) The dependent position of the filling defect (arrow) is of help in differentiating it from pneumobilia in patients with previous sphincterotomy or bilio-digestive anastomosis.

Figure 3

A 72-year-old female several years after cholecystectomy, who was referred for magnetic resonance cholangiopancreatography because of dyspeptic syndrome and vague upper abdominal pain. (a) Coronal maximum intensity projection (MIP) reconstruction from thin T₂ weighted source images depicts dilation of the upper two-thirds of the common bile duct, intrahepatic biliary tree and cystic duct remnant. A careful scrolling of the (b) coronal and (c) axial thick MIP images better shows the presence of two smoothly marginated filling defects in the cystic duct remnant and in the common bile duct below its insertion, respectively (arrows). The patient’s symptoms were relieved after calculi extraction.

Figure 4

A 57-year-old female patient presenting with biliary-like pain years after cholecystectomy. (a) The heavily T₂ weighted thick slab depicts a calculus in the distal common bile duct and biliary dilatation upstream. The papillary region looks abruptly narrowed, with a concave appearance of the distal border of the suprasphincteric part of the common bile duct (arrow). (b and c) A set of complementary repeated thick slabs demonstrates that the appearance is transitory (arrows). (d) As illustrated, this is caused by a forceful contraction of the superior sphincteric region (arrowhead) with its retrograde “invagination” (arrow) [7].

Figure 5

A 52-year-old male patient who underwent laparoscopic cholecystectomy 5 years previously. Because of several episodes of cholangitis since the time of surgery caused by a known clip inadvertently positioned at the common bile duct just below the hepatic confluence, the patient underwent repeated balloon dilatation procedures. (a) On an axial T₂ weighted turbo spin-echo image, the clip appears as an intensely low-signal structure that partially overlaps the anterior aspect of the common bile duct (arrow). (b) On coronal maximum intensity projection reconstruction from volumetric thin source images, the injury manifests as a wall-sided focal filling defect, causing a moderate luminal stricture (arrow) with slight biliary dilation upstream.

Figure 6

A 78-year-old male patient presenting with abdominal pain, fever and altered liver function tests in the post-operative period after laparoscopic cholecystectomy. Thick coronal maximum intensity projection reconstruction from T₂ weighted thin source images shows a thin rim of hyperintense fluid signal contiguous with the cystic duct stump (arrow). Free fluid is present in the perihepatic space, especially in the subhepatic site (arrowheads). Moreover, a focal stricture of the common bile duct is appreciable just below the insertion of the cystic duct remnant, suggesting a co-existing injury (curved arrow).

Figure 7

A 70-year-old male patient with a history of recurrent lithiasis and cholangitis after open cholecystectomy. Several previous endoscopic cholangiopancreatograms had been performed. Coronal maximum intensity projection reconstruction from a volumetric turbo spin-echo heavily T₂ weighted sequence shows multiple moderate-to-severe strictures of variable length along the course of the common bile duct (arrows) and intrahepatic bile ducts (arrowheads). No calculi were visible at the time of examination. Strictures were a consequence of either previous common bile duct operative injury or scarring from repeated calculi migration and cholangitis.

Figure 8

Bismuth classification of bile duct strictures after duct injury, according to their location and relationship to the hepatic duct bifurcation [9]. EBD, extrahepatic bile duct; CHD, common hepatic duct.

Figure 9

An 80-year-old female patient presenting with a history of recurrent biliary-like intense pain after previous open cholecystectomy for calculi. (a) Coronal T₂ weighted single-shot fast spin-echo image at the level of the distal intrapancreatic common bile duct depicts a smoothly marginated homogeneous stricture of the distal common bile duct (arrowheads). (b) On coronal maximum intensity projection reconstruction, the stricture involves the papillary region (arrow), with relative sparing of the main pancreatic duct. There is associated biliary tract dilation upstream. No masses were found at extended contrast-enhanced MRI of the upper abdomen. This appearance, probably representing scarring from calculi migration, was confirmed at follow-up; sphincterotomy and stent placement provided symptom relief.

Figure 10

A case of epigastric pain and elevation of serum bilirubin in a 71-year-old female patient 15 years after cholecystectomy. Magnetic resonance cholangiopancreatography found a calculus in the distal common bile duct. A complementary dynamic examination with repeated single-slice heavily T₂ weighted single-shot fast spin-echo sequences (a–c) shows no variation in the morphology of the papillary region. (d) As suggested by the scheme, elevation in the basal pressure and/or fibrosis results in a minimal or absent variation of the sphincter during contraction (left) and relaxation (right).

Figure 11

A case of recurrent biliary-like pain in a 39-year-old male patient who underwent laparoscopic cholecystectomy 5 years previously. A retained calculus was found a few days after surgery, which was extracted by sphincterotomy. Preliminary magnetic resonance cholangiopancreatography with a multislice technique (a) depicted a short tapered stricture of the sphincteric region, which is shown to maintain the same morphology during the dynamic study with repeated coronal single-slice heavily T₂ weighted single-shot fast spin-echo sequences (b–c). (d) As illustrated in the scheme, spasm and/or fibrosis of the papilla causes irregular contraction of the sphincter, causing a small amount of bile to remain in the lumen.