Sami S Judeeba, MD, Abdulelah M Alhawsawi, MD, MBBS, RCPSC, FACS, DABS, Majid M Mansouri, MBBS, FRCSC, RCSPC. King Abdulaziz University
Laparoscopic cholecystectomy is becoming the gold standard for surgical removal of the gallbladder. About 5% to 40% of people who had laparoscopic cholecystectomy experienced a persistent abdominal pain to the extent of gastric upset, change in bowel habit & nausea or recurrent vomiting. Causes for this post laparoscopic cholecystectomy pain are many, and spilled gallstones is rare cause. Spilled gallstones can lead to formation of inflammatory Pseudotumor which can mimic malignancy over years with imaging study .
A 52 year old male patient who presented with 2 years history of persistent epigastric pain, change in bowel habit, and significant weight loss for more than 15 kg over the same period. The patient had a laparoscopic cholecystectomy 7 years ago. The procedure was not straight forward and followed by placement of a draining tube that stayed for 17 days until the patient was discharged from hospital. He had uneventful postoperative course until the time of his presentation to us. His laboratory findings are in normal limits including LFT, CBC & tumor marker as well.
Colonoscopy show no gross pathology and upper GI endoscopy is normal as well. Ultrasound abdomen revealed well defined cystic structure and subcapsular liver nodule.
Patient planned for further imaging study may lead to what is going on. A CT abdomen was done and shows liver lesion at segment #6 that goes with hemangioma. Also a nodule is seen in the subcapsular region of the left hepatic lobe. A multiple ill-defined nonenhancing intraperitoneal lesion adjacent to the hepatic flexure is also seen in the subcapsular region of the right hepatic lobe. A small soft tissue masses is seen at the anterior abdominal cavity indenting the left hepatic lobe. Multiple variable sizes nodules are seen within the peritoneal cavity.
Multiplanar multi sequential liver MRI images were obtained and confirms the nature of hemangioma that is seen in the CT scan on liver segment #6 . Also Multiple lesion around the liver which is hypointense on the T1 sequences, and shows a target appearance on the T2 sequences.
A CT guided biopsy attempts to take tissue biopsy from the nodules but histopathology is reported as inconclusive result.
The patient was planned for diagnostic laparoscopy and to obtain multiple biopsies. Upon laparoscopic exploration using open technique for inserting first & other trocar under direct vision, a minimal adhesion was noticed and was released using Harmonic Ultracision. There was no omental or peritoneal gross pathology. We took multiple biopsies from the peritoneal nodules that was matched to the CT scan findings and sent to the frozen section and reveal no pathological diagnosis or malignant cell. Then we moved toward the suspected nodules at gall bladder fossea, around right liver lobe and to the nodule that is subcapsular and anterior to the liver. We found that these nodules are a spilled stone grossly and most likely is from previous cholecystectomy.
Histopathology is reported as omental fat with foreign body giant cell reaction and bile pigment that is seen under microscope.