Elizabeth Moseley, 1, Davinderbir S. Pannu, MD2, Cary Brewton, MD2, Veeral Oza, MD3 1Clemson University, Greenville, SC; 2McLeod Health, Florence, SC; 3University of South Carolina School of Medicine Greenville, Prisma Health, Greenville, SC
Introduction: Patients with cholecystitis often present with abdominal pain, nausea and vomiting. The treatment for cholecystitis often is a cholecystectomy. Pathogenesis of cholecystitis entails blockage of the cystic duct resulting in inflammation up-stream from the site of obstruction. Stones are often the cause of this obstruction, and can often enter the bile duct, causing bile duct obstruction. Cystic duct often merges with the common hepatic duct in the extrahepatic but non-pancreatic portion. Imaging such as Ultrasound and MRI in such cases would reveal a filling defect within the bile duct. We present a case where the cystic duct opened directly at the ampulla.
Case Description/Methods: A 68 year-old female presented with abdominal pain, nausea and vomiting. Laboratory testing revealed normal AST, ALT and Alkaline phosphatase. Bilirubin was elevated. Ultrasound imaging revealed findings of cholecystitis. A magnetic resonance cholangiopancreatography was performed (figure 1a) that revealed a normal common bile duct (CBD), and a dilated cystic duct with a filling defect consistent with a stone. Interestingly, it revealed cystic duct insertion close to the ampulla. During laparoscopic cholecystectomy, an intraoperative cholangiogram (figure 1b) with contrast injection into the cystic duct revealed multiple filling defects in the cystic duct with contrast draining into the small bowel through the papilla. ERCP with cholangioscopy confirmed the cystic duct opening into the ampulla. Treatment entailed ERCP with cholangioscopy and lithotripsy.
Discussion: Recognizing anatomical variants and considering these in the differential can help in understanding unusual clinical presentations of biliary pathologies.
Figure: Figure 1a: MRCP images showing stones (green arrow) in cystic duct with cystic duct opening at the ampulla; 1b: Intraoperative cholangiogram confirming cystic duct stones with cystic duct opening at the ampulla
Disclosures:
Elizabeth Moseley indicated no relevant financial relationships.
Davinderbir Pannu indicated no relevant financial relationships.
Cary Brewton indicated no relevant financial relationships.
Veeral Oza: Boston Scientific – Consultant. S4 Medical – Advisor or Review Panel Member.
Elizabeth Moseley, 1, Davinderbir S. Pannu, MD2, Cary Brewton, MD2, Veeral Oza, MD3. D0453 - Transpapillary Cystic Duct: A Rare Novel Genetic Variant, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.