Cystic Duct Remnant Syndrome

During cholecystectomy a variable length of the cystic duct is left as a remnant. Usually a cystic duct remnant measuring 1-2cm in length is left although remnants can be seen up to 6cm in length. Complications associated with remnant cystic duct are retained stones in cystic duct, bile leakage, stricture, fistula formation, dilatation of cystic duct remnant, amputation neuromas and suture granuloma of cystic duct. A rare complication is cystic duct mucocele where the remnant of cystic duct is distended with mucous [1]. Post cholecystectomy syndrome is described in patients with recurrent or persistent abdominal symptoms following cholecystectomy. The symptoms include biliary or non biliary type of abdominal pain, dyspepsia, vomiting, gastrointestinal disorders and jaundice with or without fever [2]. Normal cystic duct usually measures 4 to 6cm in length and contains concentric folds know as the spiral valves of Heister. The diameter of the duct range from 1 to 5mm. the cystic duct usually joins the extrahepatic bile duct approximately at the half way between the porta hepatis and ampulla of vater, commonly to its medial aspect. On Grey scale Ultrasonography the normal cystic duct is visualized only in 50% of the patients as an anechoic tubular structure connecting the gall bladder and extrahepatic duct [1]. The normal cystic duct is not routinely visualized on CT scan. In some CT scans it can be visualized a low attenuating tubular structure with a thin enhancing wall. MR Cholongiopancreatogram routinely demonstrates the normal cystic duct and can be traced down to the extrahapatic ducts in most of the cases. T2W sequences also show high signal intensity bile within gall bladder and duct system often delineating the cystic duct. T1W sequences also may demonstrate cystic duct when it contains concentrated high signal intensity bile [1]. The gold standard methods of demonstrating biliary tract is the direct cholangiography where injection of contrast is performed with Percutaneous transhepatic cholangiography (PTC), Endoscopic Retrograde cholangiopancreatography (ERPC) or T tube cholangiogram [1]. In an asymptomatic patient the cystic duct caliber is often the same as a normal following cholecystectomy. The caliber of the remnant approximately measures 4mm and the length measures 5 to 25mm. when the cystic duct remnant caliber is more than 4 or 5mm it is considered dilated. The terminal end of the cystic duct remnant is described to resemble a “leaf bud” in normal post cholecystectomy patients and when the remnant is pathologically dilated it is described as giving an appearance of a ‘torch bulb” [3]. The dilatation or the pouch formation of the cystic duct remnant is thought to be due to an inflammatory reaction [3]. It is important to identify these cystic duct remnants as they act as cul de sac with a potential source of infection and frequently associated with presence of stones [4].