What is the likely diagnosis for an adult patient with a history of cholecystectomy (gallbladder removal) who is experiencing recurrent right upper quadrant pain?

Post-Cholecystectomy Syndrome: Likely Biliary Causes

The most likely diagnosis is post-cholecystectomy syndrome (PCS), with retained/recurrent common bile duct stones being the most common biliary cause, followed by bile duct stricture, bile duct injury, or remnant gallbladder pathology. 1, 2, 3

Differential Diagnosis of Post-Cholecystectomy RUQ Pain

Post-cholecystectomy syndrome encompasses a heterogeneous group of biliary and non-biliary disorders that cause persistent or recurrent symptoms after cholecystectomy 2, 3:

Biliary Causes (Most Relevant)

• Retained or recurrent choledocholithiasis occurs in 5-15% of post-cholecystectomy patients and presents with colicky RUQ pain radiating to the back with intermittent symptoms 1
• Bile duct strictures from inflammatory scarring involving the sphincter of Oddi or common bile duct, typically presenting with later onset symptoms 3
• Bile duct injury from operative complications, usually presenting early in the post-operative period 2, 3
• Retained cystic duct remnant stones from incomplete surgery 3, 4
• Remnant gallbladder with stones is an exceedingly rare but documented cause of recurrent RUQ pain 4, 5
• Sphincter of Oddi dysfunction causing recurrent RUQ pain mimicking chronic cholecystitis 1, 3
• Biloma or bile leak from operative complications 1, 2

Non-Biliary Causes (Must Be Excluded)

• Peptic ulcer disease, gastroesophageal reflux, pancreatitis, hepatic pathology, and functional dyspepsia account for many PCS cases 2, 3

Diagnostic Algorithm

Step 1: Initial Imaging

Order right upper quadrant ultrasound immediately as the first-line imaging study 1, 6:

• Ultrasound detects common bile duct dilatation, visualizes bile duct stones, identifies biloma or bile duct injury, and evaluates for remnant gallbladder pathology 1
• Ultrasound is rated 9/9 (usually appropriate) by the American College of Radiology for RUQ pain evaluation 1
• Ultrasound has 96% accuracy for detecting gallbladder pathology and provides comprehensive evaluation without radiation exposure 6

Step 2: Advanced Imaging When Ultrasound is Negative or Equivocal

Proceed directly to MRCP for comprehensive biliary tree evaluation 1, 3:

• MRCP has 85-100% sensitivity and 90% specificity for detecting choledocholithiasis 7, 1
• MRCP is superior to CT for assessing suspected biliary sources of RUQ pain and provides comprehensive visualization of the entire hepatobiliary system 7, 1
• MRCP excels at detecting bile duct strictures, anatomic abnormalities, cystic duct remnant pathology, and bile duct injuries 1, 3
• MRCP is the most reliable non-invasive imaging tool for assessing patients with suspected PCS and guiding management decisions 3

Step 3: Consider Functional Studies if MRCP is Negative

• Hepatobiliary scintigraphy (HIDA scan) should be considered if MRCP is negative and sphincter of Oddi dysfunction or biliary dyskinesia is suspected 1
• HIDA scan can evaluate low-grade, partial, or intermittent biliary obstruction presenting with recurrent RUQ pain 7

Step 4: Reserve CT for Specific Scenarios Only

• CT with contrast has limited value in this context, with only ~75% sensitivity for detecting gallstones 1
• CT should only be considered after ultrasound and MRCP are negative or equivocal, or for critically ill patients with suspected complications beyond simple biliary pathology 1

Critical Clinical Pitfalls to Avoid

• Do not skip ultrasound and proceed directly to MRCP or CT—ultrasound must be the initial imaging study per American College of Radiology guidelines 1, 6
• Do not exclude the possibility of remnant gallbladder pathology even in patients with documented previous cholecystectomy, as incomplete gallbladder removal can occur 4, 5
• Recognize that post-cholecystectomy Mirizzi syndrome can occur when a retained stone in the cystic duct remnant causes extrinsic compression of the common hepatic duct, and may be misdiagnosed as simple choledocholithiasis on MRCP 8
• Do not order CT as initial imaging—it exposes patients to unnecessary radiation when ultrasound is more diagnostic and has lower sensitivity for gallstones 1, 6
• Obtain liver function tests including total and direct bilirubin, transaminases (AST/ALT), alkaline phosphatase, and GGT to help differentiate biliary obstruction from other causes 6