Recurrent choledocholithiasis with cholangitis 30 years post-cholecystectomy with negative ERCP: a case report.

Introduction and importance: Recurrent primary choledocholithiasis refers to the recurrent presence of biliary stones in the bile duct. Recurrent Choledocholithiasis is not a rare occurrence within 3 years of Cholecystectomy (CCY), with an incidence of 27.9% in one study. However, it is uncommon after 30 years of CCY. Case presentation: A 64-year-old female patient with a history of CCY and recurrent choledocholithiasis and cholangitis with liver abscess presented with signs and symptoms of cholangitis despite a negative endoscopic retrograde cholangiopancreatography (ERCP) one week before presentation. Blood cultures were positive for gram-negative rods,` consistent with her cholangitis. Clinical discussion: This case poses a question on the utility of endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) in high-risk patients for choledocholithiasis. Current guidelines recommend proceeding with ERCP directly in high-risk patients and obtaining EUS or MRCP in intermediate-risk patients. However, EUS or MRCP can be a helpful tool in scouting before proceeding with ERCP in complicated cases such as our case. Moreover, identification of patient-specific risk factors for such a rare entity would help with a better understanding of management and prevention of recurrent choledocholithiasis. Our patient had multiple other risk factors, including a dilated common bile duct and a history of multiple episodes of choledocholithiasis. Although not currently approved, certain oral medications can help reduce the risk of recurrence of primary choledocholithiasis. Conclusion: Early detection and localization of stones with EUS or MRCP is recommended in complicated cases of recurrent choledocholithiasis to prevent additional invasive procedures which in turn increase the risk of recurrence.