Giant anastomotic stone and hepatic abscess: a 40-year delayed complication of Roux-en-Y hepaticojejunostomy

Introduction

Roux-en-Y hepaticojejunostomy is a standard procedure for biliary reconstruction (1). However, this anatomical alteration can lead to long-term complications, such as cholangitis, biliary strictures, and stone formation. Although the formation of stones within the bile ducts following this surgery has been documented, the occurrence of large stones within the intestinal loop is an exceptionally rare complication. Herein, we report a case of a giant stone diagnosed 40 years after hepaticojejunostomy, which was complicated by a secondary hepatic abscess. The primary aim of presenting this case is to highlight the potential for extremely delayed and unusual complications following bilioenteric anastomosis and to underscore the critical role of multimodal imaging in the diagnosis and management of such complex conditions.

Case presentation

A 69-year-old female patient had undergone cholecystectomy and bilioenteric anastomosis at another hospital 40 years earlier. However, the specific etiology and surgical techniques were unknown. She initially presented to the outpatient clinic of our hospital with complaints of abdominal pain and fever. Additionally, she reported increased nocturnal urination and darker urine color. No other significant abnormal symptoms or signs were observed. Laboratory tests revealed anomalies in multiple indicators, including mild aminotransferase elevation, increased neutrophil and monocyte counts, elevated alkaline phosphatase, gamma-glutamyl transferase, and direct bilirubin levels, along with hypoalbuminemia, reduced total protein, low calcium, and low cholesterol levels. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Upon admission, the physician arranged for additional diagnostic procedures, which sequentially included non-contrast and contrast-enhanced abdominal magnetic resonance imaging (MRI), ultrasound-guided puncture drainage of the abscess and biopsy of the space-occupying lesion between the liver and pancreas, as well as non-contrast and contrast-enhanced abdominal computed tomography (CT). The condition was ultimately treated with surgery.

Non-contrast and contrast-enhanced abdominal MRI scans revealed a large abnormal lesion between the liver and pancreas, with a maximum cross-sectional area of approximately 10.2 cm × 7.1 cm. On T1-weighted imaging (T1WI), the lesion exhibited mixed isointensity and hypointensity, whereas on T2-weighted imaging (T2WI), it predominantly appeared hypointense. Linear hyperintensities were observed within the lesion on T2WI, surrounded by a peripheral rim of mildly high signal intensity. There was no evidence of restricted diffusion. The main body of the lesion did not enhance during contrast administration. However, delayed enhancement of the peripheral ring-like walls was noted, and communication with the intrahepatic bile ducts was evident. Multiple nodular filling defects were observed at the sites of communication (Figure 1A-1J), suggesting that lesions may be located in a duct (biliary or intestinal), most likely stones.

Figure 1 MRI images of lesions between the liver and pancreas. (A) T1WI, (B) T2WI, (C) DWI (b=0), (D) DWI (b=800), (E) ADC, (F) pre-contrast T1WI, (G) early arterial phase, (H) late arterial phase, (I) portal venous phase, (J) equilibrium phase. An abnormal mass is identified between the liver and pancreas. On T1WI, the lesion exhibits mixed isointensity and hypointensity (A), whereas on T2WI, it predominantly shows hypointensity with linear hyperintense regions within and a peripheral mildly hyperintense rim (B). No evidence of restricted diffusion is observed (C-E). During contrast-enhanced imaging, the main body of the lesion does not enhance, but a circular delayed enhancement wall is visible at its periphery (F-J), communicating with intrahepatic bile ducts. Nodular filling defects are noted at the communication site (B). ADC, apparent diffusion coefficient; DWI, diffusion-weighted imaging; MRI, magnetic resonance imaging; T1WI, T1-weighted imaging; T2WI, T2-weighted imaging.

In addition, extensive abnormal signal foci were detected in the right lobe of the liver, with a maximum cross-sectional size of approximately 8.8 cm × 6.5 cm. The lesion displayed layered changes, with an irregular central region showing hypointensity on T1WI and hyperintensity on T2WI. Diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) mapping revealed uneven diffusion restriction. Peripheral regions showed slightly elevated signals on both T1WI and T2WI, with marked heterogeneous delayed enhancement. Thickening and delayed enhancement of the intrahepatic bile duct wall were also observed, with local communication between the bile duct and the lesion in the right lobe of the liver, indicating involvement of the biliary system and resulting cholangitis.

Ultrasound-guided biopsy of the lesion between the liver and pancreas was performed. Two pale yellow tissue samples, each approximately 2 cm in length, were obtained and subjected to hematoxylin and eosin (HE) staining. Microscopic examination revealed amorphous basophilic material and a small amount of biliary content, with no identifiable native tissue structures (Figure 2). In addition, ultrasound-guided abscess puncture and drainage were carried out, followed by bacterial culture and antibiotic sensitivity testing. Results indicated Escherichia coli infection, sensitive to some antibiotics such as levofloxacin. The patient was subsequently treated with levofloxacin 500 mg daily orally for 7 days.

Figure 2 Histological features. HE staining, original magnification ×400. (A) Amorphous basophilic material. (B) Bile-like substances. HE, hematoxylin and eosin.

Given the clinical suspicion of a surgically treatable lesion between the liver and pancreas, the physician proceeded with preoperative abdominal CT scanning, including non-contrast and contrast-enhanced phases. Abdominal CT imaging revealed postoperative anatomical features consistent with a Roux-en-Y hepaticojejunostomy (Figure 3A): one end leading to a jejunal blind loop (Figure 3B), and the other connecting to the duodenum through the jejunal loop (Figure 3C). Multiple lesions were identified within the intestinal loops at the anastomotic site, with the largest measuring approximately 7.7 cm × 5.7 cm in cross-section. The lesion exhibited mixed density, with a central low-density area [CT value: 12–47 Hounsfield units (HU)] and a peripheral high-density rim (CT value: 85–106 HU), displaying layered morphology without enhancement (Figure 3D-3F). These lesions obstructed the bile duct outflow tract, causing upstream dilation of the intrahepatic bile ducts and associated gas accumulation (Figure 3A). Based on these findings, CT strongly supported the diagnosis of a large stone located on the intestinal side of the hepaticojejunostomy accompanied by other small stones. In addition, there were multiple liver abscesses in the right lobe of the liver.

Figure 3 Non-contrast and contrast-enhanced abdominal imaging. (A) Sagittal view in venous phase. (B-F) axial views in non-enhanced (D), arterial (E), and venous phases (B,C,F). The lesion is located at the bile duct-jejunal anastomosis (A), with one end (arrow) extending to the jejunal blind loop (B) and the other (arrow) connecting to the jejunal loop anastomosed with the duodenum (C). Multiple lesions are present, with the largest showing a central irregular low-density area (CT value: 12–47 HU) and a peripheral high-density region (CT value: 85–106 HU), exhibiting laminated appearance without enhancement (D-F). Upstream intrahepatic bile ducts are dilated and associated with multiple gas accumulations (arrow) (A). CT, computed tomography; HU, Hounsfield units.

Ultimately, surgical intervention was undertaken. Severe adhesions were noted in the right upper quadrant. The proximal jejunum at the previous hepaticojejunostomy was locally distended and densely adhered. A longitudinal incision (6 cm) was made along the thickened jejunal segment, revealing localized intestinal wall scarring and a large gallstone (10 cm × 8 cm) within the lumen (Figure 4), alternating yellowish-brown, and the surface was partially rough. When cut open, a typical multi-layered structure was seen, and a substance similar to flowing liquid was observed in the center. Exploration using a 5 mm Olympus (Tokyo, Japan) choledochoscope revealed tortuous intrahepatic bile ducts filled with viscous bile and flocculent debris.

Figure 4 Intraoperative photographs of the resected lesion, demonstrating a gallstone-like appearance with a multilayered structure and a centrally located substance resembling flowing liquid (arrow).

The patient was ultimately diagnosed with a massive stone located within the intestinal loop of the Roux-en-Y hepaticojejunostomy, accompanied by intrahepatic bile duct dilation, gas accumulation, and right hepatic lobe abscess. Effective treatment was achieved through surgical stone removal, abscess drainage, and targeted antibacterial therapy.

Discussion

This elderly female patient had undergone cholecystectomy and bilioenteric anastomosis 40 years prior, with unclear etiology and surgical details. She presented with an unusual space-occupying lesion between the liver and pancreas. Multimodal imaging, particularly enhanced CT with three-dimensional reconstruction, suggested a massive stone within the Roux-en-Y intestinal loop complicated by hepatic abscess. Definitive diagnosis was confirmed intraoperatively, and appropriate treatment was administered. We systematically reviewed previously reported cases of enteric stones following Roux-en-Y hepaticojejunostomy (Table 1). Although this complication is generally rare, its clinical manifestations often include abdominal pain, fever, and obstructive jaundice, frequently complicated by cholangitis or intestinal obstruction, and all reported cases had required surgical operation. Compared with previous cases, the present case demonstrates the following unique features: (I) the interval between the initial surgery and the diagnosis of the stone was 40 years, which is exceptionally rare in the literature. This prolonged course provided conditions for the stone to gradually develop to an unusually large size; (II) the stone was extremely large and located within the intestinal loop, causing distortion of local anatomy and compression of adjacent structures, posing challenges for preoperative localization and diagnosis; (III) long-term biliary stasis and enteric reflux contributed to the formation of a secondary liver abscess, further increasing clinical complexity; (IV) the use of multimodal imaging (CT + MRI) was crucial for accurate diagnosis, underscoring the importance of imaging follow-up in patients with long-term postoperative courses.

Accurate diagnosis relied heavily on multimodal imaging, which provided essential insights into lesion localization, nature, underlying pathogenesis, and therapeutic guidance. Enhanced CT was the cornerstone due to high spatial resolution (1.25 mm slice thickness), delineating anatomy precisely. Three-dimensional reconstruction clarified the anatomy of the Roux-en-Y hepaticojejunostomy performed decades ago, confirming the lesion within the intestinal loop, not the liver or pancreas. CT identified biliary obstruction near the anastomosis in the proximal jejunal limb, causing bile outflow blockage and intrahepatic bile duct dilation. Stone density heterogeneity (12–47 HU center, 85–106 HU periphery) effectively excluded the presence of pure calcium bilirubin or pure cholesterol stones. Postoperative pathological analysis revealed a mixed stone with layered cholesterol crystals and calcium bilirubin deposits. CT also identified target-like ring-enhancing lesions in the right lobe of the liver, typical of hepatic abscess, connecting the possible pathological sequence: bilioenteric anastomotic calculi → biliary obstruction → retrograde infection → hepatic abscess. It should be noted that for patients with abdominal pain and fever after bilioenteric anastomosis, contrast-enhanced CT should be the preferred imaging examination, as it can quickly investigate common serious complications such as biliary obstruction and secondary infection.

MRI complemented CT by enabling soft tissue evaluation. The marked hypointensity on T2WI corroborated calcium bilirubin content. In addition, DWI demonstrated restricted diffusion within the abscess cavity, not the stone, ruling out neoplasm. MRI clearly delineated inflammation and abscess relations, aiding therapy and overcoming CT’s soft tissue limits.

Due to the decades-long surgical history in this case, another differential diagnosis to consider is gossypiboma. However, from the perspective of imaging, its characteristic manifestation is identified as a low-density heterogeneous mass on CT scans, featuring a high-density wall and enhancement externally, along with an internal spongy pattern containing bubbles (10). Typically, it presents as a high signal on T2WI, yet the whorled stripes in the central portion are characteristically shown as low-signal on T2WI, which indicative of gauze fibers (10). Therefore, gossypiboma does not align with the imaging representation observed in this case.

Roux-en-Y hepaticojejunostomy represents a standard biliary reconstructive procedure, inducing anatomical alterations (1). Adhesive forces following the initial surgery likely contributed to intestinal loop dilation. Prolonged chronic bile stimulation could also trigger chronic inflammation of the intestinal mucosa, leading to fibrosis and decreased elasticity of the intestinal wall. This condition can cause dysmotility of the intestine, ultimately resulting in compensatory dilation. Moreover, after the operation, the peristaltic function of the proximal intestinal loop is reduced, and a relatively stagnant area is prone to form at the anastomosis site, which becomes an ideal environment for the deposition and growth of stones. Loss of Oddi sphincter control may lead to the reflux of intestinal fluids and retrograde infection of gut microbiota (11). β-glucuronidase secreted by bacteria catalyzes conjugated bilirubin breakdown, facilitating layered deposition of bilirubin calcium salts (12). These microbial communities adhere to each other using extracellular polymers as a matrix, forming a biofilm that establishes a protective zone with high resistance to immune clearance and antimicrobial agents (13). The colonization of bacteria and formation of biofilms enable gallstones to grow slowly over a chronic course lasting up to 40 years. Furthermore, abnormalities in enterohepatic circulation of bile acids following cholecystectomy contribute to metabolic disturbances (14). Factors such as advanced age, female and dietary habits collectively promote the formation and progression of gallstones (15).

Although the origin of the stone (residual vs. de novo) remains uncertain, the central low-density area suggests a nidus formed by food residue or necrotic debris, around which progressive stone accretion occurred under favorable conditions. Enlarging stones can lead to severe complications. First, larger stones can directly cause biliary obstruction and biliary hypertension, promoting the reflux of intestinal flora to invade the bile duct system, and subsequently triggering liver abscess (as shown in this case). Second, long-term obstruction can further lead to cirrhosis. Furthermore, long-term subclinical reflux cholangitis may also increase the risk of cholangiocarcinoma (16). Patients also face the dual risks of adhesive and lithogenic intestinal obstruction, necessitating comprehensive clinical assessment.

In addition, laboratory indicators contribute significant value. Mild aminotransferase elevation suggested hepatic inflammation, whereas increased neutrophil and monocyte counts pointed to bacterial infection. Elevated alkaline phosphatase, gamma-glutamyl transferase, and direct bilirubin levels indicated biliary obstruction. Hypoalbuminemia, reduced total protein, low calcium, and low cholesterol levels may reflect malnutrition, impaired synthetic function, and absorption disorders.

Conclusions

This rare case of a large stone located on the intestinal loop side of the anastomosis, complicated by liver abscess occurring 40 years after hepaticojejunostomy, highlights the importance of long-term standardized postoperative management for such patients. It serves as a reminder that clinicians must place significant emphasis on comprehensive medical history collection and basic imaging evaluation in clinical practice. Establishing a more systematic imaging examination pathway, reconstructing anatomical alterations caused by prior surgeries, and achieving precise lesion identification and diagnosis are essential components of optimal clinical care.

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1668/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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