K91.86 Retained cholelithiasis following cholecystectomy

ICD10CM code

#### Name of the Condition
- Retained cholelithiasis following cholecystectomy
- Also known as retained gallstones after gallbladder removal

#### Summary
Retained cholelithiasis following cholecystectomy refers to the presence of gallstones that remain in the bile ducts even after the gallbladder has been removed. This condition can cause pain and other complications, requiring further medical treatment.

#### Causes
- The condition occurs when gallstones present in the bile duct at the time of cholecystectomy are not completely removed.
- It may also result from new stone formation after the surgery.

#### Risk Factors
- Previous history of gallstones or biliary sludge
- Incomplete surgical removal of stones during cholecystectomy
- Presence of anatomical variations that complicate surgery

#### Symptoms
- Abdominal pain, particularly in the upper right side
- Jaundice (yellowing of the skin and eyes)
- Nausea and vomiting
- Fever and chills if infection develops

#### Diagnosis
- Ultrasound or CT scan to identify retained stones
- Magnetic Resonance Cholangiopancreatography (MRCP) for detailed imaging of the bile ducts
- Endoscopic Retrograde Cholangiopancreatography (ERCP) for both diagnosis and potential treatment

#### Treatment Options
- ERCP to remove the retained stones from the bile duct
- Medication to dissolve small stones, although this is less common
- In some cases, further surgical intervention may be necessary

#### Prognosis and Follow-Up
- The prognosis is generally good with appropriate treatment.
- Follow-up care is important to monitor for recurrence or complications.
- Regular imaging may be recommended in persistent cases.

#### Complications
- Cholangitis (infection of the bile duct)
- Pancreatitis
- Biliary obstruction leading to liver damage

#### Lifestyle & Prevention
- Maintaining a healthy diet and weight can help reduce the risk of gallstone formation.
- Staying hydrated is also beneficial.
- There is limited preventive measures once a cholecystectomy has been performed, but regular follow-ups can help catch retained stones early.

#### When to Seek Professional Help
- Seek immediate medical attention if experiencing severe abdominal pain, jaundice, high fever, or chills, indicating possible infection or blockage.

#### Additional Resources
- [American College of Gastroenterology](https://gi.org)
- [National Institute of Diabetes and Digestive and Kidney Diseases](https://www.niddk.nih.gov)

#### Tips for Medical Coders
- Ensure the condition is differentiated from gallstones that were addressed during the initial cholecystectomy.
- Verify if any additional complications, such as cholangitis, are present and code them separately.
- Avoid coding for cholecystectomy-related stones as new cases of cholelithiasis without documentation of retention post-surgery.

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