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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 69-71

Ampullary stone in chronic pancreatitis causing obstructive jaundice and cholangitis


Meenakshi Mission Hospital and Research Centre, Madurai, Tamil Nadu, India

Date of Submission01-Nov-2020
Date of Acceptance23-Nov-2020
Date of Web Publication23-Mar-2021

Correspondence Address:
Sandheep Janardhanan
Meenakshi Mission Hospital and Research Centre, Melur Road, Madurai - 625 107, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_27_20

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  Abstract 


Cholangitis is very rarely caused by impaction of a pancreatic stone in the papilla. An elderly male presented with obstructive jaundice and cholangitis that was caused by an impacted pancreatic stone. He presented as fever of 2 weeks duration and was referred as case of periampullary neoplasm for palliative stenting. However, an endoscopic retrograde cholangiopancreatogram was done which revealed the impacted stone. Precut papillotomy was done to release the stone, which led to the resolution of cholangitis.

Keywords: Ampullary stone, cholangiopancreatography (magnetic resonance cholangiopancreatography), cholangitis, endoscopic retrograde cholangiopancreatography


How to cite this article:
Janardhanan S, James A, Palaniappan A, Ardhanari R. Ampullary stone in chronic pancreatitis causing obstructive jaundice and cholangitis. Gastroenterol Hepatol Endosc Pract 2021;1:69-71

How to cite this URL:
Janardhanan S, James A, Palaniappan A, Ardhanari R. Ampullary stone in chronic pancreatitis causing obstructive jaundice and cholangitis. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2021 Apr 22];1:69-71. Available from: http://www.ghepjournal.com/text.asp?2021/1/2/69/311738




  Introduction Top


Chronic pancreatitis is an inflammatory progressive disease characterized by progressive atrophy of pancreatic parenchyma and ductular fibrosis. Classically, it present with pain and steatorrhea. We here report a case of chronic pancreatitis with impaction of a calculus in the papilla presenting with cholangitis and pyrexia, treated by endotherapy.


  Case Report Top


A 70-year-old gentleman from a rural area in South India presented with on and off high grade fever of 2 weeks duration. There was no abdominal pain or cholestatic symptoms. He was worked up by the family physician at his hometown. Baseline investigations revealed neutrophilic leukocytosis. Liver function tests showed total and direct hyperbilirubinemia with mild transaminitis, raised alkaline phosphatase, and gammaglutamyltransferase. Other causes of infective hepatitis (hepatitis A, B, C, E, leptospirosis, dengue, typhoid, scrub typhus, malaria, infective endocarditis, etc.,) were excluded, and hematological workup was negative.

Ultrasound scan of the patient was reported to be normal; however, magnetic resonance cholangiopancreatography (MRCP) taken 2 weeks later showed distal common bile duct (CBD) obstruction by proliferative growth (12 mm) causing CBD and main pancreatic duct dilatation [Figure 1]. Plasma CA 19-9 levels were elevated (171 U/ml) (N-<40 IU/ml).
Figure 1: (a and b) Pre-procedure magnetic resonance cholangiopancreatography showing common bile duct and intra-hepatic biliary radicle dilatation

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Hence, he was diagnosed with periampullary neoplasm and considering the age was deemed inoperable and referred for endoscopic retrograde cholangiopancreatography (ERCP) and stenting. We proceeded with ERCP for palliative endotherapy. After duodenal intubation and failed cannulation, precut papillotomy using a needle knife (Huibregtse, Cook Medical, Winston-Salem, NC, USA) was performed. The precut incision was extended to the roof of the papilla in a 12 O'clock direction, and surprisingly, a whitish-yellow stone was exposed [Figure 2]. The pancreatic stone was successfully removed using Roth net, and a large amount of dark-greenish bile juice gushed out.
Figure 2: Steps in endoscopic removal of ampullary pancreatic stone

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Table shows recorded serial liver function test pre- and postprocedure and 1 month follow-up [Table 1].
Table 1: Recorded serial liver function test pre- and postprocedure and 1-month follow-up

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Pancreatogram showed mildly upstream dilated pancreatic duct (Cambridge class I). Cholangiogram showed no filling defect, stone, or stricture [Figure 3]. Postprocedure, his liver function tests were normalized, and he became asymptomatic. He had follow-up 2 months later, and liver function tests were found to be within the normal limits. A follow-up MRCP scan also corroborated the findings (normal study except small pancreatic calcification suggestive of underlying chronic pancreatitis) [Figure 4].
Figure 3: Poststone extraction cholangiopancreatogram showing mildly dilated pancreatic duct

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Figure 4: One-month follow-up magnetic resonance cholangiopan creatography showing normal study except mild pancreatic calcification

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  Discussion Top


The complications of chronic pancreatitis are commonly obstructive jaundice or pancreatic stenosis. The clinical profile normally is recurrent attacks of pancreatitis and steatorrhea. Our patient had an episode of cholangitis as first presentation, which is unusual at this age.[1]

The presentation as cholangitis caused by impacted ampullary pancreatic stone in a patient with underlying chronic pancreatitis is extremely rare. Globally, around 20–30 cases have been reported mostly in Japan and Korea.[2],[3],[4] In India, such a case was first described by Naik et al. in 1991.[5] Shetty et al. has described about three cases of chronic pancreatitis with impacted ampullary pancreatic stone.[8]

The mechanism of obstructive jaundice caused by pancreatic stone may be similar to the gallstone pancreatitis, i.e., ampullary stone causing bile duct obstruction, jaundice, and cholangitis. In most of the cases, endotherapy procedures such as stone extraction, pancreatic duct stenting, or drainage of pseudocysts achieve high degree of success.[6],[7] There are no guidelines regarding the management of each scenario, but it is generally agreed that surgical intervention is rarely needed, that too only if standard endo therapy fails. [9,10]

To summarize, this was a very rare case of acute cholangitis caused by an impacted ampullary pancreatic stone in a patient with underlying chronic pancreatitis, which mimicked as periampullary malignancy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yoo KH, Kwon CI, Yoon SW, Kim WH, Lee JM, Ko KH, et al. An impacted pancreatic stone in the papilla induced acute obstructive cholangitis in a patient with chronic pancreatitis. Clin Endosc 2012;45:99-102.  Back to cited text no. 1
    
2.
Moritomo H, Nakaya S, Takeyama Y. A case of obstructive jaundice caused by incarceration of pancreatic stones in the ampulla of papilla Vater. Nihon Geka Gakkai Zasshi 1990;91:146-9.  Back to cited text no. 2
    
3.
Naitoh I, Nakazawa T, Ohara H, Ando T, Hayashi K, Okumura F, et al. A case of obstructive jaundice caused by impaction of a pancreatic stone in the papilla for which a needle knife precut papillotomy was effective. JOP 2008;9:520-5.  Back to cited text no. 3
    
4.
Adler DG, Lichtenstein D, Baron TH, Davila R, Egan JV, Gan SL, et al. The role of endoscopy in patients with chronic pancreatitis. Gastrointest Endosc 2006;63:933-7.  Back to cited text no. 4
    
5.
Naik A, Shah SH, Relekar RG, Bapat RD. Pancreatic calculus causing obstructive jaundice. Indian J Gastroenterol 1991;10:27-8.  Back to cited text no. 5
    
6.
Kinoshita H, Imayama H, Sou H, Shibata J, Ogami N, Tamae T, et al. A case of obstructive icterus caused by incarceration of a pancreatic stone in the common channel of the pancreatobiliary ducts. Kurume Med J 1996;43:79-85.  Back to cited text no. 6
    
7.
Delhaye M, Arvanitakis M, Bali M, Matos C, Devière J. Endoscopic therapy for chronic pancreatitis. Scand J Surg 2005;94:143-53.  Back to cited text no. 7
    
8.
Shetty AJ, Pai CG, Shetty S, Balaraju G. Pancreatic calculus causing biliary obstruction: Endoscopic therapy for a rare initial presentation of chronic pancreatitis. Dig Dis Sci 2015;60:2840-3.  Back to cited text no. 8
    
9.
Sarles H, Sahel J. Cholestasis and lesions of the biliary tract in chronic pancreatitis. Gut 1978;19:851-7.  Back to cited text no. 9
    
10.
Hernandez JA, Zuckerman MJ, Moldes O. Pancreatic stone presenting with biliary obstruction. Gastrointest Endosc 1994;40:521-3.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1]



 

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