INTRODUCTION
Obstructive jaundice is a common surgical problem. Chronic pancreatitis causing obstructive jaundice is uncommon; if it occurs, it is usually due to biliary stricture. Impaction of stone at the ampulla is commonly seen in patients with choledocholithiasis causing obstructive jaundice. In the absence of choledocholithiasis, the impaction of pancreatic stone at the level of the ampulla causing obstructive jaundice is a rare phenomenon.[1 gallbladder perforation associated with obstructive jaundice due to pancreatic stone impaction at the ampulla.
CASE REPORT
A 65-year-old male patient, presented with severe abdominal pain for 5 days together with jaundice and abdominal distention for 2 days. On examination, the patient was sick and hypovolemic with a pulse rate of 120 beats/min and blood pressure of 80/60 mmHg. The abdomen was distended with diffuse tenderness but no guarding or rigidity.
Blood biochemistry revealed total bilirubin, direct bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, amylase, and total white blood cell count were 4.5 mg/dL, 2.84 mg/dL, 45 IU/L, 67 IU/L, 180 IU/L, 800 IU/L, and 14,000 cells/mm3 , respectively. Ultrasonography (USG) of the abdomen showed a distended gallbladder and fluid surrounding it without cholelithiasis. Intrahepatic biliary radicles (IHBR) were not dilated, and the common bile duct (CBD) had normal caliber. There was a moderate amount of free fluid in the abdomen with evidence of chronic pancreatitis .
Contrast-enhanced computed tomography (CECT) abdomen showed an atrophic pancreas with parenchymal calcifications. There was a calculus measuring 9.5 mm × 7.3 mm at the ampulla with proximal dilatation (7 mm) of the main pancreatic duct (MPD) [Figure 1 ]. We noted a single, nonobstructing, and eccentrically placed calculus in the MPD at the level of the neck of the pancreas. Further, a distended gallbladder with a focal area of the nonenhancing wall with pericholecystic collection was present. The CBD was 7 mm in diameter without any evidence of choledocholithiasis [Figure 2 ]. Diagnostic aspiration of the peritoneal fluid was done, which showed bile-stained fluid. With these findings, the patient was diagnosed with sealed gallbladder perforation and obstructive jaundice due to a stone at the level of the ampulla, with chronic pancreatitis . However, the cause of nondilated CBD was not clear.
Figure 1: Computed tomography abdomen (axial view) showing calculus impacted at the level of the ampulla (arrow)
Figure 2: Contrast-enhanced computed tomography abdomen (axial view) showing: (a) distended gallbladder with focal areas of discontinuity in wall enhancement (yellow arrow) with surrounding hypodense fluid collection (red arrow) and (b) common bile duct of normal caliber (yellow arrow) and dilated main pancreatic duct (red arrow)
The patient was started on broad-spectrum antibiotics and intravenous fluids. An USG-guided tube cholecystostomy for biliary drainage was done. Due to significant biliary peritoneal fluid collection, a pelvic pigtail drain was placed. Repeat CECT showed collapsed gallbladder and pigtails in situ and a calculus impact at the level of the ampulla. MPD was dilated due to an eccentric stone with a normal caliber CBD [Figure 3 ].
Figure 3: Contrast-enhanced computed tomography abdomen showing: (a) (coronal multiplanar reconstruction image): percutaneous tube cholecystostomy (arrow), (b) (axial view): calculus impacted at the ampulla (arrow), (c) (axial view): dilated main pancreatic duct (red arrow) and small eccentric pancreatic calculus within the main pancreatic duct (yellow arrow), and (d) (axial view): common bile duct of normal caliber (yellow arrow)
Magnetic resonance cholangiopancreatography showed a calculus measuring 9 mm × 7 mm at the level of the ampulla, obstructing the common channel of MPD and CBD [Figure 4 a]. Another calculus of 5 mm × 4 mm in the MPD was lying eccentrically without obstructing the duct. IHBR and CBD were not dilated, but the cystic duct had an anomalous insertion in the lower part of CBD [Figure 4 b and c].
Figure 4: Image showing: (a) (magnetic resonance imaging abdomen T2 sequence – axial view): calculus at the level of the ampulla (yellow arrow) seen as a hypointense filling defect, (b) magnetic resonance cholangiopancreatography (coronal view) showing nondilated common bile duct (yellow arrow) and low medial insertion of the cystic duct (red arrow), (c) magnetic resonance cholangiopancreatography (coronal view) having common bile duct (yellow arrow), cystic duct (red arrow), and dilated main pancreatic duct (green arrow), and (d) contrast-enhanced computed tomography abdomen (coronal view) showing the stent in the common bile duct (yellow arrow) and stent in the main pancreatic duct (red arrow)
Endoscopic retrograde cholangiopancreatography, sphincterotomy, stone extraction from the ampulla, endoscopic stenting of CBD, and MPD [Figure 4d] were done. During the procedure, the stone spilled into the duodenum accidentally; hence, we could not perform a stone analysis. The patient underwent open cholecystectomy after 6 weeks. Intraoperatively, there was a small-size gallbladder with cholecystostomy in situ . Low insertion of the cystic duct was noted. Histopathological examination of the gallbladder showed changes suggestive of acalculous cholecystitis, with two rents in the wall of the bladder; these included the site of tube cholecystostomy and the sealed perforation. Subsequently, the biliary and pancreatic stents were removed endoscopically.
DISCUSSION
Obstructive jaundice is a common condition seen in surgical practice. It can be due to various benign and malignant pancreaticobiliary pathologies.[2 Pancreatic stone causing obstructive jaundice either due to compression of CBD or due to impaction at the papilla is quite rare.[1 3
All reported cases of obstructive jaundice caused by pancreatic stone had large stones measuring up to 20 mm in diameter.[1 pancreatic stone measuring almost 10 mm in size obstructing the common ampullary channel.
Patients usually present with jaundice, abdominal pain, and sometimes fever. Few patients may develop features of cholangitis. Some patients may have a palpable gallbladder or hepatomegaly; few develop splenomegaly.[4 gallbladder perforation due to a pancreatic stone causing an ampullary obstruction. However, we could not explain the cause of nondilated CBD even though the stone was obstructing the ampulla.
In the general population, the incidence of low insertion of the cystic duct is around 5.6%.[5 cystic duct . We hypothesize that a stone at the level of the ampulla would have increased the pressure in the cystic duct and gallbladder which could be due to low insertion of the cystic duct ; consequently, gallbladder perforation may ensue. This theory could explain nondilated CBD with a distended gallbladder due to a stone at the level of the ampulla. The presence of chronic pancreatitis changes along with dilated MPD and an eccentric, nonobstructing stone in MPD supports our notion that the ampullary stone must be of pancreatic origin.
Treatment of ampullary stones depends on patient presentation. If a patient presents with cholangitis, the treatment will be administering broad-spectrum antibiotics, adequate hydration, and emergency biliary decompression. Biliary decompression can be achieved either endoscopically or percutaneously. Endoscopic methods usually treat impaction biliary stones at the ampulla.[3 6
Endoscopic methods include papillary sphincterotomy, pancreatic sphincterotomy, and needle-knife precut papillotomy, followed by stone retrieval using a balloon or basket.[3 6 7 8 9 10 cholecystostomy . Once the patient was stabilized, we performed endoscopic precut papillotomy, stone extraction, and stenting of the pancreatic duct and bile duct. The cholecystostomy tube was removed after 1 week of endoscopic stenting.
Surgical treatment options for obstructive jaundice resulting from pancreatitis include pancreaticoduodenectomy, hepaticojejunostomy, open duodenotomy, and sphincterotomy.[7 gallbladder perforation .
Pancreatic stone getting impacted at the ampulla causing obstructive jaundice and gallbladder perforation is rare. However, clinicians should be aware of such presentation in patients with gallbladder perforation without cholelithiasis and choledocholithiasis. Imaging helps in the diagnosis of such conditions. Such patients can be managed with emergency biliary decompression followed by endoscopic retrieval of stone; surgical options are rarely needed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
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Conflicts of interest
There are no conflicts of interest.
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