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. Such patients can be treated with the endoscopic or surgical approach; the former is more commonly used. We report a rare case of gallbladder perforation associated with obstructive jaundice due to pancreatic stone impaction at the ampulla.
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.
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].
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 4a]. 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 4b and c].
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.
Obstructive jaundice is a common condition seen in surgical practice. It can be due to various benign and malignant pancreaticobiliary pathologies. Pancreatic stone causing obstructive jaundice either due to compression of CBD or due to impaction at the papilla is quite rare.
All reported cases of obstructive jaundice caused by pancreatic stone had large stones measuring up to 20 mm in diameter. Our patient also had a large 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. Our patient presented with an acute abdominal emergency. Initial investigations were suggestive of 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%. in our patient, there was a low insertion of the 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.
Endoscopic methods include papillary sphincterotomy, pancreatic sphincterotomy, and needle-knife precut papillotomy, followed by stone retrieval using a balloon or basket. Extracorporeal shock wave lithotripsy may be beneficial in patients with large stones. In our patient, the acute emergency condition was managed by USG-guided tube 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. Our patient was managed with endoscopic methods and later underwent open cholecystectomy for sealed 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
Conflicts of interest
There are no conflicts of interest.
1. 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
2. Abdallah AA, Krige JE, Bornman PC. Biliary tract obstruction in chronic pancreatitis
HPB (Oxford). 2007;9:421–8
3. Hernandez JA, Zuckerman MJ, Moldes O. Pancreatic stone
presenting with biliary obstruction Gastrointest Endosc. 1994;40:521–3
4. Cardoso R, Casela A, Lopes S, Agostinho C, Souto P, Camacho E, et al Portal hypertensive biliopathy: An infrequent cause of biliary obstruction GE Port J Gastroenterol. 2015;22:65–9
5. Kao JT, Kuo CM, Chiu YC, Changchien CS, Kuo CH. Congenital anomaly of low insertion of cystic duct
: Endoscopic retrograde cholangiopancreatography findings and clinical significance J Clin Gastroenterol. 2011;45:626–9
6. Little TE, Kozarek RA. Pancreatic stones as a cause of bile duct and ampullary obstruction: Endoscopic treatment approaches Gastrointest Endosc. 1993;39:709–12
7. 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
8. Sauerbruch T, Holl J, Sackmann M, Werner R, Wotzka R, Paumgartner G. Disintegration of a pancreatic duct stone with extracorporeal shock waves In a patient with chronic pancreatitis
9. Ohara H, Hoshino M, Hayakawa T, Kamiya Y, Miyaji M, Takeuchi T, et al Single application extracorporeal shock wave lithotripsy is the first choice for patients with pancreatic duct stones Am J Gastroenterol. 1996;91:1388–94
10. Inui K, Tazuma S, Yamaguchi T, Ohara H, Tsuji T, Miyagawa H, et al Treatment of pancreatic stones with extracorporeal shock wave lithotripsy: Results of a multicenter survey Pancreas. 2005;30:26–30