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CASE REPORT
Ahead of print publication  

Transient pancreatitis post laparoscopic cholecystectomy: A rare case report


1 Department of Surgery, 178 Military Hospital, Gangtok, Sikkim, India
2 Department of Anaesthesiology, 178 Military Hospital, Gangtok, Sikkim, India
3 Department of Internal Medicine, 178 Military Hospital, Gangtok, Sikkim, India
4 Department of Pathology, 178 Military Hospital, Gangtok, Sikkim, India

Date of Submission21-Feb-2020
Date of Decision06-Mar-2020
Date of Acceptance14-Apr-2020
Date of Web Publication12-Sep-2020

Correspondence Address:
Dharmendra Singh,
Department of Internal Medicine, 178 Military Hospital, c/o 99 APO, PIN 903178
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmms.jmms_14_20

  Abstract 


Acute postoperative pancreatitis is an uncommon complication following laparoscopic cholecystectomy. The common complications in the early postoperative period are usually attributable to a bile duct injury or a bleeding vessel. Pancreatitis in such a setting usually resolves by conservative management unless there is an active obstruction at the lower common bile duct. Very few cases have been documented in the literature in this contention. In this case report, a case of acute pancreatitis following laparoscopic cholecystectomy is described in terms of the clinical presentation, laboratory parameters, management strategy, and a short review of the literature.

Keywords: Gallbladder, laparoscopic cholecystectomy, pancreatitis



How to cite this URL:
Kumar M A, Pahwa B, Singh D, Sharma A. Transient pancreatitis post laparoscopic cholecystectomy: A rare case report. J Mar Med Soc [Epub ahead of print] [cited 2020 Nov 28]. Available from: https://www.marinemedicalsociety.in/preprintarticle.asp?id=294882




  Introduction Top


Diseases related to the gall bladder forms a significant proportion of workload for a general surgeon in the form of biliary colic, cholecystitis, or gallstone pancreatitis.[1] Laparoscopic cholecystectomy (LC), in its normal course has an uneventful recovery. Early complications are usually attributed to the bile duct injuries or a bleeding vessel, which usually presents with pain and alteration in drain output.[2] Acute postoperative pancreatitis (APP) following LC is quite an uncommon entity with the incidence being as low as 0.34% and can be a cause of worry for the surgeons.[3] Surprisingly, the incidence of pancreatitis following open biliary tract surgeries is to the tune of 10%.[4] However, it is pertinent to suspect pancreatitis when the patient reports typical symptoms. In this case report, we present such a case of transient pancreatitis following an uneventful surgery and its management.


  Case Report Top


A 34-year-old male patient had presented to the general surgical outpatient department of a peripheral hospital with complaints of pain in the right upper quadrant of the abdomen of 1-month duration. The pain was associated with dyspepsia and flatulence following meals. There was no history of any jaundice or pancreatitis in the past. On clinical examination, his vitals and abdominal examination were normal. On further evaluation, his hematological and biochemical parameters, including liver enzymes and alkaline phosphatase, were within the normal limits. Ultrasonography of the abdomen revealed cholelithiasis with a 1.8 cm calculus, normal wall thickness, and no intrahepatic biliary radicle dilatation (IHBRD). The diameter of the common bile duct (CBD) was reported to be 4.3 mm.

The individual underwent LC under general anesthesia. The surgery was uneventful with intra-operative findings of a normal Calot's triangle anatomy and a single calculus of approximate size of 2 cm. The patient was recovering well till postoperative day (POD) three when he developed acute onset pain in the epigastric region, which was radiating to back. The intensity of pain was moderate-to-severe, which worsened as time progressed. There was associated history of abdominal distension, nausea, and obstipation.

On examination, he had tachycardia and icterus. The abdomen was distended with tenderness in the epigastric region and around port-sites. Bowel sounds were sluggish. The digital rectal examination revealed semi-solid stools in the rectum. Urgent laboratory parameters revealed normal hematological parameters with raised liver function tests and serum amylase [Table 1]. The radiograph of the abdomen revealed distended small and large bowel. A diagnosis of acute pancreatitis was made, and the patient was shifted to the intensive care unit.
Table 1: Laboratory parameters in sequence

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Individual was managed as per standard protocol for pancreatitis. He was kept nil per orally. Intravenous fluids, injectable analgesics, and proton pump inhibitors were started. Magnetic Resonance cholangiopancreatography (MRCP) done on POD – five revealed a normal CBD and pancreas with no IHBRD and postoperative status at the site of the gall bladder [Figure 1] and [Figure 2]. He was started on oral soft diet on POD five once he passed flatus. His liver function tests normalized by POD seven and was discharged on POD-14 after removing port-site staples. On follow-up after 1 month, the individual was asymptomatic and his abdominal examination revealed healed port-site scars. His laboratory parameters, including liver function tests and serum amylase, were normal.
Figure 1: MRCP showing normal CBD and Pancreas

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Figure 2: MRCP showing post-op status

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  Discussion Top


Acute pancreatitis following cholecystectomy in the early postoperative period can be attributed to the passage of a missed stone or biliary sludge along the ampulla of Vater. Even microliths are known to cause or precipitate severe pancreatitis. Biliary microliths can pass through the CBD and cross sphincter of Oddi. This will cause a transient obstruction, which usually resolves spontaneously. It is usually accompanied by hyperbilirubinemia, which is usually obstructive in origin. Studies in the past have described the role of small gall stones, undetectable by conventional cholecystographic techniques in causing up to 75% cases of idiopathic pancreatitis.[5]

A systematic review and meta-analysis conducted in 2019 have shown an apparent reduction in the recurrence rate of idiopathic acute pancreatitis following cholecystectomy, thereby supporting the hypothesis of occult biliary disease as the cause.[6] A case of the bilobed gallbladder has been documented in literature wherein the patient developed pancreatitis months after cholecystectomy, imaging studies revealing the presence of a thin-walled gallbladder with calculi.[1] This emphasizes the importance of imaging studies in such cases. MRCP, in our case, neither showed any biliary anomaly nor the presence of residual gallbladder.

With the advent of LC, the incidence of APP has drastically reduced. This can be attributed to the forceful manipulations, pancreatic duct obstruction, and CBD explorations that are usually carried out in open surgeries.[7],[8] Postcholecystectomy pancreatitis is a misleading complication,[9] which warrants an urgent MRCP. The management of such cases is solely dependent on MRCP findings. Stone or a sludge ball in the lower end of CBD with features of pancreatic inflammation warrants endoscopic retrograde cholangiopancreatography with sphincterotomy and stenting. The backpressure changes in CBD can even lead to cystic duct stump blow-out. The patient may even land up in biliary peritonitis.[10] In our case, the CBD was normal with no signs of pancreatic inflammation; hence conservative treatment was the mainstay of management.


  Conclusion Top


Although a rare entity, acute postcholecystectomy pancreatitis should be kept in mind in the early postoperative period. Deranged liver function tests, elevated enzymes (amylase and lipase) along with MRCP, is diagnostic. The management depends on the MRCP findings, supportive treatment in cases of a normal CBD vis-à-vis an endoscopic intervention in case of obstructive etiology.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fitchett JM, Davies LL, Kumar N. Gallstone pancreatitis after laparoscopic cholecystectomy. BMJ Case Rep 2011; 2011:bcr0820114673.  Back to cited text no. 1
    
2.
Shaffer E. Acalculous biliary pain: New concepts for an old entity. Dig Liver Dis 2003;35 Suppl 3:S20-5.  Back to cited text no. 2
    
3.
Z'graggen K, Aronsky D, Maurer CA, Klaiber C, Baer HU. Acute Postoperative Pancreatitis after Laparoscopic Cholecystectomy. Results of the Prospective Swiss Association of Laparoscopic and Thoracoscopic Surgery Study. Arch Surg 1997;132:1026-30.  Back to cited text no. 3
    
4.
Keighley MR, Graham NG. The aetiology and prevention of pancreatitis following biliary-tract operations. Br J Surg 1973;60:149-52.  Back to cited text no. 4
    
5.
Ros E, Navarro S, Bru C, Garcia-Pugés A, Valderrama R. Occult microlithiasis in 'idiopathic' acute pancreatitis: Prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterol 1991;101:1701-9.  Back to cited text no. 5
    
6.
Umans DS, Hallensleben ND, Verdonk RC, Bouwense SAW, Fockens P, van Santvoort HC, et al. Recurrence of idiopathic acute pancreatitis after cholecystectomy: Systematic review and meta-analysis. Br J Surg 2020;107:191-9.  Back to cited text no. 6
    
7.
Lerch MM, Saluja AK, Rünzi M, Dawra R, Saluja M, Steer ML. Pancreatic duct obstruction triggers acute necrotizing pancreatitis in the opossum. Gastroenterol 1993;104:853-61.  Back to cited text no. 7
    
8.
Imrie CW, Dickson AP. Postoperative pancreatitis. In: Howard JM, Jordan GL, Reber HA, editors. Surgical Diseases of the Pancreas. Philadelphia, Pa: Lea and Febiger; 1987. p. 332-41.  Back to cited text no. 8
    
9.
Quallich LG, Stern MA, Rich M, Chey WD, Barnett JL, Elta GH. Bile duct crystals do not contribute to sphincter of Oddi dysfunction. Gastrointest Endosc 2002;55:163-6.]  Back to cited text no. 9
    
10.
Vagholkar K, Pawanarkar A, Vagholkar S, Pathan S, Desai R. Post cholecystectomy pancreatitis: A misleading entity. Int Surg J 2016;3:941-3.  Back to cited text no. 10
    


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    Tables

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