John  Martinelli,  MSIII,  SGUSOM         DATE:  7/7/13  Case  03.  Rotation:  Surgery/Gen    Identifying  Data:    DS  is  a  29-­‐year-­‐old  Asian  American  male,  English  speaking,  competent  appearing  and  communicative,  who  presented  to  NBIMC’s  surgical  service  on  7/3/13.  He  is  s/p  same  day  EUS  and  ERCP  related  to  a  recent  diagnosis  of  Choledocholithiasis.  He  is  also  a  physician  and  fellow  at  NBIMC.    Chief  Complaint:      Immediately  post-­‐ERCP,  DS  described  intolerable  severe  pain  focused  within  the  upper  abdominal  area.    History  of  Present  Illness:    After  a  previous  diagnosis  of  symptomatic  Choledocholithiasis,  DS  presented  on  7/3/13  to  NBIMC’s  Endoscopic  Lab  for  diagnostic  Endoscopic  Ultrasound  (EUS)  and  therapeutic  Endoscopic  Retrograde  Cholangiopancreatography  (ERCP).  Cholecystectomy  was  planned  for  7/5/13.  Findings  revealed  a  small  common  bile  duct  stone  and  sludge  as  well  as  evidence  of  a  large  gallstone.  Biliary  Sphincterotomy  with  stone  extraction  and  stent  placement  was  performed.  Immediately  following  ERCP,  DS  experienced  severe  epigastric  pain  suspicious  of  Iatrogenic  Pancreatitis  related  to  the  procedure.  Diluadid  (Hydromorphone)  was  administered  which  provided  some  relief.  An  emergent  surgical  consult  was  recommended.  Consultant  agreed  with  probable  post-­‐ERCP  Pancreatitis  with  the  recommendation  of  NPO,  IVF,  and  Diluadid.  Morning  labs  were  scheduled  and  DS  was  advised  of  the  possibility  of  discharge  the  following  day  or  continued  in-­‐patient  monitoring  pending  Cholecystectomy.  Subsequently  on  7/4/13  patient  reported  improved  pain,  however,  he  did  have  significant  nausea  and  vomiting  as  well  as  elevated  Lipase.  It  was  therefore  recommended  he  remain  in-­‐hospital  until  Cholecystectomy  the  following  day.  Robotic-­‐Assisted  Cholecystectomy  was  performed  on  7/5/13.  DS  tolerated  the  procedure  well  without  complication  and  was  discharged  same  day.    Past  Medical  History:    Unremarkable  systemic  history.  Recent  history  of  Cholecystitis  and  Choledocholithiasis  (as  above).  Negative  surgical  history.    Medications:  None.    Allergies:  NKDA.    Family  History:  Non-­‐contributory.    Social  History:  Non-­‐smoker,  Non-­‐drinker,  No  drug  use.    Physical  Exam  (on  admission):    Vitals:  96.5*,  75,  19,  116/76,  97%  (@  room  air).    GEN:  Alert  and  Oriented.  Appears  in  Pain.  CHEST:  Clear  to  Auscultation  Bilaterally.    CV:  RRR  (-­‐)m,r,g  ABD:  Soft,  Non-­‐distended,  (-­‐)  Guarding,  (-­‐)  Rebound,  (+)  TTP  @  Epigastrium.      

 Labs  (AM  7/4/13):    Na:  143  Cl:  106  BUN:  7  K:  4  Bicarb:  34*  Cr:  0.79  Glucose:  102  Hgb:  13.6  Hct:  41.1  WBC:  5.7  Platelets:  167  Lipase:  336*  ALP:  52  ALT:  169*  AST:  32  Total  Bili:  1.2*    Review  of  Systems  (on  admission):    General:  Neg  Skin:  Neg  EENT:  Neg  Pulmonary:  Neg  Gastrointestinal:  Severe  epigastric  pain  immediately  post-­‐ERCP  (as  above).  Genitourinary:  Neg  Musculoskeletal:  Neg  Neurologic:  Neg  Hematologic:  Neg  Endocrine:  Neg  Psychiatric:  Neg    Imaging:  EUS  performed  revealing  small  CBD  stone  and  sludge  with  large  gallstone.  (Images  not  available  on  CERNER).    Discussion:      GS  presented  to  the  NBIMC  surgical  service  on  the  same  day  after  EUS  and  therapeutic  ERCP  with  biliary  sphincterotomy,  stone  extraction,  and  stent  placement  for  recently  diagnosed  symptomatic  Choledocholithiasis.  Immediately  post-­‐procedure,  GS  experienced  extraordinary  pain  in  his  epigastric  region  possibly  pathognomonic  of  surgically  triggered  iatrogenic  pancreatitis.    Choledocholithiasis  can  be  described  as  gallstones  that  become  trapped  within  the  common  bile  duct.  These  stones  can  be  considered  primary  or  secondary  depending  on  their  origin  of  formation.  Primary  stones  will  originate  within  the  common  bile  duct  and  are  usually  pigmented  being  composed  of  bilirubin.  Secondary  stones  are  most  common  comprising  95%  of  all  cases  and  normally  originate  in  the  gall  bladder  being  composed  of  cholesterol.  Therefore,  the  medical  history  of  the  patient  may  indicate  possible  etiology.  For  example,  a  patient  with  hemolytic  anemia  may  be  more  susceptible  to  Primary  Choledocholithiasis  from  the  breakdown  of  hemoglobin  to  unconjugated  bilirubin.  In  our  patient  there  was  not  a  contributory  medical  history,  which  leads  us  to  assume  Secondary  Choledocholithiasis.  The  clinical  features  of  Choledocholithiasis  can  be  a  spectrum  from  asymptomatic  to  exquisite  pain  in  the  epigastric  region  and/or  right  upper  quadrant,  as  well  as  jaundice  and  scleral  icterus.  

 Laboratory  tests  such  as  Total  &  Direct  Bilirubin,  ALP,  ALT,  AST,  RUQ  Ultrasound,  Esophageal  Ultrasound  (EUS),  and  ERCP  can  be  utilized  in  the  diagnosis.  GS  demonstrated  elevated  Total  Bilirubin  and  ALT  consistent  with  the  suspected  diagnosis.  Although  EUS  was  performed,  it  has  been  shown  that  both  EUS  and  RUQ  US  cannot  be  used  to  make  a  definitive  diagnosis  due  to  lack  of  sensitivity  and  specificity.  However,  they  do  add  information  to  the  clinical  picture  to  help  make  the  proper  diagnosis.  ERCP  is  considered  the  gold  standard  in  both  the  diagnosis  and  treatment  of  Choledocholithiasis.  ERCP  in  this  case  proved  the  suspected  diagnosis.  In  certain  cases  whereby  ERCP  fails,  laparoscopic  choledocholithotomy  can  be  performed.    As  suspected  in  DS,  complications  of  ERCP  include  Pancreatitis  occurring  in  approximately  3  to  5  percent  of  individuals.  It  can  be  mild  and  self-­‐limiting,  however,  a  longer  hospital  stay  may  be  necessary  depending  on  the  severity  of  symptoms  as  well  as  laboratory  findings.  Because  of  the  significant  pain  experienced  by  DS  as  well  as  his  Lipase  level,  he  was  advised  to  stay  under  supervision  pending  Cholecystectomy.  NPO  was  recommended  as  well  as  appropriate  IVF  and  pain  management.    Although  less  of  a  concern  with  DS,  bleeding  at  the  sphincterotomy  site  can  occur  and  is  also  usually  minimal  and  self-­‐limiting.  Aspiration  of  stomach  contents  is  possible.  Intestinal  perforation  is  another  occurrence  that  requires  immediate  surgical  repair.  Infectious  Cholangitis  is  an  additional  rare  complication  that  is  of  minimal  concern  in  this  case  due  to  his  normal  WBC  and  the  acute  nature  of  his  symptoms.    Differential  Diagnosis:    

1. s/p  ERCP  Pancreatitis  2. Sphincterotomy  Hemorrhage  3. Aspiration  4. Intestinal  Perforation  5. Cholangitis  

 Assessment:    Considering  the  pertinent  physical  and  laboratory  findings  which  include  a  Clear  Chest,  CV  RRR,  Normal  WBC’s,  and  Acute  Epigastric  Pain  with  elevated  Lipase,  a  diagnosis  of  Acute  Pancreatitis  secondary  to  ERCP  was  agreed  upon.    Pathophysiology    Iatrogenic  mechanical  insult  of  the  Pancreatic  Ampulla/Duct  triggering  an  inflammatory  response.    Clinical  Features    Mild  to  severe  abdominal  pain,  back  pain,  nausea  +/-­‐  vomiting,  and  mild  fever.      Diagnosis    Diagnosis  usually  becomes  apparent  within  a  few  hours  of  the  procedure  presenting  with  clinical  features  as  above.  Elevated  Serum  or  Urinary  Amylase.  Elevated  Serum  Lipase.    Treatment    NPO,  Analgesia,  Nausea  treatment,  IV  Fluids,  and  possible  Nasogastric  Tube  placement  if  unrelieved  nausea/vomiting.  Monitor  Urine  Output.    

 Risk  Factors    Inappropriate  utilization  of  ERCP,  Sphincter  of  Oddi  Dysfunction,  Lengthy  Procedure,  Surgeon  Inexperience/Errors.    Complications    Prolonged  hospital  stay,  Increased  Morbidity,  Death.    Plan:    DS  to  remain  in-­‐patient  with  NPO,  IVF’s,  and  Analgesia  (Ancef).  Robotic-­‐Assisted  Cholecystectomy  scheduled  7/5/13  as  prophylaxis  against  future  gallstone  related  disorders.  DS  underwent  Cholecystectomy  as  scheduled  and  tolerated  procedure  well  without  complication.  He  was  discharged  same  day.