John	
  Martinelli,	
  MSIII,	
  SGUSOM	
  	
  
	
  
	
  
DATE:	
  7/7/13	
  
Case	
  03.	
  Rotation:	
  Surgery/Gen	
  
...
 
Labs	
  (AM	
  7/4/13):	
  
	
  
Na:	
  143	
  
Cl:	
  106	
  
BUN:	
  7	
  
K:	
  4	
  
Bicarb:	
  34*	
  
Cr:	
  0.79	...
 
Laboratory	
  tests	
  such	
  as	
  Total	
  &	
  Direct	
  Bilirubin,	
  ALP,	
  ALT,	
  AST,	
  RUQ	
  Ultrasound,	
 ...
 
Risk	
  Factors	
  
	
  
Inappropriate	
  utilization	
  of	
  ERCP,	
  Sphincter	
  of	
  Oddi	
  Dysfunction,	
  Lengt...
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Case Report: ERCP

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Case Report: ERCP

  1. 1. 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.      
  2. 2.   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.  
  3. 3.   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.    
  4. 4.   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.    

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