This document summarizes the case of a 29-year-old Asian American male (DS) who presented with severe abdominal pain immediately following an ERCP procedure done for choledocholithiasis. He was diagnosed with probable post-ERCP pancreatitis based on his symptoms and elevated lipase level. He was admitted and his pain improved with IV fluids and pain medication. He underwent a robotic cholecystectomy the next day without complications and was discharged same day.

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.
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.
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.
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.