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Introduction: This article reports a case of acute pancreatitis combined with calculous cholecystitis. After supportive treatment of acute pancreatitis, the patient successfully underwent laparoscopic cholecystectomy.
Cholelithiasis is a common disease with an incidence of 10-15% in developed countries, with up to 20% of the population presenting with acute calculous cholecystitis. Acute pancreatitis is also a common disease, with an annual incidence of 4.9-73.4 cases per 100,000 people worldwide, of which biliary pancreatitis accounts for about 50%, followed by alcoholic pancreatitis.
The gallbladder and pancreas are important digestive organs of the human body and are anatomically adjacent to each other, as if they were neighbors. Although both are the most common gallstone-related symptoms, they rarely occur simultaneously and have rarely been reported in the literature. However, pathological and imaging studies have shown that their co-occurrence may be much higher than thought. At the same time, due to the subclinical nature of these cases, the incidence may be higher than expected.
The patient was admitted to the hospital for epigastric pain and the initial diagnosis of acute pancreatitis was made
The patient, 83 years old, was admitted to the emergency department for sudden severe epigastric pain and had a history of ischemic heart disease, asthma, hypertension, and smoking. Patients complain of burning sensations that radiate to the back and are accompanied by nausea and vomiting. On examination, the patient's vital signs were stable. Tenderness in the upper abdomen is more pronounced on palpation and tenderness in the right upper quadrant is mild.
The blood count was elevated to 12.6×109/L and the C-reactive protein to 170. In addition, serum lipase 13000, preliminary diagnosis of acute pancreatitis. Mild liver dysfunction, bilirubin 12 μmol/L, ALT 92 U/L, AST 146 U/L, ALP 89 U/L, and GGT 117 U/L.
Abdominal ultrasound was found separately
Abdominal ultrasonography shows distension of the gallbladder with multiple gallstones. The walls of the gallbladder are thickened up to 7 mm and the probe is tender, consistent with the manifestations of cholecystitis (Figure 1). The common bile duct is 7.4 mm in diameter, there are no signs of common bile duct stones, and NO ERCP is performed. Abdominal CT reveals moderate strangulation of peripanicreatic fat without complications such as necrosis, abscess, or pseudocysts, confirming the diagnosis of pancreatitis (Figure 2).
Fig. 1 Abdominal ultrasound shows thickening of the gallbladder wall
Fig. 2 Pancreatitis with peripancreatic fat stranding CT
Based on imaging and biochemical findings, the patient's diagnosis considers acute pancreatitis with calculous cholecystitis. After conservative treatment, patients are subsequently treated with laparoscopic cholecystectomy. Postoperative pathology confirms cholelithiasis with acute onset of chronic cholecystitis.
The story of two "neighbors"
Acute cholecystitis and pancreatitis are generally present alone and rarely occur clinically simultaneously. However, there are also surveys that have revealed the relationship between the two from a histological point of view. According to the study of Scholars such as Coffin, histological evidence of 33 cases of cholecystitis was found in 184 cases of acute pancreatitis. Of these, 22 were chronic and 11 were acute cholecystitis.
In the authors' experience, some histological acute cholecystitis may be subclinical. In this case, patients present predominantly epigastric pain and pancreatitis features elevated lipase, while cholecystitis is only detected on ultrasound images showing acute cholecystitis with focal probe tenderness. The relationship between histological cholecystitis and clinically significant cholecystitis needs to be further studied.
Recommendations for the management of acute pancreatitis with calculous cholecystitis
Even if there is a clinical presence of significant cholecystitis associated with pancreatitis, the prognosis of pancreatitis in this case is good. Because this form of pancreatitis is usually a mildly severe type of edema. Cholecystectomy is used to prevent further onset of cholelithic pancreatitis. In the past, cholecystectomy was thought to have a positive effect on the course of acute pancreatitis. However, recent studies have shown that due to the high incidence and mortality of systemic inflammatory responses, as well as pancreatic edema impairing calots triangle anatomy, early surgical interventions during the inflammatory phase of acute pancreatitis should be avoided.
The progression of acute cholecystitis should be closely followed, and the timing of resection should be determined according to the pathological dominance of acute cholecystitis and pancreatitis. Unless there is evidence of cholecystitis causing sepsis, cholecystectomy should be postponed until clinical improvement in pancreatitis. In this case, acute pancreatitis is the main pathology, so cholecystectomy is delayed until the clinical improvement of pancreatitis, and acute cholecystitis is appropriately treated with intravenous antibiotics.
医脉通编译整理自：Yahng JJ, Pham T. The tales of two neighbours: when cholecystitis does not preclude pancreatitis. J Surg Case Rep. 2019 Feb 8;2019(2):rjz019. doi: 10.1093/jscr/rjz019. eCollection 2019 Feb.