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Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis
Accepted Manuscript Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis Maxime Palazzo, M.D, Marianna Arvanitakis, M.D, Ph.D, Myriam Delhaye, M.D, Ph.D, Jacques Devière, M.D, Ph.D, Arnaud Lemmers, M.D, Ph.D PII:
S0016-5107(17)32192-2
DOI:
10.1016/j.gie.2017.08.010
Reference:
YMGE 10704
To appear in:
Gastrointestinal Endoscopy
Received Date: 16 June 2017 Revised Date:
0016-5107 0016-5107
Accepted Date: 14 August 2017
Please cite this article as: Palazzo M, Arvanitakis M, Delhaye M, Devière J, Lemmers A, Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis, Gastrointestinal Endoscopy (2017), doi: 10.1016/j.gie.2017.08.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis Maxime Palazzo 1,2 M.D, Marianna Arvanitakis 1 M.D, Ph.D, Myriam Delhaye 1 M.D, Ph.D, Jacques Devière 1 M.D, Ph.D, Arnaud Lemmers 1 M.D, Ph.D
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1: Université libre de Bruxelles (ULB), Department of Gastroenterology, Hepatopancreatology and Digestive Oncology. Erasme University Hospital. Brussels, Belgium
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Corresponding author: Maxime Palazzo, MD 100 Blvd du Général Leclerc, 92110 Clichy, France Email: [email protected] Phone number: +33140875663, +33620528293 Fax number: +33140874432
SC
2: Assistance Publique Hôpitaux de Paris, Department of Digestive Endoscopy, Beaujon Hospital, Clichy, France
ACCEPTED MANUSCRIPT Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis Maxime Palazzo 1,2 M.D, Marianna Arvanitakis 1 M.D, Ph.D, Myriam Delhaye 1 M.D, Ph.D, Jacques Devière 1 M.D, Ph.D, Arnaud Lemmers 1 M.D, Ph.D
RI PT
1: Université libre de Bruxelles (ULB), Department of Gastroenterology, Hepatopancreatology and Digestive Oncology. Erasme University Hospital. Brussels, Belgium
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Corresponding author: Maxime Palazzo, MD 100 Blvd du Général Leclerc, 92110 Clichy, France Email: [email protected] Phone number: +33140875663 Fax number: +33140874432
SC
2: Assistance Publique Hôpitaux de Paris, Department of Digestive Endoscopy, Beaujon Hospital, Clichy, France
Keywords: ERCP, Chronic pancreatitis, Cholangitis
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Number of words: 198
ACCEPTED MANUSCRIPT
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A 66-year-old female with chronic pancreatitis and previous cholecystectomy presented with abdominal pain. Arterial blood pressure was 80/50 mm Hg, heart rate was 130 beats per minute, and body temperature was 39.2 °C. Clinical examination showed jaundice and tenderness in the right upper quadrant. Blood tests showed Creactive protein level (340 mg/L), total bilirubin (7.1 mg/dL), aspartate aminotransferase (AST) (135 U/L), alanine aminotransferase (ALT) (148 U/L), alkaline phosphatase (ALP) (255 U/L), and gamma-glutamyl transferase (GGT) (554 U/L). She was transferred to the intensive care unit for administration of vasoactive drugs and broad-spectrum antibiotics. An abdominal CT scan was performed. CT scan (A) showed a 9 x 7 mm impacted pancreatic stone in the ampulla with dilation of the lower part of the common bile duct at 10 mm and dilation of the distal part of the main pancreatic duct at 6 mm. The diagnosis of a cholangitis due to an impacted pancreatic stone (“pancreatic cholangitis”) was suspected. ERCP was done. A biliary sphincterotomy was performed with pus coming (B). Cholangiogram and common bile duct balloon swap showed no evidence of common bile duct stone or biliary stricture. Balloon-extraction of the pancreatic stone (C) was performed. After endoscopic procedure, pain resolution was immediate and recovery was fast. At 6 months, no recurrence occurred.
Guarantor of the article: Maxime Palazzo, MD Specific author contributions:
Maxime Palazzo : Drafting the manuscript.
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Marianna Arvanitakis : Patient management. Myriam Delhaye : Patient management
Jacques Devière : Patient management
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Arnaud Lemmers : Patient management and drafting the manuscript
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All the authors approved the final submitted draft. Financial support: None Potential competing interests: None
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
17-00893
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Cholangitis is a common clinical entity, and common bile duct (CBD) stones that cause biliary obstruction are the most frequent etiology. In addition, common bile duct stones frequently lead to gallstone pancreatitis (ie, a pancreatic illness occurs secondary to a biliary problem). This case inverts that typical order of operations, and here we see a pancreatic duct stone that leads to a biliary illness, in this case, cholangitis. The case is notable in several respects: first, pancreatic duct stones almost never compress the CBD enough to cause obstruction and lead to jaundice, let alone cholangitis. Second, the stone in question is not particularly large, so it is unusual that this could lead to enough biliary compression to progress to obstruction. Third, there is no mention of a pancreatic sphincterotomy, but I must assume one was performed before removal of the stone, but on balloon sweeps of the pancreatic duct the stone appears to be somewhat amorphous and friable—one would have expected a more cohesive stone in this setting. Still, “pancreatic cholangitis,” as the authors term it, is a truly rare phenomenon. It should be noted that not all ERCP performers have experience with pancreatic duct stone removal, and a less-skilled endoscopist could also have simply placed a biliary stent to decompress the patient and treat their cholangitis, leaving the pancreatic duct stone to be removed at a later date.
S0016-5107(17)32192-2
DOI:
10.1016/j.gie.2017.08.010
Reference:
YMGE 10704
To appear in:
Gastrointestinal Endoscopy
Received Date: 16 June 2017 Revised Date:
0016-5107 0016-5107
Accepted Date: 14 August 2017
Please cite this article as: Palazzo M, Arvanitakis M, Delhaye M, Devière J, Lemmers A, Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis, Gastrointestinal Endoscopy (2017), doi: 10.1016/j.gie.2017.08.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis Maxime Palazzo 1,2 M.D, Marianna Arvanitakis 1 M.D, Ph.D, Myriam Delhaye 1 M.D, Ph.D, Jacques Devière 1 M.D, Ph.D, Arnaud Lemmers 1 M.D, Ph.D
RI PT
1: Université libre de Bruxelles (ULB), Department of Gastroenterology, Hepatopancreatology and Digestive Oncology. Erasme University Hospital. Brussels, Belgium
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EP
TE D
M AN U
Corresponding author: Maxime Palazzo, MD 100 Blvd du Général Leclerc, 92110 Clichy, France Email: [email protected] Phone number: +33140875663, +33620528293 Fax number: +33140874432
SC
2: Assistance Publique Hôpitaux de Paris, Department of Digestive Endoscopy, Beaujon Hospital, Clichy, France
ACCEPTED MANUSCRIPT Acute suppurative cholangitis due to an impacted pancreatic stone: a rare adverse event in the setting of chronic calcified pancreatitis Maxime Palazzo 1,2 M.D, Marianna Arvanitakis 1 M.D, Ph.D, Myriam Delhaye 1 M.D, Ph.D, Jacques Devière 1 M.D, Ph.D, Arnaud Lemmers 1 M.D, Ph.D
RI PT
1: Université libre de Bruxelles (ULB), Department of Gastroenterology, Hepatopancreatology and Digestive Oncology. Erasme University Hospital. Brussels, Belgium
M AN U
Corresponding author: Maxime Palazzo, MD 100 Blvd du Général Leclerc, 92110 Clichy, France Email: [email protected] Phone number: +33140875663 Fax number: +33140874432
SC
2: Assistance Publique Hôpitaux de Paris, Department of Digestive Endoscopy, Beaujon Hospital, Clichy, France
Keywords: ERCP, Chronic pancreatitis, Cholangitis
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Number of words: 198
ACCEPTED MANUSCRIPT
M AN U
SC
RI PT
A 66-year-old female with chronic pancreatitis and previous cholecystectomy presented with abdominal pain. Arterial blood pressure was 80/50 mm Hg, heart rate was 130 beats per minute, and body temperature was 39.2 °C. Clinical examination showed jaundice and tenderness in the right upper quadrant. Blood tests showed Creactive protein level (340 mg/L), total bilirubin (7.1 mg/dL), aspartate aminotransferase (AST) (135 U/L), alanine aminotransferase (ALT) (148 U/L), alkaline phosphatase (ALP) (255 U/L), and gamma-glutamyl transferase (GGT) (554 U/L). She was transferred to the intensive care unit for administration of vasoactive drugs and broad-spectrum antibiotics. An abdominal CT scan was performed. CT scan (A) showed a 9 x 7 mm impacted pancreatic stone in the ampulla with dilation of the lower part of the common bile duct at 10 mm and dilation of the distal part of the main pancreatic duct at 6 mm. The diagnosis of a cholangitis due to an impacted pancreatic stone (“pancreatic cholangitis”) was suspected. ERCP was done. A biliary sphincterotomy was performed with pus coming (B). Cholangiogram and common bile duct balloon swap showed no evidence of common bile duct stone or biliary stricture. Balloon-extraction of the pancreatic stone (C) was performed. After endoscopic procedure, pain resolution was immediate and recovery was fast. At 6 months, no recurrence occurred.
Guarantor of the article: Maxime Palazzo, MD Specific author contributions:
Maxime Palazzo : Drafting the manuscript.
TE D
Marianna Arvanitakis : Patient management. Myriam Delhaye : Patient management
Jacques Devière : Patient management
EP
Arnaud Lemmers : Patient management and drafting the manuscript
AC C
All the authors approved the final submitted draft. Financial support: None Potential competing interests: None
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
ACCEPTED MANUSCRIPT
17-00893
AC C
EP
TE D
M AN U
SC
RI PT
Cholangitis is a common clinical entity, and common bile duct (CBD) stones that cause biliary obstruction are the most frequent etiology. In addition, common bile duct stones frequently lead to gallstone pancreatitis (ie, a pancreatic illness occurs secondary to a biliary problem). This case inverts that typical order of operations, and here we see a pancreatic duct stone that leads to a biliary illness, in this case, cholangitis. The case is notable in several respects: first, pancreatic duct stones almost never compress the CBD enough to cause obstruction and lead to jaundice, let alone cholangitis. Second, the stone in question is not particularly large, so it is unusual that this could lead to enough biliary compression to progress to obstruction. Third, there is no mention of a pancreatic sphincterotomy, but I must assume one was performed before removal of the stone, but on balloon sweeps of the pancreatic duct the stone appears to be somewhat amorphous and friable—one would have expected a more cohesive stone in this setting. Still, “pancreatic cholangitis,” as the authors term it, is a truly rare phenomenon. It should be noted that not all ERCP performers have experience with pancreatic duct stone removal, and a less-skilled endoscopist could also have simply placed a biliary stent to decompress the patient and treat their cholangitis, leaving the pancreatic duct stone to be removed at a later date.