Necrotic pancreatitis - perforated cholecystitis

Case contributed by Assis Prof Faeze Salahshour

Presentation

Acute onset epigastric pain with radiation to back, nausea, and vomiting from 8 days before, referred from another center.

Patient Data

Age: 55 years
Gender: Male

Evidence of pancreatitis is seen as pancreatic edema, peripancreatic fatty haziness, and retroperitoneal fascial thickening on the left side. The pancreatic body does not show normal enhancement despite enhancing pancreatic head or distal tail, suggestive of pancreatic necrosis (more than 50%, score 6). At least one acute fluid collection (likely acute necrotic collection) is visible in the lesser sac (Balthazar score 3, CT severity index 9). At least one stone at the pancreatic portion of the CBD and another one at the distal cystic duct just before insertion to the CBD, and several gallstones are visible, in favor of biliary pancreatitis.

The patient underwent conservative management, and ten days after the CT scan again referred for CT because of clinical deterioration.

A fluid collection with a faint incomplete wall and few foci with fat density are seen replacing the necrotic pancreatic body, in favor of acute necrotic collection. The distal CBD stone is no longer visible. The impacted distal cystic duct stone is still visible, and evidence of perforated cholecystitis is visible as the large gallbladder fundal mural defect.

On the 10th day after the second CT scan, the third CT scan for the patient was performed.

The walled-off necrosis fully developed with a complete enhancing wall and internal foci with the fat density. The gallbladder contains air, and a fistulous tract from the gallbladder fundus to the hepatic flexure of the colon is visible, suggestive of fistulization.

Annotated image

The pink and black arrows point to the cystic duct and distal CBD stones, respectively.

The light blue, orange, and yellow arrows depict the non-enhancing necrotic pancreas, acute fluid collection, and walled-off necrosis, respectively.

The red arrow shows a fat density focus within the walled-off necrosis, and the green depicts gallbladder mural defects.

The air containing gallbladder and fistulous tract to the hepatic flexure of the colon is shown by the white arrow.

Case Discussion

The patient underwent trans-gastric drainage of the acute necrotic collection.

In summary, this is a case of complicated biliary stone disease with choledocholithiasis, necrotic pancreatitis, and perforated cholecystitis leading to pancreatic walled of necrosis and cholecystocolonic fistula.

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Case information

rID: 82321
Published: 27th Sep 2020
Last edited: 6th Oct 2020
Inclusion in quiz mode: Included
Institution: Tehran University of Medical Sciences (TUMS)

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