(Patient) 73-year-old man. (Chief complaint) Right hypochondrial pain. (History of present illness) Patient was diagnosed with chronic alcoholic pancreatitis at another hospital in 2007, but because he was asymptomatic, no treatment was administered. In September 2009, the patient presented with right hypochondrial pain and was evaluated at our hospital. Abdominal contrast CT showed bile duct dilation and a stone in the papilla, blood tests indicated an inflammatory reaction, and hepatobiliary enzymes were elevated. Tentative diagnosis was acute cholangitis due to an impacted gallstone in the papilla, and the patient was admitted to hospital on the same day.
(Hospital course) Emergency ERCP was performed on the same day, and a white stone was found to be impacted at the papilla of Vater. When the proximal bulging was pushed with the cannula, the impaction was relieved, and the catheter was inserted deeply, with contrast for imaging the pancreatic duct. In the main pancreatic duct, a radiolucent area was observed, and the stone was therefore thought to have migrated into the main pancreatic duct. Next, the bile ducts were imaged, but only infected bile was seen, without radiolucency in the common bile duct. Based on these findings, the diagnosis was acute cholangitis due to impaction of a pancreatic stone in the papilla of Vater. An ENBD tube was inserted for treatment of cholangitis. On day 4, repeat ERCP was performed. The patient was taking anticoagulants, and thus the opening of the pancreatic duct was dilated with a balloon, and using a mechanical lithotriptor, the stone was crushed and retrieved. The subsequent clinical course was satisfactory, and the patient was discharged.
(Discussion) We herein presented a case of successful endoscopic treatment of acute cholangitis due to impaction of a pancreatic stone in the papilla of Vater.
