2017 Volume 31 Issue 5 Pages 874-879
A 78-year-old man presented with right upper quadrant pain as a chief complaint and was found to have peritoneal irritation and an elevated blood amylase level. Abdominal contrast-enhanced computed tomography (CT) showed high-density adipose tissue around the head of the pancreas, edematous thickening of the gallbladder wall, and ascites localized to the surface of the liver. Acute gallstone pancreatitis with acute generalized peritonitis and perforation of the gallbladder were diagnosed, and an emergency laparotomy was performed. During surgery, a perforation was identified in the fundus of the gallbladder. Intraoperative cholangiography after cholecystectomy resulted in a diagnosis of class IIb pancreaticobiliary maljunction according to Komi's new classification. A translucency believed to represent a protein plug was also present in the common channel, and after this had been discharged to duodenum by a biliary-tube. C-tube drainage was also performed. Histopathological examination showed multiple Rokitanski-Aschoff sinuses (RASs) and perforation, but there were no signs of malignancy. The substance assumed to constitute a protein plug had become incarcerated in the common channel, causing acute pancreatitis and further resulting in increased internal pressures of the pancreatic duct and the bile duct. The increased internal pressure of the bile duct resulted in the perforation of the RASs in the fundus of the gallbladder, leading to gallbladder perforation.
