Post-ERCP pancreatitis

Case contributed by Dr Michael P Hartung

Presentation

Right upper quadrant pain.

Patient Data

Age: 30 years
Gender: Male
CT

Presentation

Column of calcified gallstones filling the distal common bile duct. The bile ducts are not dilated. Cholelithiasis. 

No imaging findings of acute pancreatitis. 

MRI

Immediately following the CT

For some reason, an MRCP was felt necessary. This confirms the presence of multiple filling defects in the distal common bile duct (choledocholithiasis). 

CT

Next day, worsening abdominal pain following ERCP

Patient underwent ERCP for stone removal. The common bile duct was felt to be completely clear of stones following the procedure. However, several small filling defects remain, indicating persistent choledocholiathiasis. The stone burden was quite large and perhaps some became displaced at the time of instrumentation, making complete extraction less feasible. 

Vicarious excretion of contrast into the gallbladder. 

The patient has developed interstitial edematous pancreatitis: enlargement of the pancreas, acute peripancreatic fluid/stranding.

New small ascites.

CT

3 weeks after presentation

Multiple unorganized collections in the upper abdomen, peripancreatic region, and retroperitoneum. They are predominantly fluid insinuating about variable amounts of fat, raising the possibility of peripancreatic necrosis (lesser sac/transverse mesocolon retroperitoneum).

Symmetric enhancement of the pancreas with ductal dilation. No common bile duct stones persist. Feeding tube. Anasarca.

Case Discussion

Overview of the imaging progression with comments:

  • Choledocholithiasis at presentation. This can be definitely diagnosed on the CT and does not require MRCP before ERCP. 
  • Post-ERCP interstitial edematous pancreatitis with persistent choledocholithiasis, likely due to the multiplicity of small stones filling much of the CBD. No further intervention was performed, and the small remaining stones likely spontaneously passed based on the follow-up scan.
  • Multiple organizing collections in the abdomen and retroperitoneum at 3 weeks. Although the pancreas is enhancing symmetrically, the appearance of peripancreatic collections containing variable amounts of fat suggest a necrotizing component, complicating management. The collections do not look well-defined enough to be categorized as pseudocysts or walled-off necrosis at this time, which generally happens after 4 weeks, when a fibrous capsule/granulation tissue surround more discrete collections. 
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Case information

rID: 67124
Published: 20th Mar 2019
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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