Case report of:

Acute Biliary Pancreatitis

Noha Mamdoud

Pembimbing: dr. Arif Gunawan,Sp.Pd,MARS

Ade Ajeng Cempakadewi
030.13.005
 Acute Pancreatitis

Is an acute inflammation, non-bacterial in pancreas organ, caused by

enzyme autodigestion of the gland.

Cholecystitis

Is an inflammation of the gallbladder that occurs most commonly

because of obstruction of the cystic duct.

DEFINITION Cholelithiasis

OF: The presence of stones in the gallbladder or choledocus duct

 INTRODUCTION

Gallstones account for 90% of all cases of non alcoholic pancreatitis.

Gallstones on cystic duct (cholelithiasis) blockage of ductus flow increases
pressure fluid accumulation on interstitial.
Fluid accumulation will stimulate production of enzyme cause local destruction
Risk factor for developing gallstones: female, age, obesity, rapid weight loss, DM,
crohn disease, alcoholic cirrhosis, primary biliary disease.
Complications of ABP: (if not treated, mortality ranges from 2%-7%)
1. Local: necrosis, abcesses, hemorrhage of pancreas
2. Systemic: pleural effusion, renal insufficiency, multi organ failure
 CASE REPORT

February 13,2013: epigastric and right upper

Subject: Mr. H.H (32 year old), male,
quadrant abdominal pain. Onset, sudden. Radiating
Pakistani
to the back. Worse with eating food (relieved when
February 9, 2013: Abdominal Pain.
drinking milk)
Abdominal USG GB was distended,
Another symptoms:
common bile duct was not dilated.
-Nausea, vomiting (1x)
Referred to -Dysphagia
antoher
hospital -weight loss (80 ->78, in 1 month)
-jaundice, dark urine, clay colored stool, diarrrhea
 History Physical Examination

- Ikterik on sclera
- Allergies (-), operated (-) Compos mentis and skin
- Family history: Father & Vital Sign: - Abd: soft,
sister (+) DM - T: 36,2 tenderness in
- Lifestyle: ex-smoker (quit 6- - RR: 12x/min epigastric reg.
8 months previously), alcohol - Murphys-Cullen-
(-) -BP: 123/77 mmHg
Grey Sign: (-)
 Laboratory findings:
(Increased of) Meanings:
White cell count Sign of cholecyctitis & pancreatitis
Indicators of liver involvement. GGT in
ALP, ALT, GGT
dicate obstruction of the bile ducts.
Cause jaundice and scleral icterus.
Bilirubin Total, Direct & Indirect Direct: post hepaticbiliary disease.
Indirect: hepatic damage.
Serum & urine amylase, lactate dehydrogenase Sign of AP
Serum globulin Dehydration effecr on AP

Laboratory findings:
Meanings:
(Decreased of)
Imbalance electrolytes: Na, K, Cl, HCO3 Dehydration effect on AP
 -Thickening of the GB wall 7 mm
(normal <4 mm)
-Moderate biliary sludge
-Mild pericholecytic edema
-Dilation of CBD 1,8 cm (normal
<6mm)
-Suspicion of a 7 mm stone (distal)
- Dilation of intrahepatic biliary ducts.

Diagnosis: Acute biliary pancreatitis, acute calculus cholecyctitis, obstructive jaundice

 Treatment

1. Fluid Resuscitaion
normal saline 500 ml ringers lactate solution 500 ml (every 3 hour
on his 2nd day)
2. Antibiotic IV 100 ml (metronidazole)
3. Injection of perfalgan 100 ml (paracetamol) for analgesia.
4. IV omeprazole 20 ml (proton pump inhibitor) to suppress acidity
On the third day
1. Ceftriaxone 20 ml as antibiotic prophylaxis for the ERCP.
The consultant surgeon arranged for an ERCP for the patient.
 DISCUSSION

ABP is the inflammation of the pancreas primarily due to biliary sludge and gallstones. There are 3
main types of gallstones: cholesterol-black pigment (in gallblader), brown pigment (bile ducts).

Pathogenesis of ABP has not been fully understood. There 2 theories were identified:
1. Reflux of infected bile into the pancreas pancreas activating a cascade of proteolytic enzymes
2. Obstruction causing acinar disruption from raised pressure.

Pathophysiology of AP divided into 3 stages (according to the severity):

1. Stage 1: pancreatic injury (edema, inflammation, fat necrosis)
2. Stage 2: Local effects (retroperitoneal edema, ileus)
3. Stage 3: Systemic complications (hypotension shock, metabolic disturbances, organ failure).
 Symptoms of ABP: The efficacy of laboratory result: bilirubbin, ALP,
-Abdominal and epigastric pain ALT (>150 IU/L), AST. (ALT is the most clinically
-Nausea and vomiting usefull that AST)
-Diarrhea Imaging techniques: CT scan (to differentiate with
-Gastrointestinal hemorrhage PUD). In a few day CT scan can be used to
-Fat embolism differentiate between intertitial and necrotizing
-High temperature (32,2 38,3) sign pancreatitis.
of active inflammation or necrosis on
pancreas.

There is no difference between early ERCP and conservative therapy in the absence of
obstructive, but since had a obsctructive jaundice ERCP was more efffective.
 Case of an adult male, who was diagnosed by ABP, is mainly
caused by stones in GB.
Conservative medical therapy: fluid resuscitation, pain control
(morphine), nutrirional supoort (nasojejunal tubes), antibiotics.
Antibiotics used to prevent acute-intertitial-necrotizing and
chronic pancreatitis.
Early ERCP (endoscopy retrograde colangiopancreatography)
CONCLUSION
and endoscopic sphincterotomy are the management options for
this case.
ERCP was indicated due to the results of the ultrasound and
liver function tests, which prove the presence of gallbladder
stones. ERCP is considered both a diagnostic and therapeutic
procedure.
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