D0049 - Impacted Pancreatic Stone Resulting in Biliary Obstruction, 
Choledochal Duodenal Fistula Development, and Ascending Cholangitis

Bhavik Hirapara, DO, Dylan Lopez, MD, Kinnari Modi, DO, Ian M. Greenberg, MD, Paul Tarnasky, MD
Methodist Dallas Medical Center, Dallas, TX

Introduction: Pancreatic stones are present in about one-half of patients with chronic pancreatitis (CP). Pancreatic stones are associated with alcohol, smoking, metabolic and hereditary factors. The most common complication of pancreatic stones is acute pancreatitis. Pancreatic stones can lead to pancreatic fistulas and/or biliary obstruction when associated with bile duct strictures. Stones are typically managed by surgery, endoscopy, and extracorporeal shock wave lithotripsy. We present a case of an obstructive pancreatic stone complicated by ascending cholangitis and a choledochal duodenal fistula (CDF).

Case Description/Methods: A 69-year-old male with a history of a remote cholecystectomy, alcohol abuse, and CP presented with abdominal pain and vomiting. On arrival he was hypotensive and febrile. Blood work was significant for leukocytosis, elevated liver enzymes, and Klebsiella bacteremia. Computed tomography demonstrating intra and extrahepatic bile duct (BD) dilatation, diffuse pancreatic calcifications, and a dilated pancreatic duct. Given concern for ascending cholangitis the patient was started on antibiotics and underwent urgent endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy revealed a bulging major papilla consistent with and an impacted stone and obvious biliary drainage from a fistula proximal to the papillary orifice. Precut biliary sphincterotomy was performed revealing a 12mm impacted pancreatic stone (see Figure 1). A pancreatic septotomy was then performed resulting in spontaneous stone passage. Plastic stents were placed across both ducts to ensure drainage. Post procedure the patient improved with resolution of jaundice and abdominal pain.

Discussion: Obstructive jaundice and enteric fistulas are known complications of bile duct stones. However, there are limited reports describing obstructive jaundice secondary to pancreatic stones. To our knowledge, this is the first report of a chronic pancreatitis complication whereby pancreatic stone impaction led to chronic biliary obstruction but also with ascending cholangitis and fistula development. This case highlights a rare, but potentially dangerous complication of a large pancreatic stone that led to biliary obstruction and cholangitis that was successfully managed with ERCP.



Disclosures:


Bhavik Hirapara, DO, Dylan Lopez, MD, Kinnari Modi, DO, Ian M. Greenberg, MD, Paul Tarnasky, MD. D0049 - Impacted Pancreatic Stone Resulting in Biliary Obstruction, 
Choledochal Duodenal Fistula Development, and Ascending Cholangitis, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.