LAUSR

A 73-year-old man presented to the emergency room with diffuse abdominal pain, fever, jaundice, and drowsy mentality. The patient was a chronic alcoholic and had been admitted several times with acute pancreatitis. Laboratory test results at admission showed liver enzyme elevation in a cholestatic pattern. Abdominal computed tomography scan revealed diffusely dilated pancreatic duct with multiple pancreatoliths (Fig. 1a). Common bile duct (CBD) was also dilated, and a large calcific density was seen around the ampulla of Vater (Fig. 1b). Emergency percutaneous transhepatic biliary drainage was performed to relieve biliary obstruction. However, percutaneous transhepatic biliary drainage tubogram showed no evidence of stone within the bile duct, and only an elongated calcific density was observed in the vicinity of the far distal CBD instead (Fig. 1c, arrow). Endoscopic retrograde cholangiopancreatography performed the next day demonstrated an elongated bullet-shaped calcified stone upon insertion of the duodenoscope into the duodenal bulb (Fig. 2a). The ampullary orifice looked patulous, edematous, and erythematous with tethered mucosa induced by passage of impacted pancreatolith at the ampullary orifice (Fig. 2b). Fluoroscopic image taken before the procedure also showed that the elongated calcific density had migrated from the periampullary area to the duodenal bulb (Fig. 2c, arrow). Thus, the patient was diagnosed with extrinsic compression of distal CBD by impacted pancreatolith at the ampullary orifice. This situation could aptly be termed “pancreatolith cholangitis” as a reverse counterpart of gallstone pancreatitis. Abdominal pain caused by pancreatolith is usually due to pancreatic duct obstruction. However, there have been few case reports in the literature in which abdominal pain was due to acute cholangitis induced by pancreatolith impaction at the ampullary orifice. It is well known that the main cause of obstructive jaundice in chronic pancreatitis patients is fibrosis-induced stricture of intrapancreatic segment of the bile duct, followed by CBD stone, pancreatic cancer, etc. However, “pancreatolith cholangitis” should be included as one of the differential diagnoses of obstructive jaundice in this patient population.