A 35-year-old male patient was referred from a private hospital as a non settling case of acute on chronic pancreatitis being managed conservatively for the last 4 days. Patient had complaints of generalised pain abdomen with multiple episodes of vomiting.
On examination he was sick looking and dehydrated with tachycardia, tachypnoea and was normotensive. On examination, the abdomen was distended and tender with presence of free fluid and absent bowel sounds. Initial investigations revealed haemoglobin 15.1gm/dL, white cell count 27,100/cumm with 94% segmented neutrophils, serum bilirubin was 1.84 mg/dL, transaminases and alkaline phosphatase [ALP] were normal. Serum Amylase and Lipase were 321 U/L and 393 U/L respectively. Ultrasound abdomen showed moderate ascites with multiple pancreatic calcifications. Chest X-ray was normal and abdominal X-ray showed evidence of ileus with calcification in the region of pancreas [Figure 1, yellow arrow] with no evidence of air under diaphragm. Contrast-enhanced Computed Tomography [CECT] of abdomen showed features of acute exacerbation with chronic calcific pancreatitis with multiple intraluminal calculi and normal common bile duct. Diagnostic paracentesis showed bilious fluid.
With the provisional diagnosis of biliary peritonitis, patient was taken up for explorative laboratory. Upon exploration, 1.5 litres of bilious peritoneal fluid was aspirated, omentum was studded with calcifications. The duodenum and stomach were normal. Gallbladder was intact and didn't contain any calculus. The common bile duct was mildly dilated 8 mm with a perforation of 5 x 5 mm in supraduodenal part [Figure 2, white arrow]. It didn’t contain any calculus and distal patency was maintained. Cholecystectomy with primary closure of common bile duct perforation was done.
Post operative Magnetic Resonance Cholangiopancreatography [MRCP] showed smooth tapering of CBD into duodenum with acute on chronic mass forming pancreatitis with multiple calculi in pancreatic duct.
Patient had an uneventful postoperative recovery and was discharged on 6th post-operative day.