Doğan, İbrahim

Erkan, Gülbanu

Tuncer, Candan

Özenirler, Seren

ISRN Gastroenterology

English

Ufuk Universitesi Akademik Acikerisim Sistemi

International Scholarly Research NetworkISRN GastroenterologyVolume 2011, Article ID 481980, 2 pagesdoi:10.5402/2011/481980Case ReportA Case of Biliary Pancreatitis Which Subsided afterEndoscopic Sphincterotomy during PregnancyGulbanu Erkan,1 Ibrahim Dogan,2 Seren Ozenirler,2 and Candan Tuncer21 Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Ufuk University Hospital,Mevlana Bulvarı no. 86-88, Balgat , 06520 Ankara, Turkey2 Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine, Gazi University Hospital, 06500 Ankara, TurkeyCorrespondence should be addressed to Gulbanu Erkan, gcanbaloglu@yahoo.comReceived 2 March 2011; Accepted 17 March 2011Academic Editors: A. Amedei, T. Joh, and C. Y. YeungCopyright © 2011 Gulbanu Erkan et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.A 24-year-old pregnant patient was referred to us because of pain and tenderness in the right upper quadrant. Her liver enzymesand bilirubin levels were elevated; an abdominal ultrasound examination revealed gallstones within the gallbladder. Diagnosisof biliary pancreatitis was established based on elevated amylase levels. Oral intake was withheld; intravenous antibiotic therapyand total parenteral nutrition were administered. An endoscopic sphincterotomy without the use of fluoroscopy was performed.Abdominal pain and elevated serum amylase levels subsided after this procedure. In our case, biliary pancreatitis, which developedduring pregnancy, responded well to the endoscopic sphincterotomy, and this procedure obviated the need for surgical interventionand prevented the recurrence of pancreatitis.1. IntroductionCholelithiasis and pancreatitis are two commonly encoun-tered entities during pregnancy. In the Framingham cohort,the incidence of cholelithiasis shows a positive correlationwith the number of pregnancies, especially after the fourthpregnancy [1].The increase in the lithogenicity of the bile and decreasein the motility of the gallbladder causes the increase in theincidence of cholelithiasis during pregnancy [2].With conservative measures only, the risk of recurrenceof biliary pancreatitis during pregnancy is 72% percent [3].Thus, the importance of preventive interventions aimingto reduce the risk of recurrence of pancreatitis duringpregnancy cannot be overemphasized.In this context, we are presenting a case of acutebiliary pancreatitis during pregnancy who responded well toendoscopic sphincterotomy.2. Case ReportA 24-year-old female patient in the 32nd week of her secondpregnancy was referred to the Department of Gastroen-terology, because of pain in the right upper quadrant thatradiated to the back and the epigastrium. On palpation, thepatient had displayed tenderness in the right upper quadrant.Sclerae were icteric. An abdominal ultrasound examinationrevealed homogenous liver parenchyma, and a few gallstoneswere visualized in the gallbladder, the largest measuring23 mm in diameter. The transverse diameter, wall thicknessof the gallbladder, and intrahepatic and extrahepatic bileducts were normal. A biochemical analysis of the serumrevealed an elevated serum amylase level (1724 IU/mL);liver function tests and serum bilirubin levels wereas follows: aspartate aminotransferase—287 IU/mL, ala-nine aminotransferase—319 IU/mL, alkaline phosphatase—261 IU/mL, gamma gluthamil transferase—83 IU/mL, totalbilirubin—2,87 mg/dL, and direct bilirubin—2,44 mg/dL.Laboratory findings on admission and through followupare summarized in Table 1. The patient’s serum triglycerideand calcium levels were normal. The patient was diag-nosed as having acute biliary pancreatitis. As a result, oralintake was withheld. Intravenous fluid therapy, Ampicillin +Sulbactame 3 × 1 g/day, and total parenteral nutritionwere administered. On the second day of hospitalization,an endoscopic sphincterotomy was performed withoutthe use of fluoroscopy, and the common bile duct wasselectively cannulated with a guidewire using direct video2 ISRN GastroenterologyTable 1: Laboratory findings in the patient with biliary pancreatitis.Initial Day 1 Day 4 Normal rangesSerum amilase 1724 605 118 0–65 IU/mLTotal bilirubin 2.87 2.1 1.2 0.2–1.3 mg/dLDirect bilirubin 2.44 1.8 0.5 0–0.5 mg/dLALT 319 197 163 23 IU/mLAST 287 160 104 23 IU/mLendoscopic control. A catheter was advanced over theguidewire into the bile duct. Bile was aspirated into thecatheter to confirm cannulation of the bile duct, and thesphincterotomy was performed. The patient’s abdominalpain and the elevated amylase and lipase levels subsidedafter this procedure. Uterine contractions, which began onthe fifth day of the hospitalization, could not be haltedwith magnesium infusion, and the patient gave birth to apremature but otherwise healthy infant with a Caesariansection in the 32nd gestational week.3. DiscussionThe incidence of cholelithiasis is increased in pregnancy,especially in young multiparous women [1]. On the otherhand, the incidence of pancreatitis during pregnancy is notincreased, but it is more common in the third trimester.The most common cause of pancreatitis during pregnancyis cholelithiasis [2].In a series reported by Ramin et al., the prevalence ofacute pancreatitis in pregnancy is one in 3333 pregnancies.In this series, the mean maternal age was 24, and 72%of patients were multiparous. Acute pancreatitis, due tobiliary disease, developed in 68% of patients. The authorsconcluded that acute pancreatitis was generally associatedwith cholelithiasis in pregnant women, and the maternalprognosis was especially good with early supportive therapyand surgical therapy, if it was indicated [4].Endoscopic sphincterotomy can be performed withoutgeneral anesthesia or an abdominal incision. Baillie et al.reported a successful prophylactic endoscopic sphinctero-tomy in a single pregnant patient who had developedgallstone pancreatitis [5].Barthel et al. also reported that, in pregnancy-associatedgallstone pancreatitis, endoscopic sphincterotomy preventsrecurrence of pancreatitis and the need for a cholecystectomyduring gestation [6].In our case, an abdominal ultrasound examination wasperformed in order to clarify the etiology of right upperquadrant pain that developed in the 32nd week of pregnancy.As a result, cholecystolithiasis was discovered. After the diag-nosis of biliary pancreatitis had been established with clinicaland biochemical evidence, an endoscopic sphincterotomywas performed without the use of fluoroscopy, and theclinical symptoms of pancreatitis subsided. There was noprocedure related to maternal complication, but the deliverywas preterm. Nevertheless, fetal development was consistentwith gestational age, and no severe growth retardation or anyother complications were encountered.In conclusion, the endoscopic sphincterotomy, whichwas performed for biliary pancreatitis during pregnancy,was efficacious and obviated the need for urgent surgicalintervention and prevented the recurrence of the pancreatitiswithout causing any serious maternal or fetal complications.4. Key PointsThe incidence of cholelithiasis is increased in pregnancy,especially in young multiparous women.The most common cause of pancreatitis during preg-nancy is cholelithiasis.With conservative measures only, the risk of recurrenceof biliary pancreatitis during pregnancy is 72% percent.Preventive interventions aiming to reduce the risk ofrecurrence of pancreatitis during pregnancy are beneficial.References[1] G. D. Friedman, W. B. Kannel, and T. R. Dawber, “The epidemi-ology of gallbladder disease: observations in the Framinghamstudy,” Journal of Chronic Diseases, vol. 19, no. 3, pp. 273–292,1966.[2] L. D. Scott, “Gallstone disease and pancreatitis in pregnancy,”Gastroenterology Clinics of North America, vol. 21, no. 4, pp.803–815, 1992.[3] S. G. Swisher, K. K. Hunt, P. J. Schmit, D. T. Hiyama, R. S.Bennion, and J. E. Thompson, “Management of pancreatitiscomplicating pregnancy,” American Surgeon, vol. 60, no. 10, pp.759–762, 1994.[4] K. D. Ramin, S. M. Ramin, S. D. Richey, and F. G. Cunningham,“Acute pancreatitis in pregnancy,” American Journal of Obstet-rics and Gynecology, vol. 173, no. 1, pp. 187–191, 1995.[5] J. Baillie, S. R. Cairns, W. S. Putnam, and P. B. Cotton, “Endo-scopic management of choledocholithiasis during pregnancy,”Surgery Gynecology and Obstetrics, vol. 171, no. 1, pp. 1–4, 1990.[6] J. S. Barthel, T. Chowdhury, and B. W. Miedema, “Endoscopicsphincterotomy for the treatment of gallstone pancreatitisduring pregnancy,” Surgical Endoscopy, vol. 12, no. 5, pp. 394–399, 1998.

Case report a case of biliary pancreatitis which subsided after endoscopic sphincterotomy during pregnancy

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Case report a case of biliary pancreatitis which subsided after endoscopic sphincterotomy during pregnancy

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