Gallstone Pancreatitis Exploration
of the Biliary System in Acute and Recurrent Pancreatitis Herbert
Freund, MD; Reuven Pfeffermann, MD; Arieh
L.
Durst, MD; Nathan Rabinovici,
\s=b\ During a five-year period, 82 patients were treated for acute pancreatitis, 63 of whom were proved to have associated biliary tract disease. In 18 of the 63, the accepted preoperative diagnostic measures failed to demonstrate pathologic findings in the biliary system. In 16 of the 18 patients, stones were discovered at the time of operation, although in five they were so small as to be demonstrable only by filtering the aspirated bile through gauze. In the two of the 18 without stones, acalculous cholecystitis was present. In 14 patients the ductus choledochus and the pancreatic duct had a common path. All patients had no further pancreatitis two to eight years after cholecystectomy. In Israel,
where alcoholism is rare, three fourths of the cases of acute pancreatitis are associated with gallbladder disease. (Arch Surg 111: 1106-1107, 1976)
association of acute
pancreatitis with biliary tract established, its reported incidence to geography, nutrition, and alcohol consumption.' '-' In Israel, where alcoholism is rare and most people consume a well-balanced diet, 76% of cases of acute pancreatitis are associated with biliary tract disease. Because of this high figure, and since the x-ray examina¬ tion of the biliary tract occasionally fails to demonstrate existing disease,7 we have explored the biliary system of these patients on the basis of a high degree of suspicion only. In 1971, we1 reported on four such patients; since then we
The varying according
stones is well
have treated 14 others successfully. All of them have remained well since having had biliary tract surgery, with no evidence of pancreatitis or cholecystitis over a follow-up period of two to eight years.
Accepted
for publication Feb 27, 1976. From the Department of Surgery B, Hadassah University Hospital, Jerusalem, Israel. Reprint requests to Department of Surgery B, Hadassah University Hospital, Jerusalem (Dr Freund).
MD
SUBJECTS
During the five-year period from 1968 to 1972, eighty-two patients with acute pancreatitis were treated at the Hadassah University Hospital; 63 patients (76%) had proved associated biliary tract disease, six (7.2%) had pancreatitis due to miscella¬ neous known causes, and in 13 (15.8%) the cause of pancreatitis was undetermined. In 18 of the 63 patients with proved biliary tract-associated pancreatitis, the accepted preoperative diagnostic measures failed to demonstrate the disease in the biliary system. This group of patients is the subject of the present report. There ten women and eight men, aged 27 to 81 years (average, 56.5). The diagnosis of acute pancreatitis was based on a characteristic history, physical findings of pancreatitis, and elevated serum and urine amylase levels. The clinical and laboratory features of these 18 patients are summarized in the Table. Serum and urine levels of amylase were elevated in all patients; 12 patients had elevated serum bilirubin levels and 13 had elevated alkaline phosphatase levels. These 18 patients had a total of 39 oral cholecystograms and 25 intravenous cholecystograms, none of them demonstrating biliary tract disease. They experienced 40 hospital admissions including the ones on which operations were performed. Twelve patients were operated on electively, while the other six under¬ went emergency operation, usually when the acute attack failed to resolve or when other causes of an acute abdomen could not be ruled out. At operation, acute or chronic inflammation of the gallbladder was found in all patients, gallstones were found in 16, and some degree of pancreatitis in 16. Operative cholangiography demon¬ strated a common entrance of the ductus choledochus and pancreatic duct at the papilla of Vater in 14 patients. In five patients (No. 4, 5, 14, 16, and 17) palpation and cholangiography showed no stones, and only bile aspiration and filtration through gauze demonstrated tiny stones, 1 to 2 mm in diameter. All patients underwent cholecystectomy; in six, choledochotomy was also performed. There was no operative mortality. Postoperative complications-namely, wound infection, deep phlebothrombosis, and pulmonary emboli-occurred in three patients (16%). The average hospital stay after operation was 15.6 days (range, 9 to 44). The follow-up period on our 18 patients ranges from two to eight years, with no signs or symptoms of recurrent pancreatitis since the removal of the gallbladder. were
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Summary
of Cases Common Entrance
Patient/Age, yr
No. of
No. of
Cholecystograms
Hospital
Admissions
1/60 2/81
Operation Emergency
Stones Found at
Cholecys¬
Surgery
titis
at
Papilla
of Vater
Special Features
+
Elective
Operated
on twice; edema of gall¬ bladder wall; no stones palpable,
3/54 4/68 5/57 6/48 7/37
Elective
3/34
Elective
9/72 10/44 11/27 12/58 13/70 14/68
Elective
15/70 16/47 17/56 18/68
Elective Elective Elective Elective
seen, or
Emergency
Stones
on
Elective
Stones
on
aspirated aspiration aspiration
Elective
Emergency Edema of
gallbladder wall; no stones palpable, seen, or aspirated Edema of gallbladder wall; no stones palpable, seen, or aspirated Cholecystoduodenal fistula
Emergency Emergency Elective
Elective
Emergency
COMMENT
Stones on No stones rated
aspiration palpable,
Stones Stones
aspiration aspiration
on on
seen, or
aspi¬
need for
The incidence of pancreatitis-associated biliary tract disease is high in certain countries of the world,7' including Israel' It is so common that sometimes pancreatitis is the first or only symptom of gallbladder disease, and therefore every effort is made to prove biliary tract disease in every patient with pancreatitis. However, oral and intravenous cholecystograms can be misleading,7 since a normal cholecystogram is occasionally associated with the finding of stones or inflammation at operation. In this series, patients with acute pancreatitis, and no evidence of any of the other known causes for pancreatitis, were subjected to operation despite repeated normal x-ray examinations of their biliary systems. In all our patients, correctable disease of the biliary tract was found at operation. At operation, when gallbladder and bile ducts seem to be normal on inspection and palpation, bile should be aspi¬ rated and filtered through a piece of gauze in order to reveal the presence of very tiny stones otherwise not detectable. Another important step in this kind of surgery is an intraoperative cholangiogram. The common entrance of the ductus choledochus and ductus pancreaticus at the papilla of Vater is a frequent and important feature of biliary tract-associated pancreatitis. It was present in 14 of 18 patients in this study. It is our conviction that, in the presence of pancreatitis, if a common entrance is demon¬ strated on operative cholangiography, cholecystectomy should be performed even when no stones can be palpated or found on bile aspiration, as was done in four of our patients (No. 3, 8, 9, and 15). Other important features to be noticed during operation that might give a clue to gallbladder disease and indicate '
cholecystectomy are edema of the gallbladder, cystic duct, or adjacent peritoneum (cases 3, 8, and 9). It has become our practice to try to prove gallbladder disease roentgenographically in all cases of pancreatitis. When this fails, operative exploration of the biliary system is under¬ taken. At operation any of the following should be consid¬ ered an indication for cholecystectomy: palpable stones in the gallbladder or common duct or both; tiny gallbladder stones found on bile aspiration and filtration through gauze'; signs of edema or inflammation of gallbladder, bile ducts, or adjacent peritoneum; common entrance of common duct and pancreatic duct demonstrated on opera¬ tive cholangiography. Early cholecystectomy in cases of gallstone pancreatitis is safe and avoids recurrent attacks of pancreatitis, observed when operation is delayed.''7 Once the biliary tract stone disease is corrected, recurrence of pancreatitis is rare."7 The fact that among our 18 patients no recurrent attacks of pancreatitis occurred during a follow-up period of two to eight years proves and justifies this approach. References 1. Cole WH: The treatment of acute pancreatitis. Int Abstr Surg 67:31-38, 1938. 2. White TT: Pancreatitis. London, Edward Arnold Ltd, 1966, pp 1-16. 3. Reid DRK, Rogers IM: The negative cholecystogram in gallbladder disease. Br J Surg 62:581, 1975. 4. Pfefferman R, Luttwak EM: Gallstone pancreatitis. Arch Surg 103:484-486, 1971. 5. Schiller WR, Suriyapa C, Anderson MC: A review of experimental pancreatitis. J Surg Res 16:69-90, 1974. 6. Kelly TR: Gallstone pancreatitis. Arch Surg 109:294, 1974. 7. Paloyan D, Simonowitz D, Skinner DB: The timing of biliary tract operations in patients with pancreatitis associated with gallstones. Surg Gynecol Obstet 141:737, 1975.
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of the Biliary System in Acute and Recurrent Pancreatitis Herbert
Freund, MD; Reuven Pfeffermann, MD; Arieh
L.
Durst, MD; Nathan Rabinovici,
\s=b\ During a five-year period, 82 patients were treated for acute pancreatitis, 63 of whom were proved to have associated biliary tract disease. In 18 of the 63, the accepted preoperative diagnostic measures failed to demonstrate pathologic findings in the biliary system. In 16 of the 18 patients, stones were discovered at the time of operation, although in five they were so small as to be demonstrable only by filtering the aspirated bile through gauze. In the two of the 18 without stones, acalculous cholecystitis was present. In 14 patients the ductus choledochus and the pancreatic duct had a common path. All patients had no further pancreatitis two to eight years after cholecystectomy. In Israel,
where alcoholism is rare, three fourths of the cases of acute pancreatitis are associated with gallbladder disease. (Arch Surg 111: 1106-1107, 1976)
association of acute
pancreatitis with biliary tract established, its reported incidence to geography, nutrition, and alcohol consumption.' '-' In Israel, where alcoholism is rare and most people consume a well-balanced diet, 76% of cases of acute pancreatitis are associated with biliary tract disease. Because of this high figure, and since the x-ray examina¬ tion of the biliary tract occasionally fails to demonstrate existing disease,7 we have explored the biliary system of these patients on the basis of a high degree of suspicion only. In 1971, we1 reported on four such patients; since then we
The varying according
stones is well
have treated 14 others successfully. All of them have remained well since having had biliary tract surgery, with no evidence of pancreatitis or cholecystitis over a follow-up period of two to eight years.
Accepted
for publication Feb 27, 1976. From the Department of Surgery B, Hadassah University Hospital, Jerusalem, Israel. Reprint requests to Department of Surgery B, Hadassah University Hospital, Jerusalem (Dr Freund).
MD
SUBJECTS
During the five-year period from 1968 to 1972, eighty-two patients with acute pancreatitis were treated at the Hadassah University Hospital; 63 patients (76%) had proved associated biliary tract disease, six (7.2%) had pancreatitis due to miscella¬ neous known causes, and in 13 (15.8%) the cause of pancreatitis was undetermined. In 18 of the 63 patients with proved biliary tract-associated pancreatitis, the accepted preoperative diagnostic measures failed to demonstrate the disease in the biliary system. This group of patients is the subject of the present report. There ten women and eight men, aged 27 to 81 years (average, 56.5). The diagnosis of acute pancreatitis was based on a characteristic history, physical findings of pancreatitis, and elevated serum and urine amylase levels. The clinical and laboratory features of these 18 patients are summarized in the Table. Serum and urine levels of amylase were elevated in all patients; 12 patients had elevated serum bilirubin levels and 13 had elevated alkaline phosphatase levels. These 18 patients had a total of 39 oral cholecystograms and 25 intravenous cholecystograms, none of them demonstrating biliary tract disease. They experienced 40 hospital admissions including the ones on which operations were performed. Twelve patients were operated on electively, while the other six under¬ went emergency operation, usually when the acute attack failed to resolve or when other causes of an acute abdomen could not be ruled out. At operation, acute or chronic inflammation of the gallbladder was found in all patients, gallstones were found in 16, and some degree of pancreatitis in 16. Operative cholangiography demon¬ strated a common entrance of the ductus choledochus and pancreatic duct at the papilla of Vater in 14 patients. In five patients (No. 4, 5, 14, 16, and 17) palpation and cholangiography showed no stones, and only bile aspiration and filtration through gauze demonstrated tiny stones, 1 to 2 mm in diameter. All patients underwent cholecystectomy; in six, choledochotomy was also performed. There was no operative mortality. Postoperative complications-namely, wound infection, deep phlebothrombosis, and pulmonary emboli-occurred in three patients (16%). The average hospital stay after operation was 15.6 days (range, 9 to 44). The follow-up period on our 18 patients ranges from two to eight years, with no signs or symptoms of recurrent pancreatitis since the removal of the gallbladder. were
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 06/09/2015
Summary
of Cases Common Entrance
Patient/Age, yr
No. of
No. of
Cholecystograms
Hospital
Admissions
1/60 2/81
Operation Emergency
Stones Found at
Cholecys¬
Surgery
titis
at
Papilla
of Vater
Special Features
+
Elective
Operated
on twice; edema of gall¬ bladder wall; no stones palpable,
3/54 4/68 5/57 6/48 7/37
Elective
3/34
Elective
9/72 10/44 11/27 12/58 13/70 14/68
Elective
15/70 16/47 17/56 18/68
Elective Elective Elective Elective
seen, or
Emergency
Stones
on
Elective
Stones
on
aspirated aspiration aspiration
Elective
Emergency Edema of
gallbladder wall; no stones palpable, seen, or aspirated Edema of gallbladder wall; no stones palpable, seen, or aspirated Cholecystoduodenal fistula
Emergency Emergency Elective
Elective
Emergency
COMMENT
Stones on No stones rated
aspiration palpable,
Stones Stones
aspiration aspiration
on on
seen, or
aspi¬
need for
The incidence of pancreatitis-associated biliary tract disease is high in certain countries of the world,7' including Israel' It is so common that sometimes pancreatitis is the first or only symptom of gallbladder disease, and therefore every effort is made to prove biliary tract disease in every patient with pancreatitis. However, oral and intravenous cholecystograms can be misleading,7 since a normal cholecystogram is occasionally associated with the finding of stones or inflammation at operation. In this series, patients with acute pancreatitis, and no evidence of any of the other known causes for pancreatitis, were subjected to operation despite repeated normal x-ray examinations of their biliary systems. In all our patients, correctable disease of the biliary tract was found at operation. At operation, when gallbladder and bile ducts seem to be normal on inspection and palpation, bile should be aspi¬ rated and filtered through a piece of gauze in order to reveal the presence of very tiny stones otherwise not detectable. Another important step in this kind of surgery is an intraoperative cholangiogram. The common entrance of the ductus choledochus and ductus pancreaticus at the papilla of Vater is a frequent and important feature of biliary tract-associated pancreatitis. It was present in 14 of 18 patients in this study. It is our conviction that, in the presence of pancreatitis, if a common entrance is demon¬ strated on operative cholangiography, cholecystectomy should be performed even when no stones can be palpated or found on bile aspiration, as was done in four of our patients (No. 3, 8, 9, and 15). Other important features to be noticed during operation that might give a clue to gallbladder disease and indicate '
cholecystectomy are edema of the gallbladder, cystic duct, or adjacent peritoneum (cases 3, 8, and 9). It has become our practice to try to prove gallbladder disease roentgenographically in all cases of pancreatitis. When this fails, operative exploration of the biliary system is under¬ taken. At operation any of the following should be consid¬ ered an indication for cholecystectomy: palpable stones in the gallbladder or common duct or both; tiny gallbladder stones found on bile aspiration and filtration through gauze'; signs of edema or inflammation of gallbladder, bile ducts, or adjacent peritoneum; common entrance of common duct and pancreatic duct demonstrated on opera¬ tive cholangiography. Early cholecystectomy in cases of gallstone pancreatitis is safe and avoids recurrent attacks of pancreatitis, observed when operation is delayed.''7 Once the biliary tract stone disease is corrected, recurrence of pancreatitis is rare."7 The fact that among our 18 patients no recurrent attacks of pancreatitis occurred during a follow-up period of two to eight years proves and justifies this approach. References 1. Cole WH: The treatment of acute pancreatitis. Int Abstr Surg 67:31-38, 1938. 2. White TT: Pancreatitis. London, Edward Arnold Ltd, 1966, pp 1-16. 3. Reid DRK, Rogers IM: The negative cholecystogram in gallbladder disease. Br J Surg 62:581, 1975. 4. Pfefferman R, Luttwak EM: Gallstone pancreatitis. Arch Surg 103:484-486, 1971. 5. Schiller WR, Suriyapa C, Anderson MC: A review of experimental pancreatitis. J Surg Res 16:69-90, 1974. 6. Kelly TR: Gallstone pancreatitis. Arch Surg 109:294, 1974. 7. Paloyan D, Simonowitz D, Skinner DB: The timing of biliary tract operations in patients with pancreatitis associated with gallstones. Surg Gynecol Obstet 141:737, 1975.
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