A 22‐year old previously healthy man developed acute‐onset right upper quadrant pain, vomiting, and jaundice. He consumed 4–6 alcoholic drinks occasionally and denied diarrhea, bloody stools, or fevers. Medical history was notable for a possible diagnosis of irritable bowel syndrome without previous workup. On examination, he was tachycardic and visibly jaundiced and had moderate abdominal tenderness to palpation in the right upper quadrant. Laboratory evaluation revealed a white blood cell count of 29,500, hemoglobin of 10.8 with a mean corpuscular volume of 77, total bilirubin (Tbil) of 9.4, amylase 1458, lipase 4081, AST 166, ALT 201, and alkaline phos‐phatase (AP) of 662. Right upper quadrant ultrasound showed gallstones, choledocholithiasis, and a common bile duct of 0.6 cm. He was treated with piperacillin/tazobactam and underwent an endoscopic retrograde cholangio‐pancreatogram (ERCP) with cholelith retrieval and sphincterotomy. His pain improved, and his pancreatic enzymes normalized. His hemoglobin decreased to 8.5 on hospital day (HD) 2, with no evident blood loss. Iron was 19, ferritin 49.5, and transferrin saturation 5.6%, and the fecal occult blood test was negative. Direct antibody test (Coombs) IgG was 31 positive, and a warm antibody was identified. Reticulocyte count was 3%. Lactate dehydrogenase and haptoglobin were within normal limits, and a peripheral smear revealed no schistocytes or spherocytes. He underwent cholecystectomy on HD 5, with pigment gallstones identified grossly. On HD 8, his liver chemistries were persistently abnormal (AST 62, ALT 87, AP 492, Tbil 7). A repeat ERCP and MRCP (Fig. 1) revealed diffuse rarefaction of the intrahepatic bile ducts with short dilated segments diagnostic of primary sclerosing cholangitis (PSC). He was treated with ursodiol, and follow‐up was arranged with the liver transplant clinic. A colonoscopy performed 1 month after discharge revealed histologic evidence of quiescent ulcerative colitis (UC).
FIGURE 1. Magnetic resonance cholangiopancreatogram showing findings consistent with primary sclerosing cholangitis.
Gallstone pancreatitis is a common diagnosis among hospitalized patients. However, it is an unusual presentation in an otherwise healthy young man and should prompt further investigation. His microcytic anemia, although mild and certainly not uncommon among hospitalized patients, was another clue to his underlying diagnoses. This patient developed gallstone pancreatitis from pigment gallstones, most likely secondary to a chronic warm antibody autoimmune hemolytic anemia in the setting of iron‐deficiency anemia, presumably due to UC. Both warm antibody hemolysis and PSC are associated with UC.
It is important to consider all aspects of a patient's presentation, particularly those aspects that deviate from typical patterns, to avoid missing important diagnoses. Furthermore, these clues can point toward an underlying, unifying diagnosis that ultimately is the root of the problem, and it is only by treating the true disease process and not the secondary manifestations that good outcomes can be provided.
A. Odden ‐ none; J. Rohde ‐ none
To cite this abstract:Odden A, Rohde J. Gallstone Pancreatitis in a Previously Healthy 22‐Year Old Man: What Does Not Fit?. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 354. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/gallstone-pancreatitis-in-a-previously-healthy-22year-old-man-what-does-not-fit/. Accessed January 21, 2020.