S1823 Recurrent Gallstones in a Patient With a Congenitally Absent Gallbladder and Cholangiocarcinoma

Abstract

Introduction: Petersen's space hernia is an internal hernia that can occur after Roux-en-Y gastrojejunostomy. The intestinal loops herniate through a defect between the retroperitoneum, the transverse mesocolon and the small bowel limbs. We present a case of recurrent pancreatitis in a patient with Roux-En-Y bypass found to have common channel hernia through a Petersen's space defect. Case Description/Methods: We present the case of a 34-year-old female with a history of Roux-en-Y surgery in 2018 and subsequent recurrent pancreatitis who presented to the emergency department with a chief complaint of severe epigastric and left lower quadrant abdominal pain associated with hematemesis. Patient reported 3 episodes of pancreatitis within 1 year previously. CT abdomen and pelvis showed mildly dilated common bile duct and intrahepatic biliary dilatation with no evidence of pancreatitis. Significant lab work included elevated lipase at 184 U/L. Patient was admitted to the medical service. Gallbladder ultrasound revealed no evidence of cholelithiasis, a prominent CBD of 9 mm and redemonstrated mild intrahepatic biliary dilatation. MRCP revealed a mesenteric swirl in the mid abdomen which was suspicious for an internal hernia in the setting of antecolic Roux-en-Y gastric bypass. It also showed focally dilated intrahepatic with underlying segmental atrophy. General surgery consultation was sought, with eventual plans for diagnostic laparoscopy after ruling out marginal ulcer via EGD. An EGD was performed which did not show evidence of marginal ulcer. Patient then underwent diagnostic laparoscopy which revealed a 360-degree volvulus of the common channel through a Petersen's space defect; this was carefully reduced, and the Petersen's space defect was closed. Patient also underwent laparoscopic cholecystectomy. Patient did not have any further episodes of pancreatitis after surgery. Discussion: This case demonstrates recurrent pancreatitis in a patient with a history of Roux-En-Y bypass found to have a common channel volvulus through a Petersen's space defect. It is our understanding that the volvulus likely caused compression of the pancreaticobiliary system, thus causing recurrent pancreatitis. Reduction of the volvulus and closing of the Petersen's defect resulted in complete resolution of recurrent pancreatitis in the patient.

A Unique Case of Gallbladder Agenesis and Cholangiocarcinoma

“…The relationship between GA and cholangiocarcinoma is unclear, as only one case report has documented this; however, it is known that chronic inflammation in the hepatobiliary tract is a risk factor for cholangiocarcinoma [4][5][6]. This is seen with primary sclerosing cholangitis or in those with pancreaticobiliary maljunction, in which the regurgitation of bile and pancreatic juices in the common bile duct may activate enzymes and lead to mutagenic substances [5].…”

“…Those who are symptomatic often present with biliary colic in their second or third decade of life and are diagnosed intraoperatively, as the diagnosis is originally mistaken for cholelithiasis or cholecystitis [1][2][3]. Cholangiocarcinoma (CCA) is a cancer of the biliary tract, arising from conditions causing chronic inflammation [4][5][6]. It is the second most common malignancy of the hepatobiliary tract after hepatocellular carcinoma [4].…”

“…Conditions such as liver fluke infection, primary sclerosing cholangitis, chronic viral hepatitis infections, and pancreaticobiliary maljunctions can lead to chronic inflammation, potentially causing cholangiocarcinoma [5]. The risk of cholangiocarcinoma in those with pancreaticobiliary maljunction is more than 285 times higher than in the general population, and the incidence in patients with primary sclerosing cholangitis is between five and 10 cases per 100,000 [4][5][6]. The incidence of cholangiocarcinoma in GA is not known, as only one case report has ever described this relationship [4,6].…”

“…The risk of cholangiocarcinoma in those with pancreaticobiliary maljunction is more than 285 times higher than in the general population, and the incidence in patients with primary sclerosing cholangitis is between five and 10 cases per 100,000 [4][5][6]. The incidence of cholangiocarcinoma in GA is not known, as only one case report has ever described this relationship [4,6]. Herein we present the case of a patient presumed to have choledocholithiasis who was found to have congenital gallbladder agenesis diagnosed intraoperatively with pathologic results of cholangiocarcinoma.…”

“…Cholangiocarcinoma (CCA) is a cancer of the biliary tract, arising from conditions causing chronic inflammation [ 4 - 6 ]. It is the second most common malignancy of the hepatobiliary tract after hepatocellular carcinoma [ 4 ].…”