Gallstones and timely surgical intervention – wait or operate ?

Uvod. Žučna kalkuloza (ŽK) je najčešći uzrok bilijarnog pankreatitisa. Nakon smirivanja akutne faze pankreatitisa (AP), u skoro svim slučajevima primenjuje se hirurško lečenje (holecistektomija). Cilj rada. Prikazati pravo vreme za operaciju žučnih kamenaca u slučaju pankreatitisa kao komplikacije. Prikaz slučaja. Pacijent starosti 85 godina, javlja se zbog bolova u trbuhu. Pacijent afebrilan, eupnoičan, bleđe boje kože, normalne prebojenosti vidljivih sluznica; TA 140/80 mmHg, difuzna bolna osetljivost abdomena. Nativni rendgen abdomena pokazao je hidroaerične nivoe. Pacijent upućen hirurgu i hitno je operisan. Nije urađena holecistektomija. Zbog kardiovaskularne bolesti i promena na krvnim sudovima, pacijent je imao dve kardiohirurške intervencije. Tri meseca nakon kardiohirurškog zahvata, pacijent se javlja izabranom lekaru jer je požuteo. Fizikalnim pregledom ustanovljena žuta prebojenost kože i vidljivih sluznica, afebrilan, bez bolne osetljivosti abdomena. Pregledom krvi na infektivne agense, negativna antitela na viruse hepatitisa B, C i HIV. Abdominalnom ultrasonografijom viđen kamen u žučnoj kesici, postoji opasnost od recidivantnog bilijarnog pankreatitisa. Pacijent podvrgnut operativnom zahvatu totalne holecistektomije. Zaključak. Pacijenti sa žučnim kamencem imaju povećan rizik od akutnog pankreatitisa. Holecistektomiju treba obaviti za vreme prve hospitalizacije kod postojanja kalkuloze žučne kesice sa komplikacijom bilijarnog pankreatitisa. Ključne reči: žučni kamenci, pankreatitis, holecistektomija, primarna zdravstvena zaštita Abstract


Introduction
Acute biliary pancreatitis is on the rise worldwide. One of the possible reasons is the rise in the the number of obese people, which bears higher risk of gallstones 1 . The gallstones originate from the precipitation of the gallbladder contents, cholesterol, and bilirubin. Due to the lack o symptoms, many patients are unaware of their existence. Over 70% of gallstones are asymptomatic 2,3 . Clinical manifestations of gallbladder calculi vary, and the disease may start abruptly with abdominal pain, nausea, vomiting, intermittent fever. Jaundice is rare.
Abdominal sonography is a diagnostic method of choice for gallbladder calculosis and its complications 2,4 . Complications such as septicemia, peritonitis, ileus are rare. Gallstones are the most common cause of biliary pancreatitis. 5 Bile activates pancreatic enzymes, thus causing a cascading reaction of enzymatic damage and autodigestion of the pancreas. The treatment of acute gallbladder inflammation includes the use of medications and surgery. The acute phase treatment includes pain alleviation, infection healing, and improvement of the patient`s general condition. After the alleviation of the acute phase of the disease, surgical intervention is performed in the majority of cases (cholecystectomy) 6,7 .
The incidence of acute pancreatitis varies worldwide, due to different etiological factors. It ranges from 5% to 80% in the EU countries, with a somewhat lower incidence in the United Kingdom (England, Scotland), Netherlands, Germany and high incidence in Finland. 8 The most common cause of acute pancreatitis (40% -70%) is biliary tract disorders, followed by alcohol abuse (25% -30%). The Serbian research data show gallstones are the most common cause of acute pancreatitis (around 51%) 9 .

Objective
Our article aimed to show the right time for surgical intervention in gallstone cases with consecutive pancreatitis as a complication.

Case report
We presented the case of an older male patient with two episodes of acute pancreatitis before the cholecystectomy was performed. The methodology included a case report from the GP practice in Primary health center, Novi Beograd and a review of the patient`s medical records.

Diskusija
Kamenci u žučnoj kesici su čest uzrok akutnog pankreatitisa 1,6,10 . U radu smo izneli pojavu akutnog pankreatitisa kod starijeg muškarca provociranu kalkulozom žučne kesice. Pojava pankreatitisa je češća kod pacijenata sa žučnim kamencem 2 Murat i saradnici su pokazali da pacijenti starijeg životnog doba, više od 70 godina starosti, sa teškim komorbiditetima imaju približno dvostruki rizik od smrti 11 . nosed with gallstones ten years ago, using ultrasonography. The patient uses his medications regularly (ACE inhibitors, beta-blockers, oral antidiabetics, and alfa receptor blockers). Physical examination confirmed the patient was afebrile, eupnoeic, pale, BP 140/80 mmHg and had palpable abdominal tenderness. Urgent lab results were obtained and they showed no abnormalities. A native abdominal X-ray was performed and it was positive for hydroaeric levels. Abdominal sonography findings were inconclusive due to a large amount of gas in the abdomen, but a gallstone was seen. The patient was urgently referred to a surgeon. Due to the signs of ileus, urgent surgery was performed. Discharge letter diagnosis included Pancreatitis acuta, Ileus paralyticus, Diverticulosis colonis sygmoidei. Operation: Laparotomia explorativa, Adhaesiolysis. He was discharged as recovered and was advised about healthy nutrition. Cholecystectomy was not performed.
Three months after the second cardiosurgical intervention the patient presented at his GP office with jaundice. Physical examination confirmed a yellow color of skin and mucosae, the patient was afebrile and had no abdominal tenderness. Lab results: ESR 80 (ref<20), total bilirubin 84.9 (ref 0-21), direct bilirubin 67.2 (ref<5.1), AST 245, ALT 478 (ref 0-40), alkaline phosphatase 282, CRP 82, serum amylase 340. Serological blood tests were negative for hepatitis B, C, and HIV. Abdominal sonography confirmed distended gallbladder, wall thickness was marginal but not striated, intrahepatic bile ducts were segmentally dilated, ductus choledocus was dilated with calculus of 8mm. The cholestatic syndrome was diagnosed and there was a risk of recidivant biliary pancreatitis. The patient underwent surgery again with total cholecystectomy. Discharge diagnosis: Calculosis vesicae felleae, Pancreatitis recidivans, Cholecystectomia.

Discussion
Gallstones are the frequent cause of acute pancreatitis. 1,10,16 We presented the case of acute pancreatitis in an older man caused by the calculosis of the gallbladder. Pancreatitis is more common in patients with gallstones 2 . Murat et al showed that older patients, over 70 years of age and severe comorbidities have twice the higher risk of death 11 .
Comorbidity is recognized as an important risk factor in patients with acute pancreatitis. The Serbian research showed the patients with severe comorbidities were at higher risk of death, compared to those without them. Of 19 patients who died, 16 (84.2%) were with comorbidities 9 . Acute pancreatitis is a potentially fatal disease, with the death rate 1% -5%, with decreasing tendency in recent years. 12 Should the surgeon have removed the gallbladder which contained gallstones during the first surgical intervention and thus avoided repeated surgical intervention and recurrent pancreatitis 6.8.13.14 ?
The research shows it is better to perform cholecystectomy as soon as possible because there are fewer complications 7 . Postponing cholecystectomy for a few weeks puts a patient at risk of complications. A small incidence ofy complications connected with cholecystectomy suggests that it may be performed during the same hospitalization 1,15 . Johnstone et al recommend cholecystectomy as a definitive treatment during the first hospitalization or within two weeks from hospital admission, in order to reduce the incidence of recurrent pancreatitis. Their research showed 11% of patients were readmitted with the diagnosis of recurrent pancreatitis 15 . The research data indicate gallstones initiate pancreatitis attacks, but not the progression of the disease which is dependant on the number of digestive enzymes. It is safe to say, cholecystectomy should be performed during the first hospitalization. No difference was found in the representation of complications among patients who underwent early cholecystectomy as opposed to late cholecystectomy 15 . For the sake of treatment, besides adequate nutritional habits, medications, surgical treatment is also performed (cholecystectomy). Targeted treatment of patients with gallstones decreases morbidity, mortality and treatment costs.
The limitations of this case report are due to the data we were unable to obtain during the hospital treatment (diagnostic procedures and medications), which were reported in the discharge papers. Anyhow, we do hope that the presented data may serve as an incentive in following and upgrading current guidelines for the prevention of recurrent pancreatitis due to gallstones.

Conclusion
Patients with gallstones are at higher risk for acute pancreatitis. Pancreatitis should be treated in accordance with the cause, targeted and multidisciplinary. Cholecystectomy should be performed during the first hospitalization in the cases of gallbladder calculosis with biliary pancreatitis as a complication. It reduces the risk of recurrent pancreatitis. Pancreatitis is a severe problem, especially if combined with comorbidities, in which case it raises mortality risk.