MGR Post-ERCP Pancreatitis

C.C> Known CBD stone P.I> F/60 건강검진 목적으로 시행한 복부 초음파 및 전산화단층촬영에서 distal CBD stone, bile duct dilatation 소견 있어 제거 위해 입원함 PMHx> 특이 병력은 없음 CBC/DC WBC (mm3) 5,410 (seg.45.1%) Hb (g/dl) 12.4 Hct (%) 41.2 Platelet 248,000 PT (INR) 1.06 Chemistry TB/DB (mg/dL) 0.5/0.1 Prot/Alb (g/dL) 7.2/4.3 AST/ALT (IU/L) 32/19 ALP/rGT 74/28 BUN/Cr 15/0.6 Amylase/lipase 120/39 CRP < 0.3

Review of systems Physical examination General fever(-) chills(-) weight loss(-) Respiratory cough(-) sputum(-) dyspnea(-) GI A/N/V/D/C(-/-/-/-/-) abd discomfort(-) hematochezia(-) melena(-) hematemesis(-) GU flank pain(-) hematuria(-) dysuria(-) Physical examination Vital sign 110/60mmHg - 60/min - 20/min - 36.6℃ - 98% General Alert mentality Not so ill looking appearance Chest Clear breathing sound s rale Regular heart beat s murmur Abdomen Soft & flat abdomen, no palpable mass Normoactive bowel sound

EKG (2013.10.20) 그림 넣기 NSR (HR 70)

CXR (2013.10.20)

ERCP 시술 전 (2013.9.27) Distal CBD의 lumen 내에 iso to high attenuation의 lesion이 있음, mild dilatation of CBD

Problem list> #1. Known asymptomatic CBD stone Impression> Plan> #1. ERCP, prophylactic antibiotics, NPO

E R C P (2013.10.21) Guidewire 삽입 후 EST 시행함. EST시행 후 Titan balloon catheter 삽입 후 EPBD (up to 2atm) 시행함. Memory basket 으로 수 차례 CBD clearing 하였으며, 8mm size의 oval한 yellow stone extraction됨.

ERCP 시술 1일 V/S 140/95mmHg-78/min-20/min-36 °C S> 심한 복통 O> 심와부의 저명한 압통, 반발통 V/S 140/95mmHg-78/min-20/min-36 °C A> #2. Post ERCP pancreatitis P> NPO, massive hydration, pain control, Nafamostat CBC/DC WBC (mm3) 15,550 (seg. 93.0%) Hb (g/dl) 14.3 Hct (%) 42.0 Platelet 245,000 PT (INR) 1.16 Chemistry TB/DB (mg/dL) 0.53/0.11 Prot/Alb (g/dL) 7.2/4.3 AST/ALT (IU/L) 69/33 ALP/rGT 78/57 BUN/Cr 15/0.6 Amylase/lipase 1987/1437 CRP 0.61 protease inhibitors로 nafamostat(Futhan)

ERCP 시술 2일 V/S 80/50mmHg-150/min-28/min-38.4°C O> 복부 전반의 저명한 압통, 반발통 V/S 80/50mmHg-150/min-28/min-38.4°C A> #3. Septic shock d/t post ERCP pancreatitis c peritonitis P> ICU care, broad spectrum antibiotics CBC/DC WBC (mm3) 8,060 (seg. 82.3%) Hb (g/dl) 16.9 Hct (%) 50.0 Platelet 245,000 PT (INR) 1.16 Chemistry TB/DB (mg/dL) 0.48/0.25 Prot/Alb (g/dL) 4.8/2.8 AST/ALT (IU/L) 68/35 ALP/rGT 53/36 BUN/Cr 15/0.6 Amylase/lipase 1027/476 CRP 19.2

시술 2일째 CT Plan) PTGBD & PCD insertion Bowel decompression (Rectal tube, L-tube drainage)

PTGBD & PCD PTGBD Peritoneal Peritoneal Rt perirenal Lt ant pararenal Perisplenic 시술 2일째 (10/23) CT찍은날 바로 PCD insertion함

시술 7일까지의 경과 극심한 복부 팽만 지속 배액에서 동정된 세균 : P.aerusinosa +MRCNS amylase 1987 38.7 ℃ 23.36 lipase 1437 38.0 ℃ 37.7 ℃ 19,720/mm3 36.7 ℃ WBC 130 IU 687 18,320 7.56 15,500 8.87 mg/dL 10,300 130 IU 82 476 0.61 45 CRP . 1 2 3 4 5 6 7th day 극심한 복부 팽만 지속 배액에서 동정된 세균 : P.aerusinosa +MRCNS

Sustained paralytic ileus prox. Jejunal tube insertion

Insertion of drainage catheter into Rt. retroperitoneal space. 시술 10일째 발열, 복통 Secondary pancreatitis -> retroperitoneum으로 PCD 1개 더 insertion Insertion of drainage catheter into Rt. retroperitoneal space.

시술 20일째 S> 복통과 복부 팽만 호전 경구 식이 O> WBC & Chemistry WBC (mm3) 10,550 TB/DB (mg/dL) 0.79/0.65 Prot/Alb (g/dL) 4.8/2.6 AST/ALT (IU/L) 25/26 ALP/rGT 209/112 BUN/Cr 23/0.5 Amylase/lipase 223/111 CRP 4.42

시술 23일째 11/11 tubogram : distal CBD에 stricture소견 보이며 조영제의 passage가 느려져 있음 11/12 ERCP : Duodenum 진입, EST를 한 papilla에 erythematous edema가 관찰됨. Cannulation시행함. Double pigtail stent (7 Fr, 7 cm) 삽입

임상 경과 (2013.10~ 2013.11) 10.21 10.22 10.23 10.29 ERCP & Stone removal Post-ERCP Pancreatitis PTGBD & PCD (x5) insertion L-tube insertion to prox. jejunum P. Aeruginosa + MRCNS → Meropenem + vancomycin P. Aeruginosa → Pip/taz 11.04 11.12 11/14 Successful insertion of drainage catheter( 10 Fr catheter) into right retroperitoneal space. PCD (x1) insertion ERCP & Double pigtail stent insertion P. Aeruginosa + IRAB → pip/taz + Tigecycline

시술 53일째 (2013.12.23) 2.1cm 12/23 Remained retroperitoneal abscess (about 7.6 x 4.5cm in size), commonicating with the 2nd portion of the duodenum.

시술 81일째 (2014.1.21) 1/21 Pancreas CT Aggravated abscess formation at right retroperitoneal space(9.5x6.8x4.0cm). - remained sinus tract(3cm), communicating with dudodenal 2nd portion. - widening of sinus tract(4.6cm), communicating with subcutaneous fat of right flank area.

PCD insertion (2014.1.22) Pancreas CT (2014.2.17) CT상 abscess가 커져서 PCD 삽입하였고 그 뒤 f/U CT상 abscess 줄어든 양상을 확인할 수 있었다

EGD (2014.1.15) EGD (2014.2.18) 1.15일 시행한 EGD : Proximal 2nd portion ( AOV 근위부 )로 small diverticulum like fistula가 관찰되며 이 부위로 dirty pus-like material이 배출되는 양상이 관찰됨. 2.18일 시행한 f/u EGD : 이전에 보이던 pus like discharge 는 보이지 않음. -> Duodenal fistula, healed

임상 경과 (2013.12~ 2014.2) 12.11 1.12 1.21 1.22 Fistula tract between abscess and duodenum & PCD insertion PCD remove CT : aggravation abscess PCD (x1) insertion 2.18 2.25 Duodenal fistula, healed Discharge

Final diagnosis #1. Asymptomatic CBD stone, removed state #2. Post-ERCP severe pancreatitis #3. Post-ERCP peritonitis c abscess formation