A 55 year-old female was transported from Sanpete Valley Hospital to Utah Valley Medical Center with gallbladder disease, gallbladder sludge, and resolving pancreatitis. Patient was admitted 2 weeks ago with pain in the epigastric region and right upper quadrant. She stated that her pain actually began 2-3 days before admission to the hospital. At that time, the patient denied any nausea, vomiting, fever, and chills. When patient was admitted to the hospital 2 weeks ago her amylase with elevated to 411(normal amylase 23-300) and her lipase was elevated to 3988 (normal 23-300). They are both now resolved. As of this morning her amylase was 32 and lipase was 127. In addition, the patient reports a history of previous pancreatitis 3-4 years ago. She states she was in and out of the hospital multiple times over a couple of months period and was actually transferred to Utah Valley Regional Medical Center and evaluated. An ultrasound at that time was normal and there was no definite reason found for her pancreatitis, possible reasons included obstruction, medicines, and a pseudocyst. A MRI was done and showed no dilation of her pancreatic duct. Her pancreatitis resolved and she was not having any symptoms until this latest episode 2-1/2 weeks ago. Currently, she states that she has continued pain in the right upper quadrant and epigastric region despite a decrease in her pancreatic enzymes. She does not have any increase in pain or nausea with any certain foods or eating. She does not have a history of alcohol use. She was transported today to see a General Surgeon to have gallbladder removed.

What is Pancreatitis?

What is Gallbladder Sludge?

Past Medical History: Hypothyroidism, depression, rheumatoid arthritis, and insomnia.

Past Surgical History: Tonsillectomy and hysterectomy.

Diagnostic Imaging:
Ultrasound of the abdomen done April 8 shows gallbladder full of sludge. There is no wall thickening. The common bile duct has a normal diameter. There is some obscuration of the tail of the pancreas due to overlaying bowel gas. A CT abdomen and pelvis done April 3 shows a fairly marked amount of streaky increased density of the fat adjacent to the pancreas with indistinction of some of the margins of the pancreas consistent with pancreatitis. There is also presence of some small amount of fluid adjacent to the right side of the head of the pancreas and adjacent to the porta hepatis as well as some fluid extending inferiorly adjacent to the inferior aspect of the liver adjacent to the gallbladder and hepatic flexure of the colon.

Preoperative Diagnosis: Pancreatitis, cholecystitis.

Operative Report:

The patient was taken to the operating room where under general anesthesia her abdomen was prepped with Hibiclens and draped. An incision was made below the umbilicus at her previous scar. Dissection was carried down to the fascia. The peritoneal cavity was sharply entered. A blunt Hasson trocar was placed and secured with the 0 Vicryl sutures. A window was found in right upper quadrant. Three 5-mm ports were placed, 2 along the right lateral subcostal border, a third between the xiphoid and umbilicus just right of midline. The gallbladder was retracted superiorly to the right. Cystic duct was identified and isolated. A clip was placed across the cystic duct at its junction with the gallbladder. A small nick was made with scissors, a catheter was inserted and secured with a clamp. Fluoroscopy was used to obtain a cholangiogram. This did show a moderate length cystic duct. There was free flow into the duodenum. Proximal ducts were well seen. Catheter was removed. Cystic duct was clipped and divided. Cystic artery was dissected free along with several small branches clipped, and divided. Gallbladder was dissected free from the liver deb using cautery. Gallbladder was placed into an EndoCatch and removed through the umbilical port sit. Gallbladderwas opend. No gross stones were seen. There did appear to be some mild cholesterolosis. Patient was sutured and the umbilical port site using an Endoclose. Gallbladder fossa and right gutter were thoroughly irrigated and suctioned. Hemostasis was adequate. Instruments, ports and as much CO2as possible were removed. The umbilical port sutures were secured. Subcutaneous tissues were closed by suture and steri-strips applied. The patient tolerated the procedure well and was taken to the recovery room in satisfactory condition.

Patient was admitted overnight for observation and released the next day with her pancreatitis resolved.