S3321 Strangulated Gallstones: A Novel Case of Gallstone-Induced Pancreatitis in a Hiatal Hernia

Introduction: Pancreatitis occurs in 600 out of 100,000 people. Most commonly due to gallstones and alcohol use, the incidence of pancreatitis is increasing, owing to more than 200,000 discharges yearly. Supportive care with fluids and analgesics is the mainstay, but in the case of gallstones, endoscopic retrograde cholangiopancreatography (ERCP) is indicated to evacuate retained stones. We present a case of pancreatitis with a unique anatomy that added to the challenge of management. Case Description/Methods: An 80-year-old woman with history of gastroesophageal reflux disease and diverticulitis presented to the hospital with sudden-onset epigastric abdominal pain. Vital signs were stable, hepatic function panel showed alanine aminotransferase (ALT) of 405, aspartate aminotransferase (AST) of 470, alkaline phosphatase (ALP) of 165, total bilirubin of 3.5, and lipase of 353 U/L. Computer tomography of the abdomen/pelvis was concerning for biliary ductal dilatation, gallbladder distension, and the majority of the pancreas within a large paraesophageal hernia. Magnetic Resonance Cholangiopancreatography was notable for cholelithiasis and choledocholithiasis without gallbladder wall thickening or main pancreatic duct dilatation. Patient underwent ERCP with ultrasound and was noted to have multiple common bile duct stones. Complete removal was accomplished with biliary sphincterotomy and balloon extraction. Patient successfully underwent cholecystectomy later during the same admission. Discussion: Patients with gallstone pancreatitis generally undergo ERCP to ensure evacuation of stones. However, this presentation in the setting of a herniated pancreas is rare. The unique anatomy does not favor the traditional travel of a biliary stone into the main pancreatic duct. Furthermore, in a patient with complex anatomy undergoing intervention, the risk of iatrogenic injury is increased. Paraesophageal hernias with visceral involvement are considered the rarest form of hiatal hernia, occurring in less than 5% of cases. Few reports exist of pancreatitis due to herniation and subsequent irritation to visceral tissue or blood supply. This case was challenging as the presentation could implicate gallstones as the etiology, but an anatomical cause is also possible and likely recurrent unless the hernia is repaired. This patient's presentation showcases a unique subset of patients that pose a diagnostic and management dilemma with very real consequences of morbidity, with risk for recurrence without intervention.