Hindawi Publishing Corporation Case Reports in Surgery Volume 2013, Article ID 263046, 3 pages http://dx.doi.org/10.1155/2013/263046 Case Report A Case of Concomitant Perforated Acute Cholecystitis and Pancreatitis Marlon Perera, Toan Pham, Sumeet Toshniwal, Yasmin Lennie, Steven Chan, and Nezor Houli Department of Surgery, Western Health, Footscray, Melbourne, VIC 3012, Australia Correspondence should be addressed to Marlon Perera; marlonlperera@gmail.com Received 29 May 2013; Accepted 2 July 2013 Academic Editors: N. A. Chowdri, R. Hasan, M. L. Quek, and Y. Rino Copyright © 2013 Marlon Perera et al. Tis is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Concomitant cholecystitis and gallstone pancreatitis is an infrequent clinical encounter, reported sparsely in the literature. Concurrent acute cholecystitis and pancreatitis complicated by gall bladder perforation has not been reported before. Presentation of Case. We report a 39-year-old female presenting with concomitant cholecystitis and acute pancreatitis, complicated by gallbladder perforation. Discussion. Tere is much controversy surrounding the timing of cholecystectomy following gallstone pancreatitis, with the recent literature suggesting that “early” operation is safe. In the current case, gallbladder perforation altered the “routine” management of gallstone pancreatitis and posed as a management dilemma. Conclusion. Clinical judgement dictated timing of operative management and ultimately cholecystectomy was performed safely. 1. Case Report A 39-year-old female, previously well, was admitted with a diagnosis of acute pancreatitis with concurrent acute calculus cholecystitis. Te patient presented with a one-day history of acute onset sharp pain in the epigastrium, associated with nausea and vomiting. She was exquisitely tender in the epigas- trium and right upper quadrant, with no peritoneal signs on examination. Laboratory investigations showed a white cell count of 14.2 × 10 6 /L, with 81% neutrophils, 28 U/L biliru- bin, 237 U/L ALT, 192 U/L AST, 145 U/L ALP 171 U/L GGT, lipase 1445 U/L, and LDH 630 U/L, and serum glucose was 7.9mmoL/L. Te patient was classed as grade 1 pancreatitis using Ranson’s criteria [1]. Biliary ultrasound on admission showed acute cholecystitis, with gallbladder wall thickness of 5 mm and multiple calculi, the largest at 6 mm and no evi- dence of biliary tree dilation. Te patient was initially managed with empiric parental antibiotics; cefriaxone 1 g daily and metronidazole 500 mg 8 hourly. On day 2 of admission, liver function became increas- ingly deranged, with bilirubin increasing to 77 U/L. Te patient complained of acute exacerbation of pain and repeat sonography showed worsening cholecystitis with a high suspicion of a small gallbladder posterior wall perforation, associated with an increase of pericholecystic fuid collection (Figure 1). Computerized tomography (CT) of the abdomen and Pelvis showed large amounts of free fuid within the gallbladder fossa, confrming gallbladder perforation. Tere was marked fat stranding in the upper abdomen surrounding the pancreas and extensive free fuid in the perihepatic region and perisplenic region, upper abdomen, iliac fossae and Pouch of Douglas (Figure 2). Te patient underwent a semielective laparoscopic chole- cystectomy. Intraoperatively, the diagnosis of perforated necrotic cholecystitis was confrmed with 600 mls of bilious free fuid within the peritoneum (Figure 3). Intra-operative cholangiogram was otherwise unremarkable, though a prom- inent pancreatic duct was noted. Tere was no obvious com- mon bile duct obstruction. Te patient improved clinically over the postoperative period with rapid improvement in infammatory markers, enabling the patient to be discharged three days postoperatively. 2. Discussion Concomitant acute cholecystitis and gallstone pancreatitis is common clinical constellation that has been documented in the literature. However, to the authors’ knowledge, no such