DOI: https://doi.org/10.36347/sjmcr.2026.v14i06.034

Pages: 1462-1465

Low Phospholipid-Associated Cholelithiasis (LPAC) syndrome is an underdiagnosed cause of biliary disorders, typically characterized by recurrent biliary symptoms despite cholecystectomy. Although LPAC classically presents with recurrent biliary pain, acute pancreatitis may represent an unusual revealing manifestation. We report a case of LPAC syndrome diagnosed following an episode of acute pancreatitis. A 45-year-old man with a history of biliary pancreatitis and cholecystectomy presented with epigastric pain and vomiting. Laboratory investigations revealed elevated serum lipase, marked hepatocellular cytolysis, and cholestasis. Contrast-enhanced CT demonstrated Balthazar grade C acute pancreatitis with segmental intrahepatic bile duct dilatation. Transabdominal ultrasound was unremarkable, and magnetic resonance cholangiopancreatography (MRCP) showed peripancreatic inflammation without bile duct dilatation. This imaging discordance prompted further evaluation with endoscopic ultrasound (EUS). EUS, performed after resolution of the acute inflammatory phase, identified multiple punctate hyperechoic intrahepatic foci distributed along the segmental bile ducts, associated with posterior acoustic shadowing and comet-tail artifacts, consistent with intrahepatic cholesterol microlithiasis. Alternative causes of intrahepatic hyperechoic foci were excluded based on imaging characteristics and clinical context. LPAC syndrome was diagnosed, and treatment with ursodeoxycholic acid was initiated. At 6-month follow-up, the patient remained asymptomatic, with normalization of liver biochemical parameters. This case underscores the importance of considering LPAC syndrome in patients with unexplained biliary symptoms or idiopathic pancreatitis after cholecystectomy and highlights the added diagnostic value of EUS when cross-sectional imaging is inconclusive.