Acute suppurative pancreatic ductitis associated with pancreatic duct obstruction
28 May 2013 (online)
A 70-year-old man with abdominal pain and high fever was referred to our hospital because of suspected branch duct intraductal papillary mucinous neoplasm and pancreatolithiasis. Laboratory results showed a total bilirubin of 4.7 mg/dL, slight elevation in the serum pancreatic enzyme level and marked elevation in the serum C-reactive protein level and white blood cell count. Plain computed tomography (CT) showed mild swelling of the pancreas and a 10-mm calcified stone in the head of the pancreas ([Fig. 1]). Due to the presence of obstructive cholangitis and pancreatitis, endoscopic retrograde cholangiopancreatography was carried out for drainage. When a catheter was inserted in the papilla of Vater, there was discharge of a large amount of pus mixed with pancreatic juice ([Fig. 2]). The pancreatic juice was purulent ([Fig. 3], left tube), but the drained bile was not ([Fig. 3], right tube). Klebsiella oxytoca was isolated from the pancreatic juice. Following nasobiliary drainage and medical treatment with antibiotics and gabexate mesilate, the patient recovered quickly with no fever and the abdominal pain. The final diagnosis was acute suppurative pancreatic ductitis (ASPD).
Weinman  reported the first case of ASPD characterized by purulent discharge. Acute suppurative cholangitis due to biliary ductal obstruction is a common disease, but there have been only a few reported cases of ASPD  . Drainage of the pancreatic duct is quite effective for relief of ASPD. Therefore an endoscopist should keep in mind the possibility of ASPD in cases suspected of having suppurative cholangitis.
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