Acute suppurative pancreatic ductitis associated with pancreatic duct obstruction

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).

Fig. 1 Abdominal plain computed tomography (CT) in a 70-year-old man with abdominal pain and high fever, showing a 10-mm calcified stone in the head of the pancreas.

Fig. 2 Endoscopic view showing discharge of a large amount of pus mixed with pancreatic juice after a catheter was inserted in the papilla of Vater.

Fig. 3 A cannula was inserted deep into the common bile duct and the pancreatic duct, and bile and pancreatic juice were aspirated, respectively. The pancreatic juice was purulent (left tube), but the bile was normal (right tube).

Weinman [1] 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 [2] [3]. 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.

Endoscopy_UCTN_Code_CCL_1AZ_2AM

• References

• 1 Weinman DS. Acute suppuration of the pancreatic duct. Gastrointest Endosc 1995; 41: 268-270
• 2 Tajima Y, Kuroki T, Susumu S et al. Acute suppuration of the pancreatic duct associated with pancreatic ductal obstruction due to pancreas carcinoma. Pancreas 2006; 33: 195-197
• 3 Fujimori N, Igarashi H, Ito T. Acute obstructive suppurative pancreatic ductitis. Clin Gastroenterol Hepatol 2011; 9: A28