A woman aged 57 was admitted with a 3-month history of moderate
right upper quadrant abdominal pain. Abdominal ultrasonography revealed
multiple solid liver nodules. Computed tomography (CT) of the thorax, abdomen,
and pelvis confirmed liver metastases with no obvious primary tumor. Serum
biochemistry showed only a mild increase in γ-glutamyl transpeptidase.
Carcinoembryonic antigen and CA19 – 9 were increased to
60 – 80 times the normal values. Esophagogastroduodenoscopy
revealed Helicobacter pylori-positive erosive
gastritis and duodenal mucosal hyperplasia after biopsy of a suspiciously
enlarged duodenal papilla. At the same time colonoscopy found the primary tumor
– a 20-mm ulcerated adenocarcinoma in the left colon.
Four hours after the endoscopy procedures, the patient complained of
abdominal pain. Serum amylases, lipases, and C-reactive protein were increased
to 20 – 30 times the normal values. CT scan showed grade E
severe acute pancreatitis (Balthazar score) ([Figs. 1] and [2])
[1]. The Ranson score was 6 at 48 hours after admission
[2]. Magnetic resonance cholangiopancreatography
diagnosed a complete pancreas divisum ([Fig. 3]).
After 4 weeks of intensive care the patient resumed normal
alimentation. At 6 weeks a CT scan showed a large pseudocyst at the level of
the pancreatic body and tail ([Fig. 4]) and
progression of liver metastasis. The patient was unresponsive to systemic
chemotherapy. Two weeks later (8 weeks after the acute pancreatitis) the
patient died from right atrial compression secondary to liver metastases.
Fig. 1 Contrast-enhanced
computed tomographic (CT) imaging revealed pancreatic necrosis of more than
50 % of the gland.
Fig. 2 Contrast-enhanced CT
imaging revealed diffuse peripancreatic and bilateral parietocolic fat
necrosis.
Fig. 3 Coronal magnetic
resonance cholangiopancreatography imaging revealed pancreas divisum: the
dorsal duct (arrowhead) draining independently into the first duodenum (minor
papilla), superior and anterior to the common bile duct (arrow).
Fig. 4 CT imaging at 6 weeks
shows a large pseudocyst measuring 13 × 8.5 cm at
the level of the pancreatic body and tail.
An asymptomatic rise in amylase concentration can be observed after
30 % of papilla biopsies [3]. A single case
of mild pancreatitis was reported after papilla biopsy in a patient with
Gardner’s syndrome [4]. Papillary edema due to
biopsy may obstruct the pancreatic duct causing pancreatitis; this probably
happens more easily in the minor papilla in complete pancreas divisum
[5]. As far as we know this is the first case of severe
acute pancreatitis after duodenal papilla biopsy.
Endoscopy_UCTN_Code_CPL_1AH_2AB
