P1129 - An Unusual Case of Acute Pancreatitis Secondary to Duodenal Stenosis in a Patient with Crohn’s Colitis

Feenalie Patel, MD, Benjamin Bick, MD, MSCR
Indiana University School of Medicine, Indianapolis, IN

Introduction: We present an interesting case of a patient with small bowel Crohn’s disease who developed acute pancreatitis secondary to an inflammatory duodenal stricture involving the major papilla. This case highlights an unusual cause of acute pancreatitis in patients with Crohn’s disease.

Case Description/Methods: Patient is a 52-year-old male with a past medical history of Crohn’s disease with duodenal and distal small bowel involvement. He was referred for management of necrotizing pancreatitis after a second episode of acute idiopathic pancreatitis. His first episode of acute pancreatitis was originally thought to be from azathioprine, and this was discontinued with a plan to transition to infliximab. He developed acute pancreatitis a second time despite being off of azathioprine for 2 months. Labs revealed lipase 29,997 units/L (73–393 units/L), total bilirubin 0.7 mg/dL (0-1.0 mg/dL), alkaline phosphatase 102 units/L (25-125 units/L), alanine aminotransferase 101 units/L (7-52 units/L), aspartate aminotransferase 96 units/L (13-39 units/L), albumin 3.0 grams/dL (3.5-5.0 gram/dL), calcium 8.2 mg/dL (8.5-10.5 mg/dL), triglycerides 89 mg/dL (0-150 mg/dL), and Immunoglobulin G4 levels 11 mg/dL (4-86 mg/dL). Computed axial tomography of the abdomen and pelvis with contrast displayed acute necrotizing pancreatitis of the pancreatic body/tail. Magnetic resonance cholangiopancreatography revealed a duodenal stricture in the second portion of the duodenum traversing the pancreatobiliary drainage via the major papilla. An upper endoscopy showed duodenal stenosis with inflammation involving the papilla, and small bowel biopsies demonstrated ulcerated small intestinal mucosa with acute and chronic inflammation. The patient was treated with high-dose steroids, infliximab, and nasojejunal tube feeding for pancreatic rest. He was closely followed for signs of developing infected necrosis while on immunosuppression. Follow-up imaging demonstrated resolution of the duodenal stricture and improvement of pancreatic necrosis, with neither requiring further interventions. To date he has not had recurrent episodes of acute pancreatitis.

Discussion: In patients with Crohn’s disease, pancreatitis due to duodenal stenosis is rare. Hypotheses for the mechanism of pancreatitis include obstruction to pancreatic outflow through the ampulla of Vater. Treating Crohn’s duodenitis aggressively with immunosuppression is safe in patients with necrotizing pancreatitis and can help prevent recurrence of pancreatitis.


Figure: Figure 1: (A) Magnetic resonance cholangiopancreatography (MRCP) revealed a duodenal stricture of 34 mm (red asterisk) in the second portion of the duodenum traversing the pancreatobiliary drainage via the major papilla. (B) Upper endoscopy confirmed duodenal stenosis in the second part of the duodenum with involvement of the papilla (arrow). (C) Repeat MRCP three months later following treatment with high-dose steroids and infliximab demonstrates resolution of the duodenal structure.


Disclosures:
Feenalie Patel indicated no relevant financial relationships.
Benjamin Bick indicated no relevant financial relationships.


Feenalie Patel, MD, Benjamin Bick, MD, MSCR. P1129 - An Unusual Case of Acute Pancreatitis Secondary to Duodenal Stenosis in a Patient with Crohn’s Colitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.