1289 Transverse Colonic Stricture in a Patient With Recurrent Necrotizing Pancreatitis

Abstract

INTRODUCTION: An isolated colonic stricture is a rare sequela of recurrent pancreatitis, but may present a diagnostic challenge as it presents similarly to more common etiologies of isolated colonic stricture, such as inflammatory bowel disease (IBD) and malignancy. CASE DESCRIPTION/METHODS: A 48-year-old man with a history of alcohol–induced recurrent necrotizing pancreatitis requiring multiple debridements presented with a week of colicky right- sided abdominal pain and constipation. CT abdomen revealed markedly distended cecum and ascending colon, a 13-cm mid-transverse colonic stricture with marked associated stranding, and a 6-cm intra-pancreatic fluid collection. The isolated colonic stricture was thought to be due to either colonic ischemia secondary to his history of multiple episodes of severe necrotizing pancreatitis, or extrinsic compression by the pancreatic fluid collection on the transverse colon. Initial workup showed mildly elevated inflammatory markers and ascitic fluid cytology, which was negative for malignancy. On imaging, it was unclear if the stranding in the bowel was contiguous from the peri-pancreatic inflammation. See Figures 1 and 2. Colonoscopy was attempted but the colonoscope could not be passed beyond 50 cm due to marked tortuosity. The visualized portions of the mucosa appeared normal. The patient underwent a laparoscopic diverting loop ileostomy, during which narrowing of the mid-transverse colon was noted to be grossly consistent with cicatricial reaction to prior severe necrotizing pancreatitis, with adherence to the pancreatic head and neck. No neoplastic process was noted, and there was no necrotic tissue or abscess visualized. The strictured area was thought not to be amenable to resection given the frozen nature and presence of large peri-gastric and peri-colic varices and thus diverting loop ileostomy was performed along with adhesiolysis. DISCUSSION: Colonic stricture is a rare sequela of acute or chronic pancreatitis, which is thought to occur as a consequence of diffusion of ischemia and necrosis through the mesentery to the colon. Alternatively, it has also been suggested that pancreatitis may lead to colonic stricture by way of extrinsic compression on the colon by a pancreatic pseudocyst. Although rare, in the appropriate clinical context, clinicians may consider acute and chronic pancreatitis as possible etiologies of isolated colonic stricture along with more common etiologies.