3021 Recurrent Obstructive Jaundice from Iatrogenic Pancreatic Duct Stricture

Abstract

INTRODUCTION: There is always an intrinsic risk of complications with ERCP. The most common early complication include pancreatitis, followed by infection, bleeding and perforation.1 Late complications include pancreatic ductal and parenchymal changes, stent migration and malfunction due to occlusion. Here we present a case of an elderly man with recurrent obstructive jaundice and underwent multiple ERCP. CASE DESCRIPTION/METHODS: An 81 years old man was admitted for two weeks history of dark brown urine, light brown colored stools and diffuse itching of the skin. His past medical history included HTN and HLD. He had admission for similar symptoms twice within last one year. On initial admission, he was noted to have obstructive jaundice picture with multiple gall stones, dilated intrahepatic ducts, CBD and pancreatic duct. He underwent ERCP with removal of multiple small gall stones and later underwent cholecystectomy with normal liver functions on follow up. He required sphincteroplasty on later admission. He denied fever, chills, abdominal pain, weight loss, nausea, vomiting, and changes bowel habits. He denied alcohol or any drug abuse. On physical examination, he was afebrile, and was found to have scleral icterus, yellowish discoloration of skin and excoriations in extremities. Laboratory investigation revealed worsening hepatic function with ALT 192, AST 140, ALP 779, GGT of 1098, total bilirubin of 11.3 and direct bilirubin of 8.1. Other blood test results were normal including WBCs, serum electrolytes, TSH, toxicology screen, kidney functions, viral hepatitis panel and coagulation profile. US abdomen showed dilated common bile duct to 18 mm, pancreatic duct and intrahepatic ducts. MRCP showed persistent chronic CBD dilated to 14 mm, pancreatic duct to 4 mm and marked intrahepatic biliary dilatation and a focal stricture was seen in proximal pancreatic duct. He underwent ERCP and was found to have ampullary stenosis. Sphincterotomy was performed. His signs and symptoms resolved on follow up visit. DISCUSSION: It is challenging to diagnose biliary strictures. Most pancreatic duct stricture are iatrogenic from operative trauma. Moreover, it is difficult to estimate the procedural complications as there is always an inherent bias and patient underreporting. However, ERCP is associated with fourfold increased rates of severe complications than other endoscopic procedures. To avoid these complications, the procedure should be performed by experienced provider and trend towards therapeutic approach as opposed to diagnostic approach.