A Case of Necrotising Pancreatitis Following Ampullary Biopsy

Abstract

Acute pancreatitis is a rare, but potential complication of ampullary biopsy. Most patients will recover without major complications. However, 20% of patients will develop a moderate or severe acute pancreatitis with local or systemic complications or organ failure. The patients who develop organ failure or infected necrosis face an increased mortality rate of 30%. To the best of authors knowledge this case represents one of four published articles that reports acute pancreatitis as a complication of ampullary manipulation.Figure 1Figure 2A 72 year old male with a past medical history of recurrent ampullary adenomas presented for a routine EGD and colonoscopy. Patient was discharged home and the ampullary biopsies showed no abnormalities. Later that day, the patient presented to the emergency department with acute epigastric pain that radiated to his back with nausea and vomiting. He was hemodynamically stable and afebrile on arrival. He was tender to palpation but exhibited no signs of peritonitis. Initial lab tests showed lipase >2250. Liver function tests, leukocyte count and lipid panel were all within normal limits. He does not drink, take any medications, or have any other risk factor that could potentially be a cause of his pancreatitis. Thus, he was diagnosed with acute pancreatitis secondary to EGD with ampullary biopsy. The patient's epigastric pain did not improve the first 4 days after conservative management with aggressive intravenous fluids and pain control. He started spiking fevers with no known source. A CT abdomen was done and it showed that the patient had developed necrotizing pancreatitis and was started on cefepime and metronidazole. His course was further complicated by non-cardiogenic pulmonary edema which improved after fluids were stopped and a trial of furosemide. He clinically improved and was discharged on day 8 to resume Ciprofloxacin and Metronidazole for a total 21 days.Figure 1Figure 2This case reflects one of four case reports of patients developing acute pancreatitis following ampullary biopsy, three of which also developed pancreatic necrosis. Physicians should be aware of acute pancreatitis as a rare but potential complication of endoscopy with ampullary biopsy. If patients do develop acute pancreatitis, it is essential to manage them with adequate fluid resuscitation and to remain vigilant for signs of necrotizing pancreatitis which has a very high mortality rate.