A Rare Case of Acute Pancreatitis From an Ulcer at the Duodenal Papilla

Abstract

Background: Acute pancreatitis is a fairly common diagnosis accounting for significant amount of mortality and morbidity. Rarely peptic ulcer can cause acute pancreatitis if the ulcer bed is above the pancreas. However it is extremely rare to have acute pancreatitis with a peptic ulcer present in the diverticulum surrounding the duodenal papilla. Here we present a case of an elderly woman who presented with upper gastrointestinal bleeding and acute pancreatitis. Case Discussion: A 93-year-old female with a past medical history of peripheral vascular disease, cerebrovascular accident, atrial fibrillation not on anticoagulation, GERD presents with a few episodes of having bowel movements with bright red blood per rectum. Patient denied alcohol use. Physical examination was unremarkable. Hemoglobin was 9mg/dL which was her baseline, and all over value were with in normal limits. On the first night of her admission she developed severe abdominal pain and hematemesis. An emergent CT scan of the abdomen with contrast showed a hyperdense probable dilated duodenum with fluid and debris in the lumen. Amylase and Lipase were elevated to 1000 units/L and 1600 units/L respectively. White blood cell count and liver function panel were unchanged from admission. An esophagoduodenoscopy (EGD) done at that time showed a large adhering clot in the descending duodenum preventing further visualization. Due to the limited visualization on the earlier EGD, a repeat EGD was done on the following day, which showed two large diverticulum along medial wall of descending duodenum. Both of them showed signs of ulceration and visible vessels inside the diverticulum. One of the ulcer was encircling the duodenal papilla and on clear visualization the whole papilla seemed slightly edematous. The patients abdominal pain improved significantly by day 2 and the pancreatic enzymes started trending down. Other pertinent laboratory studies included a normal triglyceride level. Her condition gradually improved in the subsequent days and she was discharged to rehabilitation center. Discussion: Our case is unique in the way that pancreatitis was caused by the edema of the duodenal papilla and resulting obstruction of the pancreatic duct. This obstruction was so transient and non contributing once the duodenal ulcer is cleared up by endoscopy. Clinicians should be aware of these unusual causes of acute pancreatitis in those the regular etiologies don't fit and should aid in early reversal to change the impact of morbidity/mortality of acute pancreatitis.Figure 1