Acute Pancreatitis After Removal of Retained Pancreatic Duct Stent Placed for Post-ERCP Pancreatitis Prophylaxis: A Rare Complication

Abstract

Prophylactic pancreatic duct (PD) stent placement is now performed often in patients at high risk of developing post-ERCP pancreatitis (PEP). Removal of retained PD stents 5 to 7 days after initial ERCP is considered low risk for endoscopic complications. We herein describe a case of acute pancreatitis (AP) occurring after EGD with PD stent removal. A 67 year old female presented with history of right-sided abdominal discomfort and pruritus. Physical exam showed jaundice and RUQ tenderness without rebound. Laboratory data revealed ALT 104 U/L, AST 81 U/L, Alkp 267 U/L, Tbil 9.1 mg/dL, Dbil 6.2 mg/dL, albumin 3.2 g/dL, INR 1.5, normal CBC. Ultrasound showed cholelithiasis and dilated CBD of 7 mm. A soft tissue mass in the gallbladder and a 6.8 cm vascular right hepatic lobe lesion were detected. CT revealed a heterogeneous mass around the gallbladder fossa with extensive porta hepatis confluent lymphadenopathy, resulting in moderate intrahepatic biliary ductal dilatation and mass effect upon the main portal vein. A percutaneous biopsy of the gallbladder mass was performed and IHC stains were consistent with a neuroendocrine tumor. Initial ERCP for biliary drainage resulted in failed CBD cannulation. Repeat ERCP demonstrated technical difficulty in accessing CBD. Placement of a straight 5 Fr x 3 cm plastic PD stent with internal flange prior to precut sphincterotomy was employed. As CBD cannulation was again unsuccessful, EUS-guided rendezvous ERCP with hepatogastric biliary access was performed. A single SEMS was placed across two focal CBD strictures. Biliary decompression was successful. EGD with PD stent removal was performed at day 7 after ERCP for retained PD stent. Within 24 hours of EGD, the patient developed moderate epigastric abdominal pain, nausea, and vomiting. Serum lipase was 308 U/L and a CT abdomen demonstrated peri-pancreatic inflammatory stranding involving the body, neck, and head of pancreas. The patient was admitted to the hospital for 2 days. Conclusions: 1) Acute pancreatitis after endoscopic removal of retained PD stent placed during ERCP for PEP prophylaxis is uncommon; 2) AP in this setting may be related to plastic stents with internal flange; 3) Endoscopists should be aware of this complication as part of the informed consent process.