Acute Pancreatitis as Initial Presentation of Crohn’s Disease: Report of a Rare Case

Abstract

Introduction: Acute pancreatitis related to Crohn’s disease (CD) has rarely been reported, but whether a causal association exist remains unclear. Forgut CD occurs in 0.5-4% of patients with ileocolonic CD. The pathogenesis of pancreatitis in CD seems to be multifactorial. We sought to describe a case of acute pancreatitis before the establishment of CD. Methods: A 19-year-old African American male with history of hypertension was admitted to our hospital for sharp epigastric abdominal pain of 10 days duration and 10 Ibs of weight loss. He presented 1 year previously with similar pain and was diagnosed with peptic ulcer disease, confirmed with an upper endoscopy. Omeprazole was prescribed, which he has been taking since then. He denied smoking, drinking alcohol, and using NSAID or recreational drugs. No drugs known to be involved in the causation of pancreatitis were taken by the patient. He was found to have lipase of 3,000 but normal liver chemistry, triglyceride, calcium, IgG4, and anti-neutrophilic antibody. Abdominal ultrasound ruled out gallstone or any biliary dilation, whereas abdominal CT revealed mild dilation of stomach, narrowing of second part of the duodenum, and changes consistent with acute pancreatitis, though no pseudocyst and mass were noted. Classical treatment strategies including food restriction, fluid, and electrolyte restoration were sought. Further investigation with an upper esophagogastroduodenoscopy was performed to determine the cause of the duodenal narrowing, which revealed moderate ulceration in duodenal bulb with mild post-bulbar stenosis. Biopsies showed fibrinopurulent exudate consistent with ulcer, with no evidence of Helicobacter pylori infection. Results: He responded to conservative therapy. Given his young age, concern regarding duodenal CD was raised. He subsequently underwent MR enterography, which showed a moderate degree of thickness and narrowing of terminal ileum. Colonoscopy was performed, which showed aphthous-like ulcers in the ileocecal valve, a moderate degree of erythema, and edema scattered throughout the colon. Histology was consistent with inflammatory infiltration of lamina propria and granulomas. Treatment with certolizumab pegol was initiated. He had total resolution of his abdominal pain and Harvey Bradshaw score of zero in 3-month clinic follow-up. Discussion: Patients with inflammatory bowel disease are prone to develop acute pancreatitis with numerous possible etiologies. In the present case, duodenal involvement was likely the predisposing factor. Search for etiological factors should focus attention on serious side effects of medical treatment, morphological abnormalities in the upper GI tract, gallstone, sclerosing cholangitis, and extra intestinal manifestation. Disclosure - Dr. Sarah Glover - Advisory Committee: Abbvie, Grant/Research Support: Biogen, Bristol Myers Squibb, Celgene, Elan, Janssen, Pfizer and UCB.