Pancreatitis by Compression

Abstract

Diverticula are a rare cause of pancreatitis. We present a case of acute pancreatitis secondary to compression from a periampullary duodenal diverticulum (PAD). A 38-year-old male presented with acute epigastric abdominal pain. He denied other symptoms and had no history of alcohol intake, trauma, or taking any medications. He was afebrile and hemodynamically stable. On exam, his abdomen was tender to palpation in the epigastrium. His labs were notable for a WBC 11.5 k/mm3, lipase 5,410 IU/L, AST 87 IU/L, ALT 72 IU/L, ALP 126 IU/L, total bilirubin 0.5mg/dL, normal triglycerides and calcium levels. He was admitted with suspected biliary pancreatitis and medical management was initiated with intravenous fluids, bowel rest, and pain control. His liver enzymes subsequently increased to an AST 469 IU/L, ALT 503 IU/L and total bilirubin 1.4 mg/dL. An abdominal ultrasound done prior to admission for similar symptoms was negative for gallbladder stones or sludge. Computed Tomography Scan showed mild common bile duct and pancreatic duct dilatation with an edematous pancreatic head consistent with pancreatitis. An Endoscopic Retrograde Cholangiopancreatography showed a large diverticulum with food impaction obscuring the major duodenal papilla. Some food particles were removed from the diverticulum using a grasping snare and a Roth net. Due to remnant food debris, the ampulla could not be located to allow for cannulation within the large diverticulum. Magnetic Resonance Cholangiopancreatography revealed an enlarged pancreatic head with a large 3cm duodenal diverticulum compressing its inferior portion at the ampulla of Vater with no evidence of biliary stones. The patient's symptoms and laboratory abnormalities improved after ERCP, and he was discharged with surgical follow-up for possible intervention in event of recurrent pancreatitis attacks. Duodenal diverticula rarely cause pancreatitis, but should be kept in mind as a potential etiology. About 70-75% of duodenal diverticula occur in the periampullary region. Factors that contribute to the development of these diverticula include age, weakening of intestinal smooth muscles, and increased intraduodenal pressure. Mechanical pressure from the diverticulum and diverticular inflammation from narrowing at the duodenal papilla leads to complications of PAD. Surgical intervention is not indicated for asymptomatic patients. Patients who are symptomatic may necessitate surgical or endoscopic intervention, such as sphincterotomy. We present a rare case of acute pancreatitis caused by compression from a periampullary duodenal diverticulum.Figure 1Figure 2Figure 3