S1662 Unusual Etiology of Papillary Stenosis Resulting in Pancreatitis

Abstract

Introduction: Celiac Disease (CD) is known as chronic inflammation characteristically affecting the proximal small bowel. Although pancreatitis has been found to be related to CD, no specific etiology has been identified. Several cases have been reported describing CD resulting in papillary stenosis, but few have been due to duodenal scalloping causing obstruction and furthermore, stenosis. Case Description/Methods: A 74-year-old female with a past medical history of type 2 diabetes mellitus, hypertension, hyperlipidemia, stroke, celiac sprue, hypothyroidism and psoriatic arthritis presented to the emergency department (ED) with epigastric pain associated with nausea and abdominal distention. In the ED the patient was given morphine for pain control, ondansetron and a liter normal saline bolus. Patient was noted to have transaminitis with AST 480, ALT 255, elevated total bilirubin at 1.4 with a direct bilirubin of 0.7. Lipase was 54. CT abdomen showed diffuse diverticulosis without diverticulitis as well as questionable peripancreatic fat stranding. The patient underwent an MRCP which revealed no intra hepatic biliary dilatation, with mild extra hepatic biliary dilatation, and the common bile duct measuring 12 mm. No bile duct stones or biliary stricture was identified. She subsequently underwent an EGD which prompted an ERCP, with EGD revealing esophageal protruding lesions. On ERCP, scalloping was noted in the duodenum in close proximity to the ampulla, and a biopsy was consistent with celiac disease. She was suspected to have papillary obstruction and stenosis from duodenal scalloping. Of note, TTA was found to be high for CD at 27 indicating CD which was not well controlled. A stent was placed, and the patient was subsequently discharged a few days later after improvement of symptoms. Discussion: Pancreatico-biiliary diseases have been well documented in association with CD. Postulated mechanisms include reduced gallbladder emptying due to impaired cholecystokinin release, and pancreatitis due to malnutrition. It is likely that mucosal inflammation seen in CD involving the papilla and surrounding duodenal area is the likely contributing factor to predisposing these patients to pancreatitis. Several cases have been reported of specifically papillary stenosis secondary to CD inflammation, but few have been due to anatomical obstruction resulting from the disease. It is well known that patients with CD are at increased risk of developing acute and chronic pancreatitis, but most commonly idiopathic.