Pancreatic Obstruction Research Articles

Surgical treatment of hereditary pancreatitis in four children in one and the same family

BACKGROUND: Hereditary pancreatitis is an autosomal dominant disease with high gene penetration (80%), manifested with signs of chronic and recurrent pancreatitis. This pathology is rarely met in children. In the world literature, the idea of surgical approach in treating hereditary pancreatitis is evidently supported because it helps to eliminate symptoms of pancreatic obstruction, to prevent complications and to slow down the process of pancreatic atrophy. CLINICAL CASE DESCRIPTION: The article describes a case of hereditary pancreatitis with an autosomal dominant type of inheritance, with a mutation in PRSS1 gene in children in one and the same family. Due to the longitudinal pancreatic jejunostomy, patients could have a good clinical remission. CONCLUSION: The discussed clinical case describes a successful surgical technique which has given good outcomes in treating hereditary pancreatitis in children.

S1597 A Rare Presentation of Lemmel’s Syndrome as Acute Cholangitis With Acute Pancreatitis

Introduction: Duodenal diverticula are most commonly found in the second part of the duodenum adjacent to the ampulla of Vater. Periampullary diverticula (PAD) are extraluminal pseudo-diverticula lacking a mucosal layer. Although typically asymptomatic, they can rarely cause pancreaticobiliary obstruction. Obstructive jaundice can develop secondary to PAD without choledocholithiasis, a rare phenomenon called Lemmel’s Syndrome. We report a rare case of Lemmel’s syndrome presenting not only with acute cholangitis but also with concurrent pancreatitis, successfully treated with ERCP. Case Description/Methods: An 83-year-old female presented with upper abdominal pain, nausea, diarrhea, and rigors. She is s/p cholecystectomy and labs revealed AST 688 U/L, ALT 305 U/L, Alkaline Phosphatase 201 U/L, total bilirubin 3.4 mg/dL, lipase 968 U/L, and lactate 2.9 mmol/L. An abdominal CT scan showed severe dilation of the common bile duct of 2.1 cm with edematous appearance of the pancreatic head, findings of acute pancreatitis, and a large duodenal diverticulum adjacent to the pancreatic head (Fig 1). Her hospital course was complicated by gram negative bacteremia, concerning for acute cholangitis. MRCP confirmed marked dilation of the common bile duct extending to the Ampulla of Vater with a large periampullary diverticulum, without choledocholithiasis or mass lesions (Fig 2). The patient underwent ERCP which revealed a large duodenal diverticulum compressing the distal bile duct, treated with biliary sphincterotomy and stent placement (Fig 3-4). She showed gradual clinical improvement with this endoscopic approach and was discharged home with subsequent follow up for stent removal performed 6 weeks later. Discussion: Although common among duodenal diverticula, PAD are rarely symptomatic. The underlying pathogenesis remains unclear but is believed to be related to mechanical obstruction, inflammation, and fibrosis. Lemmel’s syndrome can be mistaken for pseudocysts, necrotic collections, periampullary tumors, and pancreatic head neoplasms. Physicians should have a high index of suspicion for Lemmel’s syndrome in patients with large symptomatic PAD, which although commonly presents as biliary obstruction causing acute cholangitis, can rarely also cause pancreatic obstruction leading to pancreatitis, as seen in our patient. Timely diagnosis and endoscopic treatment of Lemmel’s syndrome can be effective in the treatment of acute cholangitis and pancreatitis.Figure 1.: CT scan showing CBD dilation with large periampullary diverticulum.Figure 2.: MRI showing dilated CBD and PD with distal large periampullary diverticulum.Figure 3.: Endoscopic view of large periampullary diverticula with intradiverticular papilla seen on ERCP.Figure 4.: Fluoroscopic view of dilated CBD as a result of Lemmel’s syndrome.

Recurrent acute pancreatitis during a ketogenic diet\u2014a case report and literature review

BackgroundThe ketogenic (“keto”) diet has been gaining more attention lately in the medical literature and the lay media as a potentially effective method for weight control and management of type 2 diabetes. Though rare, there have been case reports of serious side effects. Here, we present a peculiar case of pancreatitis presumably associated with the ketogenic diet.Case presentationA 35-year-old man on a calorie-restricted ketogenic diet presented to the emergency department with weekly abdominal pain on Monday mornings, each time after dietary indiscretions (“cheat days”) on the weekend. It was found that he had a clinical presentation consistent with acute pancreatitis with no associated alcohol use, hypertriglyceridemia, pancreatic obstruction, or other anatomic abnormalities. The patient’s symptoms resolved with conservative management and progressive reintroduction of a standard diet.ConclusionThis case indicates that the ketogenic diet could lower the threshold for acute pancreatitis, and that an episodic stressor may trigger an acute attack in the absence of traditional risk factors.

S1856 Single Session Endoscopic Ultrasound-Directed Transgastric ERCP (“EDGE”) in Roux-en-Y Gastric Bypass Patient With Pancreatic Mass and Biliary Obstruction With Intentional Maintenance of Gastrogastrostomy

S1856 Single Session Endoscopic Ultrasound-Directed Transgastric ERCP (“EDGE”) in Roux-en-Y Gastric Bypass Patient With Pancreatic Mass and Biliary Obstruction With Intentional Maintenance of Gastrogastrostomy

Is a Sphincterotomy Needed for Metal Biliary Stent Placement in Patients Without Pancreatic Obstruction

There is ongoing debate in the endoscopy community as to whether the placement of a metal biliary stent warrants a concomitant biliary sphincterotomy.

Endoscopic retrograde cholangiopancreatography in children with symptomatic pancreaticobiliary maljunction: A retrospective multicenter study.

Endoscopic retrograde cholangiopancreatography (ERCP) has been widely used in pediatric patients with cholangiopancreatic diseases. To evaluate the efficacy, safety, and long-term follow-up results of ERCP in symptomatic pancreaticobiliary maljunction (PBM). A multicenter, retrospective study was conducted on 75 pediatric patients who were diagnosed with PBM and underwent therapeutic ERCP at three endoscopy centers between January 2008 and March 2019. They were divided into four PBM groups based on the fluoroscopy in ERCP. Their clinical characteristics, specific ERCP procedures, adverse events, and long-term follow-up results were retrospectively reviewed. Totally, 112 ERCPs were performed on the 75 children with symptomatic PBM. Clinical manifestations included abdominal pain (62/75, 82.7%), vomiting (35/75, 46.7%), acholic stool (4/75, 5.3%), fever (3/75, 4.0%), acute pancreatitis (47/75, 62.7%), hyperbilirubinemia (13/75, 17.3%), and elevated liver enzymes (22/75, 29.3%). ERCP interventions included endoscopic sphincterotomy, endoscopic retrograde biliary or pancreatic drainage, stone extraction, etc. Procedure-related complications were observed in 12 patients and included post-ERCP pancreatitis (9/75, 12.0%), gastrointestinal bleeding (1/75, 1.3%), and infection (2/75, 2.7%). During a mean follow-up period of 46 mo (range: 2 to 134 mo), ERCP therapy alleviated the biliary obstruction and reduced the incidence of pancreatitis. The overall effective rate of ERCP therapy was 82.4%; seven patients (9.3%) were lost to follow-up, eight (11.8%) re-experienced pancreatitis, and eleven (16.2%) underwent radical surgery, known as prophylactic excision of the extrahepatic bile duct and hepaticojejunostomy. ERCP is a safe and effective treatment option to relieve biliary or pancreatic obstruction in symptomatic PBM, with the characteristics of minor trauma, fewer complications, and repeatability.

Endoscopic ultrasound-guided rendezvous in benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire.

Background and study aims The aim of this study was to assess the efficacy and safety of endoscopic ultrasound-guided rendezvous (EUS-RV) for benign biliary or pancreatic disorders with a 22-gauge needle and a 0.018-inch guidewire. Patients and methods Patients who underwent EUS-RV after failed biliary or pancreatic cannulation for benign disorder were candidates for this study. For EUS-RV, a 22-gauge needle and a 0.018-inch guidewire were used. Inclusion criteria were unsuccessful biliary or pancreatic cannulation for therapeutic endoscopic retrograde cholangiopancreatography (ERCP) with benign biliary or pancreatic obstruction. Exclusion criteria included malignant biliary or pancreatic obstruction, inaccessible papilla due to surgically altered upper gastrointestinal anatomy or duodenal stricture, and previous sphincterotomy and/or biliary stent placement. The primary outcome was the technical success rate of biliary or pancreatic cannulation, and the secondary outcome was the rate of adverse events. Results Thirty-one patients were evaluated. The overall technical success rate was 80.6 % (81.5 % in biliary and 75 % in pancreatic cases). Adverse events (AEs) were identified in 12.9 % of patients, including one with biliary peritonitis, one with abdominal pain and one with severe pancreatitis plus pneumomediastinum. Only one of the AEs (3.3 %) was directly related to the rendezvous procedure. Conclusions EUS-RV may be a safe and feasible salvage method for unsuccessful cannulation for benign disorders. Use of a 22-gauge needle with a 0.018-inch guidewire may be the first option for benign pathology.

Complications of Inpatient Endoscopic Retrograde Cholangiopancreatography in Pancreatic Cancer versus Biliary Obstruction

Complications of Inpatient Endoscopic Retrograde Cholangiopancreatography in Pancreatic Cancer versus Biliary Obstruction

Sa1274 EFFECT OF ENDOSCOPIC TRANSPAPILLARY METALLIC STENT PLACEMENT WITH/ WITHOUT ENDOSCOPIC SPHINCTEROTOMY ON POST-ERCP PANCREATITIS IN PATIENTS WITH MALIGNANT BILIARY OBSTRUCTION

Effect of endoscopic sphincterotomy (ES) prior to metallic stent (MS) placement in patients with distal malignant biliary obstruction (MBO) to prevent post-ERCP pancreatitis (PEP) remains to be fully elucidated, because the safety of non-adding ES for the cases without main pancreatic obstruction is unclear. To evaluate the efficacy and safety of non-adding ES prior to MS placement in patients with distal MBO, including those without MPD obstruction. Between January 2006 and August 2017, 285 patients with distal MBO were treated with MS placement in our tertial referral center, of which 74 were excluded because of a former history of ES, and/or prior MS placement. Finally, 211 patients were retrospectively enrolled in this study. Sixty-nine patients underwent ES just before MS placement (ES group), whereas 142 underwent MS placement without ES (non-ES group). We evaluated (1) the patients’ characteristics, (2) the incidence of PEP within 2 days after the procedure, (3) the incidence of bleeding, cholangitis, cholecystitis, and perforation within 30 days after the procedure, and (4) the effect of ES/ non-ES on the time to MS dysfunction. (1) Sex (man): ES, 40; non-ES, 83 (p = 0.947). Age (median): ES, 71 (range, 11–89); non-ES, 67 (range, 43–90) (p = 0.659). The etiology of MBO (bile duct cancer/ gall bladder cancer/ lymph node metastasis/ pancreatic cancer/ ampullary cancer): ES, 12/4/12/41/0; non-ES, 14/3/12/107/6 (p = 0.018). MPD obstruction: ES, 43; non-ES, 117 (p = 0.019). (2) PEP occurred in 11 patients in the ES group and in 20 in the non-ES group (p = 0.721). Among the patients without MPD obstruction (26 in the ES group and 25 in the non-ES group), PEP occurred in 10 patients in the ES group and in five in the non-ES group (p = 0.148). (3) Bleeding was significantly higher in the ES group (three patients) than in the non-ES group (zero patient, p = 0.034). Further, the incidence of cholangitis (four vs. five patients, p = 0.13), cholecystitis (four vs. four patients, p = 0.497), and perforation (zero patient in both) in the ES and non-ES groups, respectively, was not significantly different. (4) The median follow-up periods in the ES and non-ES groups were 191 (range, 14–999) and 204 (range, 12–1846) days, respectively. MS dysfunction was observed in 15 and 30 patients in the ES and non-ES groups, respectively (p = 0.919). The median time to MS dysfunction in the ES and non-ES groups was 145 (range, 6–465) and 114 (range, 2–759) days, respectively (p = 0.803). The study concluded that performing ES prior to MS placement for distal MBO does not reduce the incidence of PEP, but elevates the risks of bleeding related to ES. Hence, routine ES should be avoided prior to MS placement for distal MBO.

Pancreatic duct obstruction after pancreaticojejunostomy: implications for early prediction and prevention of long-term pancreatic complications

BackgroundPancreatic duct obstructions are common in patients with pancreaticoduodenectomy. However, it is often neglected in follow up. This study was to review the outcomes of pancreatic duct obstruction and explore the prevention of pancreatic duct obstruction.MethodsA retrospective analysis of 78 patients undergoing pancreaticojejunostomy without reccurence of disease within 24 months between 2004 and 2014. Pancreatic duct obstruction and long-term pancreatic complications were analysed.ResultsTwenty-five patients developed pancreatic duct obstruction following pancreaticojejunostomy, 13 of whom were found to have long-term pancreatic complications. The presence of pancreatic duct obstruction and early pancreatic obstruction were associated with long-term pancreatic complications, respectively (p = 0.002, p = 0.002). There are 10 patients with pancreatic duct stent more than 24 months, the postoperative median pancreatic parenchymal thickness in these 10 patients (17.1 mm, range 8.0 to 24.7 mm) was not significantly change than the median in them preoperative (16.4 mm, range 7.2 to 24.7 mm; p = 0.747). All of them have no long-term pancreatic complications, though the difference was not significantly (p = 0.068).ConclusionsEarly pancreatic duct obstruction is associated with postoperative pancreatic long-term complications. Sustained internal pancreatic stent may improve pancreatic duct obstruction.

Interventional radiofrequency ablation: A promising therapeutic modality in the management of malignant biliary and pancreatic duct obstruction.

Background: Malignant biliary and/or pancreatic obstruction has often encountered in the advanced stages of periampullary and cholangicarcinomas. HabibTM Radiofrequency (RF) ablation has been successfully used in the management of various cancers of liver and pancreas. Percutaneous HPB probe (EMcision Ltd, London, UK) is a new addition to this class of tools. It is an endoluminal Radiofrequency (RF) catheter which works on the principle of ablation and induces coagulative necrosis to recanalize the obstructed duct. The aim of this study is to address the technical details of canalization, feasibilities and outcomes of percutaneous endo-luminal Radiofrequency (RF) catheter in patients with unresectable malignancy with obstructed bile and pancreatic duct (PD).Material and Method: A total of 134 patients with inoperable malignant obstruction of biliary and PD underwent RF based percutaneous endoluminal RF ablation in a tertiary referral centre between December 15th, 2010 to August 7th, 2015. This device was used in a sequential manner with an intent to recanalize the obstructed. Following the initial catheter drainage of the duct, subsequent percutaneous endobiliary RF ablation, the metallic stent was placed to recanalize the obstructed bile and PD secondary to unresectable malignancy under real-time fluoroscopic guidance.Results: The percutaneous RF based ablation of obstructed bile duct and PD with metallic stent placement was successfully achieved in 130 (97.01%) cases. The three failures were noted in cases of biliary obstruction whilst, one with PD obstruction. The patency restored in 124 and patients, where the procedure was successfully completed and revealed clinical improvement reported.Conclusion: The percutaneous endoluminal RF based ablation of obstructed duct with metallic stent placement appeared to be a safe, effective procedure and may improve survival in patients with advanced stage cancer presenting with biliary and PD obstruction. Considering the above mentioned evidence, this modality may stand ahead of stenting alone. This could be considered as viable modality in management of such patients where very limited treatment options are available.

Rare Combinations of Late Complications of Acute Pancreatitis and Other Diseases

Acute pancreatitis is a severe surgical disease which can be accompanied by gastrointestinal bleeding and bleeding from pancreatic pseudocysts, bowel obstruction, and perforations of peptic ulcers. The cases in which the aforementioned pathological processes were the main cause of hospitalization and lesions of the pancreas (abscess, pseudocyst) were diagnosed during treatment as a background disease are noteworthy. Clinical development and treatment of the disease were analyzed in 5 patients with the following basic pathologies: perforations of peptic ulcers (2 patients), ulcerous bleeding (1 patient), adhesive bowel obstruction (1 patient), myelofibrosis, splenomegaly (1 patient). During treatment, all the patients developed symptoms of late complications of necrotizing pancreatitis in the form of pseudocysts and abscesses which were not diagnosed before hospitalization and were characterized by an asymptomatic course. Based on the anamnesis it was revealed that all the patients were previously treated in surgical department with the diagnosis of acute pancreatitis. The possibility of an uncontrolled asymptomatic development of late complications of acute pancreatitis which further manifest themselves as background pathology and aggravate the course of other diseases was emphasized.

Management of complicated duodenal diverticula

The duodenum is the second most common location of intestinal diverticula after the colon. Duodenal diverticulum (DD) is usually located in the second portion of the duodenum (D2), close to the papilla. Most duodenal diverticula are extraluminal and acquired rather than congenital; more rare is the congenital, intraluminal diverticulum. DD is usually asymptomatic and discovered incidentally, but can become symptomatic in 1% to 5% of cases when complicated by gastroduodenal, biliary and/or pancreatic obstruction, by perforation or by hemorrhage. Endoscopic treatment is the most common first-line treatment for biliopancreatic complications caused by juxtapapillary diverticula and also for bleeding. Conservative treatment of perforated DD based on fasting and broad-spectrum antibiotics may be offered in some selected cases when diagnosis is made early in stable patients, or in elderly patients with comorbidities who are poor operative candidates. Surgical treatment is currently reserved for failure of endoscopic or conservative treatment. The main postoperative complication of diverticulectomy is duodenal leak or fistula, which carries up to a 30% mortality rate.

Usefulness of a Guiding Sheath for Fluoroscopic Stent Placement in Patients with Malignant Gastroduodenal Obstruction

Self-expandable metallic stent placement is widely used to manage malignant gastroduodenal obstructions. However, there are difficulties in negotiating a guidewire (GW) and a stent delivery system (SDS). To investigate feasibility, usefulness, and safety of a guiding sheath for fluoroscopic stent placement in patients with malignant gastroduodenal obstructions. In July 2001 to August 2011, 726 patients with malignant gastroduodenal obstructions underwent stent placement. Guiding sheath was used in patients in whom a GW could not be passed through the obstruction and a SDS failed to reach the obstruction. Sheath usefulness was evaluated based on the ability of the sheath to successfully assist. The technical success rate and the most frequent reasons for the use of a sheath were evaluated. The guiding sheath was needed in 148 of 726 patients (20%). The overall technical success rate was 98% with the guiding sheath. In two of 148 patients, stent placement failed because, the GW could not be passed through the obstruction, in the other, the SDS could not be passed. A minority of patients reported mild discomfort. Patients with pancreatic cancer and duodenal obstruction were significantly more likely to require the use of guiding sheaths (P = 0.002, P < 0.001, respectively). Using a guiding sheath for fluoroscopic stent placement appears to be feasible, useful and safe in patients with malignant gastroduodenal obstructions.

Is endoscopic therapy the treatment of choice in all patients with chronic pancreatitis?

Chronic pancreatitis (CP) is a progressive inflammatory disease of the pancreas characterized by destruction of the pancreatic parenchyma with subsequent fibrosis that leads to pancreatic exocrine and endocrine insufficiency. Abdominal pain and local complications (bile duct or duodenal stenosis and pancreatic tumor) secondary to CP are indications for therapy. At the beginning, medical therapy is used. More invasive treatment is recommended for patients with pancreatic duct stones (PDS) and pancreatic obstruction in whom standard medical therapy is not sufficient. Recently, Clarke et al assessed the long-term effectiveness of endoscopic therapy (ET) in CP patients. The authors compared ET with medical treatment. They reported that ET was clinically successful in 50% of patients with symptomatic CP. In this commentary, current CP treatment, including indications for ET and surgery in CP patients, is discussed. Recommendations for endoscopic treatment of CP according to the European Society of Gastrointestinal Endoscopy Clinical Guidelines are reviewed. Different surgical methods used in the treatment of CP patients are also discussed. ET is the most useful in patients with large PDS, pancreatic duct obstruction and dilation. It should be the first-line option because it is less invasive than surgery. Surgery should be the first-line option in patients in whom ET has failed or in those with a pancreatic mass with suspicion of malignancy. ET is a very effective and less invasive procedure, but it cannot be recommended as the treatment of choice in all CP patients.

Wandering spleen with pancreatic volvulus and colonic obstruction in an elderly patient

Introduction: Wandering spleen is a rare condition, caused by elongation or maldevelopment of splenic ligaments resulting in splenic hypermobility. Very few cases, if any, have been documented in the elderly population. Herein, we report a case of wandering spleen with pancreatic volvulus and colonic obstruction in an 87-year-old female. Case Report: The patient presented with recurrent abdominal pain and distension. Imaging done at admission revealed a wandering spleen in the pelvis, with splenomegaly and enlarged splenic vein. An explorative laparotomy was performed, the spleen was found to be in the pelvis, there was a volvulus of the distal pancreas. The pancreas had adhesion bands across the distal tail and there was one particular band that was going across to the descending colon causing an internal hernia and colonic obstruction. A splenectomy with a distal pancreatectomy and subtotal colectomy was performed. Conclusion: Wondering spleen is most commonly seen in children and adults with a higher incidence in women especially in the childbearing age. The cause can be congenital or acquired. The most common presentation in patients with wandering spleen is abdominal pain with associated genito-urinary complaints. Due to the longstanding history of this patient, it is crucial to consider wandering spleen in differential diagnosis of patients with non-specific abdominal pain. It is very important to diagnose such cases early so as to prevent complications, especially in elderly population, where symptoms and signs may not point towards the condition.

Large duodenal hematoma associated with transcatheter arterial embolization following endoscopic hemostasis in a cirrhosis patient: Case report

To date, there has been no report on duodenal intramural hematoma following transcatheter arterial embolization in bleeding duodenal ulcer refractory to endoscopic hemostasis. We experienced a case of obstructive cholangitis and pancreatitis secondary to duodenal intramural hematoma associated with transcatheter arterial embolization, following endoscopic hemostatic procedures for a bleeding duodenal ulcer in a patient with cirrhosis. The patient was successfully treated with percutaneous transhepatic biliary drainage. We suggest that transcatheter arterial embolization can be a cause of duodenal intramural hematoma, and that percutaneous transhepatic biliary drainage, rather than surgical intervention, can be useful in the treatment of biliary or pancreatic obstruction secondary to duodenal intramural hematoma, especially in patients with bleeding diathesis.

Contrast enhanced ultrasonography in the diagnosis of IgG4-negative autoimmune pancreatitis: A case report.

Autoimmune pancreatitis (AIP) is a rare disorder frequently manifesting as a mass-like lesion that may lead to obstructive jaundice. We report here a case of pancreatic obstruction with painless jaundice, and elevation of CA 19-9 without elevation of serum IgG4. Contrast enhanced ultrasonography (CE US) revealed the possibility of AIP, and the final pathological findings confirmed the diagnosis.

DIRECT PERORAL CHOLANGIOSCOPY AND PANCREATOSCOPY FOR DIAGNOSIS OF A PANCREATOBILIARY FISTULA CAUSED BY AN INTRADUCTAL PAPILLARY MUCINOUS NEOPLASM OF THE PANCREAS: A CASE REPORT

Here, we report a case of a pancreatobiliary (PB) fistula caused by an intraductal papillary mucinous neoplasm (IPMN) of the pancreas. The PB fistula was suspected after endoscopic retrograde cholangiopancreatography (ERCP) and diagnosed after direct visualization with a direct peroral cholangioscopy and pancreatoscopy by using an ultra-slim endoscope. No previous reports exist on the precise diagnosis of a PB fistula with direct peroral cholangioscopy and pancreatoscopy. In our case report, a 69-year-old man underwent an ERCP because of a pancreatic head mass and biliary tract obstruction. During ERCP, a fistula between the common bile duct (CBD) and main pancreatic duct (MPD) was suspected. After endoscopic sphincterotomy, we examined both the CBD and MPD with an ultra-slim videoendoscope (GIF-N260; Olympus Optical Co, Tokyo, Japan) under direct visualization and biopsy of the mass. The analysis of the biopsy specimen confirmed this mass to be an IPMN of the pancreas. When we examined the CBD, one fistula with copious mucin secretion was identified at the distal CBD. In conclusion, direct peroral cholangioscopy and pancreatoscopy using the ultra-slim endoscope is an efficient tool for diagnosis of PB fistula and pancreatic IPMN.

Chronic Pancreatitis an Extraintestinal Manifestation of Crohnʼs: Fact or Fiction?

Purpose: 32 year old male with history of pancreatitis, presents with 2 days of severe epigastric pain. Patient denied weight loss, night sweats, or bloody diarrhea. Medical history is significant for 2 bouts of acute pancreatitis 4 years ago, takes no medications and drinks 2 beers a month. On exam vitals were stable with epigastric tenderness. Labs: amylase 662U/L (0-137U/L), lipase 1395U/L (12-70 U/L), total bilirubin 0.3mg/dL (0.1-1.5 mg/dL), AST 13 IU/L (7-40IU/L), ALT 10 IU/L (7-40 IU/L), calcium 9.5 mg/dL (8.5-10.5 mg/dL), triglyceride 44 mg/dL (35-150 mg/dL), IgG subclasses 1-4 normal and WBC 11 K/uL (4.5-11.5 K/uL). CT: mild peripancreatic inflammatory stranding extending throughout the pancreas. Ultrasound: normal gallbladder without cholelithiasis or ductal dilatation and unremarkable pancreas. Patient was treated with narcotics and IV fluids. Hospital day #3 patient had worsening abdominal pain and distention. Patient was treated with nasogastric tube, followed by colonoscopy for decompression. Colonoscopy: scattered erythema, blunting of vascular pattern, and ulcers extending from cecum to descending colon; biopsies taken. Pathology: chronic active colitis with non-caseating granuloma without dysplasia; consistent with Crohn's disease (CD). EUS showed features suggestive of mild chronic pancreatitis. We report a case of pancreatitis as the initial presentation of CD. Pancreatitis is one of several known extraintestinal manifestations of CD and UC. The incidence of pancreatitis as a true extraintestinal manifestation has been a difficult task to prove, as it is rare and many of the drugs used to treat IBD may also cause pancreatitis. Barthet et al found a 1.2% incidence chronic pancreatitis by following all IBD patients over a 15 yr period at a group of French hospitals. Seyrig et al. similarly reported a 1.5% incidence. The previously reported studies may easily be underestimating the incidence in IBD, considering they only evaluated symptomatic patients. It has been reported that some cases of pancreatic involvement may indeed be asymptomatic in IBD. Generally in the natural history of IBD most extraintestinal manifestation occur after the diagnosis, however, a literature review proves that pancreatitis may precede the diagnosis of IBD. The mechanism of pancreatic involvement in IBD is unknown. It has been suggested that inflammatory involvement of the duodenal papilla may cause pancreatic obstruction, thereby leading to pancreatitis. However Barthet et al, reported only 1 periampullary involvement. Others have reported on intrapancreatic granulomatous inflammation. It is important that more research be conducted to understand the mechanism of injury to the pancreas in IBD.