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Obstructive pancreatitis in Crohn’s disease
HPB 1999Volume I, Number 3, 127- 130
Obstructive pancreatitis in Crohn's disease G Viola and RCN Williamson Department of Gastrointestinal Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, UK
Discussion
Background Recent reports link Crohn's disease to both acute pancreatitis
Although the association between pancreatitis and Crohn's
and exocrine pancreatic insufficiency.
disease is generally unexplained, when dilatation of the main
Case outlines
pancreatic
Two cases of recurrent acute-on-chronic pancreatitis are presented in men with Crohn's disease (aged 39 and 50 years). Pancreatitis was related to obstruction of the main
duct
is
documented
longitudinal
pan-
creaticojejunostomy may prevent new episodes of acute inflammation (as in these two patients).
Keywords
pancreatic duct, caused in one case by a failed anastomosis
recurrent pancreatitis, pancreatic duct drainage, Crohn's dis-
after a previous operation for Crohn's disease and, in the
ease.
other, by direct duodenal involvement with Crohn's disease.
Results Surgical
treatment
comprising
longitudinal
pancreatico-
jejunostomy was successful in each patient.
Introduction Both acute pancreatitis and impaired pancreatic function have been reported in patients with Crohn's disease during recent years [1-3]. The cause of pancreatitis remains unknown in most of these cases. Crohn's disease might just be coincidental or, by distorting the anatomy, it could be the direct cause of pancreatitis. Endoscopic pancreatography is difficult in such patients. Two cases are presented of recurrent acute-on-chronic pancreatitis in patients with Crohn's disease, in whom investigation revealed a dilated pancreatic duct. In each patient, pancreatic drainage has interrupted the cycle of repeated attacks of pancreatitis.
Case reports Case 1 A 39-year-old man was referred with a combination of recurrent acute pancreatitis, duodenal peptic ulcer and ileal Croh n's disease which had occasioned four operations at other hosp itals over the last 13 years. Initially, he had received a vagotomy and pyloroplasty, and 1 year later h e underwent Billroth II antrectomy (for recurrent ulcer) ,
Correspondence to: Professor RCN Williamson, Deportment ofGastrointestinal Surgery, Imperial College School of MediCine, Hammersmith Hospital, Du Cone Rood, London WI 2 ONN, UK
plus jejunoileal resections for multiple Crohn's strictures. During this operation both the bile duct and the pancreatic duct were inadvertently transected and each duct was reimplanted into the duodenal stump. He developed a postoperative biliary fistula which hea led spontaneo usly, but recurrent attacks of acute pancreatitis led to a third laparotomy 17 months later. On this occas ion the pancreatic duct anastomosis was revised and an end-to-side cho ledochojejunostomy was performed. After 10 years a stricture of the choledochojejunostomy was treated by performing a cholecystenterostomy. Over the 5 years before referral to this Department, he had suffered several further attacks of abdominal pain and hyperamylasaemia, with one episode of trans ient pancreatic pse udocyst; five percutaneous coeliac blocks had been performed for chronic pain. There were no other obv ious risk factors for pancreatitis, such as alcoh ol consumption or gallstones. There was evidence of both endocrine and exocrine pancreatic insufficiency. CT scan showed sufficient dilatation of the main pancreatic duct for the operation of longitudinal pancreaticojejunostomy to be considered feasib le. At laparotomy, there were no signs of active intestinal
© 1999 Is is Medical Media Ltd.
127
G Viola and RCN Williamson
Crohn's disease, while the pancreas was small and indurated throughout, consistent with chronic pancreatitis. On-table ambigrade pancreatography showed a dilated main pancreatic duct, with tapering in the tail and a stricture in the h ead of the gland. The main pancreatic duct was opened for 9 cm, and a long side-to-side pancreaticojejunostomy was performed to a retrocolic Roux loop. Recovery was uneventful, and the patient had no further attacks of acute pancreatitis for the next 5 years. He then developed a Crohn's stricture of the transverse colon, which was resected in another unit but he died from the consequences of anastomotic leak.
ease 2 A 50-year-old man was referred with recurrent attacks of acute pancreatitis. Crohn's disease of both the duodenum and the ileum had been diagnosed 19 years earlier, and he h ad received a gastroenterostomy to bypass the duodenum and then two limited ileal resections. Repeat attacks of acute pancreatitis over the past 8 years had led to five hospital admissions. The last attack was the most severe, necessitating a 2-week hospital stay. No risk factors for pancreatitis were identified; mesalazine therapy for Crohn's disease did not co incide with the ep isodes of acute pancreatitis. Pancreatic imaging with MRCP and CT scan (Figure 1) showed dilatation of the main pancreatic duct and punctate calcification. ERCP was attempted, but failed because of tight duodenal stenos is, which was confirmed by barium meal. At operation there were multiple adhesions. The pancreas was eventually exposed and showed evidence of chronic inflammation, but the diseased duodenum was only partly seen. The remaining jejunum and ileum were macroscopically normal. Amb igrade on-table pancreatography showed a dilated and irregular main pancreatic duct (Figure 2), which was opened for a length of 10 cm to allow side-to-side pancreaticojejunostomy Rouxen- Y. Although ostensibly healthy, the gallbladder was removed in case of microlithiasis. On-table cholangiography sh owed a stricture of the distal bile duct, so the bile duct was transected and anastomosed to the efferent loop of the gastrojej unostomy. Recovery from this operation was uneventfu l, and there have been no further
Figure I. CT scans in Case 2. (I a) Unenhanced scan showing a focus of pancreatic calcification (arrow) and dilatation of the pancreatic duct in the head of the gland (double arrows). (I b) The contrastenhanced scan shows that the dilatation also affects the duct in the neck and body of pancreas (arrow).
attacks of acute pancreatitis in the succeed ing 18 months.
Discussion The incidence of acute pancreatitis in patients with Crohn's disease 0.4-3.5 %) is higher than it is in the general
128
Figure 2. On-table pancreatogram in Case 2. The X-rays have been obtained by insertion of a needle into the pancreatic duct in the neck of the gland, so that contrast can flow both ways ('ambigrade' technique). There is diffuse ectasia of the pancreatic ductal tree, with little flow of contrast to the duodenum.
Obstructive pancreatitis in Crohns disease population [1,2] (7.4 cases per 100000 inhabitants per year). Asymptomatic increments of serum amylase or lipase levels have been reported in 15 % of patients affected by Crohn's disease [1] . The obscure pathogenesis of acute pancreatitis in these patients raises the possibility that it is an extra-intestinal manifestation of Crohn's disease. Although there is little evidence of pancreatic granulomas [4], intestinal Crohn's disease is associated with reduced pancreatic exocrine function (in up to 66% of cases) and the presence of pancreatic auto-antibodies (31 %) [3]. Several drugs used to treat Crohn's disease have been linked with acute pancreatitis, including azathioprine [5], sulphasalazine [6] and mesalazine [7]. Moreover, gallstones have been observed in 13- 34% of patients with Crohn's ile itis or ileal resection [8]. Thirdly, pancreatic duct stenosis, associated with sclerosing cholangitis, occurs in up to 30% of patients with Crohn's disease [9] . Both patients reported here had obstruction of the main pancreatic duct, one due to an astomotic failure following an unconventional operation (pancreatoduodenostomy) and one due to direct duodenal involvement by Crohn's disease. Duoden al pathology is common in Crohn's disease. Although clinical evidence of Crohn's duodenitis occurs in only 4% of patients [10], systematic endoscopic studies show a duodenal lesion in up to 34% of cases, rising to 53 % on biopsy [11]. Peptic ulcers are most frequently found, while granulomas are detected in 8% of patients [11].
It appears that Crohn's disease of the duodenum can be a direct cause of acute pancreatitis, as illustrated by our second case. In 1993 Eisner and colleagues [12] collected nine reported cases of acute (relapsing) pancreatitis in duodenal Crohn's disease and three subsequent cases have been described [13-15]. Inflammation of the papilla could allow reflux of duodenal contents into the main pancreatic duct, causing activation of pancreatic enzymes, and there is radiological evidence to this effect [16,17]. Stricture of the terminal pancreatic duct could also cause pancreatitis, whatever its cause [12,18,19]. In support, extrahepatic biliary obstruction has been reported in seven patients with pancreatitis and duodenal Crohn's disease [18], Case 2 representing an eighth such patient. For the treatment of pancreatitis in Crohn's disease, any surgical or endoscopic approach to the papilla will be difficult in patients with florid Crohn's duodenitis. O perative pancreatography may be valuable in such patients, especially the 'ambigrade' ductograms that can
be obtained by direct needling of the duct in the neck or proximal body of pancreas [20]. Our limited experience suggests that when chronic pancreatitis is associated with dilatation of the main pancreatic duct, longitudinal pancreaticojejunostomy may prevent repeated episodes of acute inflammation.
References Tromm A, Huppe 0, Micklefield GH et al. Acute pancreatitis complicating Crohn's disease: mere coincidence or causality?
Gut 1992;33:1289-9 1. 2 Weber P, Se ibold F, Jenss H. Acute pancreatitis in Crohn's disease. ] Clin Gastroenterol 1993;17:286-9 1. 3 Seibold F, Scheurlen M, Muller A et al. Impa ired pancreatic function in patients with Crohn's disease with and without pancreatic autoantibodies. ] Clin GastroenteroI1996;22:202-6. 4 Gschwantler M, Kogelbauer G, Klose W et al. The pancreas as a site of granulomatous inflammation in Crohn's disease. Gastroenterology 1995; 108: 1246-9 . 5 Echarri A, Borda F, Jimenez FJ et al. Acute pancreatitis caused by azathioprine in patient with Crohn disease. Rev Esp Enferm Dig 1996;88:645-6 . 6 Debongnie JC, Dekoninck X. Sulfasalazine, 5-ASA and acute pancreatitis in Crohn's disease. ] Clin Gastroenterol 1994; 19: 348-9. 7 McLeod RS, Wolff BG, Steinhart AH et al. Prophylactic mesalazine treatment decreases pos toperative recurrence of Crohn's disease. Gastroenterology 1995;109:404-13. 8 Williams SM, H arned RK. Hepatobiliary complications of inflammatory bowel disease. Radial Clin North Am 1987;25: 175-88. 9 Danzi JT. Extraintestinal manifestations of idiopa thic inflammatory bowel disease. Arch Intern Med 1988;148:297302. 10 Poggioli G, Stocchi L, Laureti S et al. Duodenal involvement of Crohn's disease: three different clinicopathologic patterns. Dis Colon Rectum 1997;40:179-83 . 11 Schmitz-Moormann P, Malchow H , Pittner PM. Endoscopic and bioptic study of the upper gastrointestinal tract in Crohn's disease patients. Pathol Res Pract 1985; 179:3 77-87. 12 Eisner TO, Goldman IS, McKinley MJ. Crohn's disease and pancreatitis. Am] Gastroenterol 1993;88:583-6. 13 G omez CA, Leon CT, Pajares JM, Mate JJ. Crohn's disease of the duodenum complicated by sclerosing cholangitis and pancreatitis. Rev Esp Enferm Dig 1996;88:497- 504. 14 Evans JS, George DE, Barwick KW, Lafer OJ. Crohn's disease presenting as chronic pancreatitis with biliary tract obstruction. ] Pediatr Gastroenterol Nutr 1996;22:384-8. 15 Panizo AJ, Duran AA, Gomez RM , Garcia AJ. Acute pancreatitis and malabsorption with tetany second ary to Crohn's disease with duodenal involvement. Rev Esp Enferm Dig 1997; 89:225-7. 16 Legge DA, H offman HN , Carlson He. Pancreatitis as a
129
G Viola and RCN Williamson complication of regional enteritis of the duodenum. Gas troenterology 1971 ;61: 83 4- 7. 17 Meltze r SJ, Korelitz BI. Pancreatitis and duodenopancreatic reflux in C rohn's disease . Case report and review of the literature. ] C lin Gastroenterol 1988; 10:555-8. 18 Spiess SE, Braun M, Vogelzang RL, Craig RM. Crohn's disease of the duodenum co mplicated by pancreatitis and common bile duct obs truction. Am ] Gas troenterol 1992; 87:1033-6 .
/30
19 Newman LH , Wellinger JR, Present DH, A ufses A H Jr. C rohn's disease of the duodenum assoc iated with pancreatitis: a case report and rev iew of the literature. Mt Sinai] Med 1987;54:429-32 . 20 Desa LA, Williamson RCN . O n-tab le pancreatography: importance in planning operati ve strategy. Br ] Surg 1990; 77:1145- 50.
Obstructive pancreatitis in Crohn's disease G Viola and RCN Williamson Department of Gastrointestinal Surgery, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, UK
Discussion
Background Recent reports link Crohn's disease to both acute pancreatitis
Although the association between pancreatitis and Crohn's
and exocrine pancreatic insufficiency.
disease is generally unexplained, when dilatation of the main
Case outlines
pancreatic
Two cases of recurrent acute-on-chronic pancreatitis are presented in men with Crohn's disease (aged 39 and 50 years). Pancreatitis was related to obstruction of the main
duct
is
documented
longitudinal
pan-
creaticojejunostomy may prevent new episodes of acute inflammation (as in these two patients).
Keywords
pancreatic duct, caused in one case by a failed anastomosis
recurrent pancreatitis, pancreatic duct drainage, Crohn's dis-
after a previous operation for Crohn's disease and, in the
ease.
other, by direct duodenal involvement with Crohn's disease.
Results Surgical
treatment
comprising
longitudinal
pancreatico-
jejunostomy was successful in each patient.
Introduction Both acute pancreatitis and impaired pancreatic function have been reported in patients with Crohn's disease during recent years [1-3]. The cause of pancreatitis remains unknown in most of these cases. Crohn's disease might just be coincidental or, by distorting the anatomy, it could be the direct cause of pancreatitis. Endoscopic pancreatography is difficult in such patients. Two cases are presented of recurrent acute-on-chronic pancreatitis in patients with Crohn's disease, in whom investigation revealed a dilated pancreatic duct. In each patient, pancreatic drainage has interrupted the cycle of repeated attacks of pancreatitis.
Case reports Case 1 A 39-year-old man was referred with a combination of recurrent acute pancreatitis, duodenal peptic ulcer and ileal Croh n's disease which had occasioned four operations at other hosp itals over the last 13 years. Initially, he had received a vagotomy and pyloroplasty, and 1 year later h e underwent Billroth II antrectomy (for recurrent ulcer) ,
Correspondence to: Professor RCN Williamson, Deportment ofGastrointestinal Surgery, Imperial College School of MediCine, Hammersmith Hospital, Du Cone Rood, London WI 2 ONN, UK
plus jejunoileal resections for multiple Crohn's strictures. During this operation both the bile duct and the pancreatic duct were inadvertently transected and each duct was reimplanted into the duodenal stump. He developed a postoperative biliary fistula which hea led spontaneo usly, but recurrent attacks of acute pancreatitis led to a third laparotomy 17 months later. On this occas ion the pancreatic duct anastomosis was revised and an end-to-side cho ledochojejunostomy was performed. After 10 years a stricture of the choledochojejunostomy was treated by performing a cholecystenterostomy. Over the 5 years before referral to this Department, he had suffered several further attacks of abdominal pain and hyperamylasaemia, with one episode of trans ient pancreatic pse udocyst; five percutaneous coeliac blocks had been performed for chronic pain. There were no other obv ious risk factors for pancreatitis, such as alcoh ol consumption or gallstones. There was evidence of both endocrine and exocrine pancreatic insufficiency. CT scan showed sufficient dilatation of the main pancreatic duct for the operation of longitudinal pancreaticojejunostomy to be considered feasib le. At laparotomy, there were no signs of active intestinal
© 1999 Is is Medical Media Ltd.
127
G Viola and RCN Williamson
Crohn's disease, while the pancreas was small and indurated throughout, consistent with chronic pancreatitis. On-table ambigrade pancreatography showed a dilated main pancreatic duct, with tapering in the tail and a stricture in the h ead of the gland. The main pancreatic duct was opened for 9 cm, and a long side-to-side pancreaticojejunostomy was performed to a retrocolic Roux loop. Recovery was uneventful, and the patient had no further attacks of acute pancreatitis for the next 5 years. He then developed a Crohn's stricture of the transverse colon, which was resected in another unit but he died from the consequences of anastomotic leak.
ease 2 A 50-year-old man was referred with recurrent attacks of acute pancreatitis. Crohn's disease of both the duodenum and the ileum had been diagnosed 19 years earlier, and he h ad received a gastroenterostomy to bypass the duodenum and then two limited ileal resections. Repeat attacks of acute pancreatitis over the past 8 years had led to five hospital admissions. The last attack was the most severe, necessitating a 2-week hospital stay. No risk factors for pancreatitis were identified; mesalazine therapy for Crohn's disease did not co incide with the ep isodes of acute pancreatitis. Pancreatic imaging with MRCP and CT scan (Figure 1) showed dilatation of the main pancreatic duct and punctate calcification. ERCP was attempted, but failed because of tight duodenal stenos is, which was confirmed by barium meal. At operation there were multiple adhesions. The pancreas was eventually exposed and showed evidence of chronic inflammation, but the diseased duodenum was only partly seen. The remaining jejunum and ileum were macroscopically normal. Amb igrade on-table pancreatography showed a dilated and irregular main pancreatic duct (Figure 2), which was opened for a length of 10 cm to allow side-to-side pancreaticojejunostomy Rouxen- Y. Although ostensibly healthy, the gallbladder was removed in case of microlithiasis. On-table cholangiography sh owed a stricture of the distal bile duct, so the bile duct was transected and anastomosed to the efferent loop of the gastrojej unostomy. Recovery from this operation was uneventfu l, and there have been no further
Figure I. CT scans in Case 2. (I a) Unenhanced scan showing a focus of pancreatic calcification (arrow) and dilatation of the pancreatic duct in the head of the gland (double arrows). (I b) The contrastenhanced scan shows that the dilatation also affects the duct in the neck and body of pancreas (arrow).
attacks of acute pancreatitis in the succeed ing 18 months.
Discussion The incidence of acute pancreatitis in patients with Crohn's disease 0.4-3.5 %) is higher than it is in the general
128
Figure 2. On-table pancreatogram in Case 2. The X-rays have been obtained by insertion of a needle into the pancreatic duct in the neck of the gland, so that contrast can flow both ways ('ambigrade' technique). There is diffuse ectasia of the pancreatic ductal tree, with little flow of contrast to the duodenum.
Obstructive pancreatitis in Crohns disease population [1,2] (7.4 cases per 100000 inhabitants per year). Asymptomatic increments of serum amylase or lipase levels have been reported in 15 % of patients affected by Crohn's disease [1] . The obscure pathogenesis of acute pancreatitis in these patients raises the possibility that it is an extra-intestinal manifestation of Crohn's disease. Although there is little evidence of pancreatic granulomas [4], intestinal Crohn's disease is associated with reduced pancreatic exocrine function (in up to 66% of cases) and the presence of pancreatic auto-antibodies (31 %) [3]. Several drugs used to treat Crohn's disease have been linked with acute pancreatitis, including azathioprine [5], sulphasalazine [6] and mesalazine [7]. Moreover, gallstones have been observed in 13- 34% of patients with Crohn's ile itis or ileal resection [8]. Thirdly, pancreatic duct stenosis, associated with sclerosing cholangitis, occurs in up to 30% of patients with Crohn's disease [9] . Both patients reported here had obstruction of the main pancreatic duct, one due to an astomotic failure following an unconventional operation (pancreatoduodenostomy) and one due to direct duodenal involvement by Crohn's disease. Duoden al pathology is common in Crohn's disease. Although clinical evidence of Crohn's duodenitis occurs in only 4% of patients [10], systematic endoscopic studies show a duodenal lesion in up to 34% of cases, rising to 53 % on biopsy [11]. Peptic ulcers are most frequently found, while granulomas are detected in 8% of patients [11].
It appears that Crohn's disease of the duodenum can be a direct cause of acute pancreatitis, as illustrated by our second case. In 1993 Eisner and colleagues [12] collected nine reported cases of acute (relapsing) pancreatitis in duodenal Crohn's disease and three subsequent cases have been described [13-15]. Inflammation of the papilla could allow reflux of duodenal contents into the main pancreatic duct, causing activation of pancreatic enzymes, and there is radiological evidence to this effect [16,17]. Stricture of the terminal pancreatic duct could also cause pancreatitis, whatever its cause [12,18,19]. In support, extrahepatic biliary obstruction has been reported in seven patients with pancreatitis and duodenal Crohn's disease [18], Case 2 representing an eighth such patient. For the treatment of pancreatitis in Crohn's disease, any surgical or endoscopic approach to the papilla will be difficult in patients with florid Crohn's duodenitis. O perative pancreatography may be valuable in such patients, especially the 'ambigrade' ductograms that can
be obtained by direct needling of the duct in the neck or proximal body of pancreas [20]. Our limited experience suggests that when chronic pancreatitis is associated with dilatation of the main pancreatic duct, longitudinal pancreaticojejunostomy may prevent repeated episodes of acute inflammation.
References Tromm A, Huppe 0, Micklefield GH et al. Acute pancreatitis complicating Crohn's disease: mere coincidence or causality?
Gut 1992;33:1289-9 1. 2 Weber P, Se ibold F, Jenss H. Acute pancreatitis in Crohn's disease. ] Clin Gastroenterol 1993;17:286-9 1. 3 Seibold F, Scheurlen M, Muller A et al. Impa ired pancreatic function in patients with Crohn's disease with and without pancreatic autoantibodies. ] Clin GastroenteroI1996;22:202-6. 4 Gschwantler M, Kogelbauer G, Klose W et al. The pancreas as a site of granulomatous inflammation in Crohn's disease. Gastroenterology 1995; 108: 1246-9 . 5 Echarri A, Borda F, Jimenez FJ et al. Acute pancreatitis caused by azathioprine in patient with Crohn disease. Rev Esp Enferm Dig 1996;88:645-6 . 6 Debongnie JC, Dekoninck X. Sulfasalazine, 5-ASA and acute pancreatitis in Crohn's disease. ] Clin Gastroenterol 1994; 19: 348-9. 7 McLeod RS, Wolff BG, Steinhart AH et al. Prophylactic mesalazine treatment decreases pos toperative recurrence of Crohn's disease. Gastroenterology 1995;109:404-13. 8 Williams SM, H arned RK. Hepatobiliary complications of inflammatory bowel disease. Radial Clin North Am 1987;25: 175-88. 9 Danzi JT. Extraintestinal manifestations of idiopa thic inflammatory bowel disease. Arch Intern Med 1988;148:297302. 10 Poggioli G, Stocchi L, Laureti S et al. Duodenal involvement of Crohn's disease: three different clinicopathologic patterns. Dis Colon Rectum 1997;40:179-83 . 11 Schmitz-Moormann P, Malchow H , Pittner PM. Endoscopic and bioptic study of the upper gastrointestinal tract in Crohn's disease patients. Pathol Res Pract 1985; 179:3 77-87. 12 Eisner TO, Goldman IS, McKinley MJ. Crohn's disease and pancreatitis. Am] Gastroenterol 1993;88:583-6. 13 G omez CA, Leon CT, Pajares JM, Mate JJ. Crohn's disease of the duodenum complicated by sclerosing cholangitis and pancreatitis. Rev Esp Enferm Dig 1996;88:497- 504. 14 Evans JS, George DE, Barwick KW, Lafer OJ. Crohn's disease presenting as chronic pancreatitis with biliary tract obstruction. ] Pediatr Gastroenterol Nutr 1996;22:384-8. 15 Panizo AJ, Duran AA, Gomez RM , Garcia AJ. Acute pancreatitis and malabsorption with tetany second ary to Crohn's disease with duodenal involvement. Rev Esp Enferm Dig 1997; 89:225-7. 16 Legge DA, H offman HN , Carlson He. Pancreatitis as a
129
G Viola and RCN Williamson complication of regional enteritis of the duodenum. Gas troenterology 1971 ;61: 83 4- 7. 17 Meltze r SJ, Korelitz BI. Pancreatitis and duodenopancreatic reflux in C rohn's disease . Case report and review of the literature. ] C lin Gastroenterol 1988; 10:555-8. 18 Spiess SE, Braun M, Vogelzang RL, Craig RM. Crohn's disease of the duodenum co mplicated by pancreatitis and common bile duct obs truction. Am ] Gas troenterol 1992; 87:1033-6 .
/30
19 Newman LH , Wellinger JR, Present DH, A ufses A H Jr. C rohn's disease of the duodenum assoc iated with pancreatitis: a case report and rev iew of the literature. Mt Sinai] Med 1987;54:429-32 . 20 Desa LA, Williamson RCN . O n-tab le pancreatography: importance in planning operati ve strategy. Br ] Surg 1990; 77:1145- 50.