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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 1  |  Issue : 2  |  Page : 66-68

Acute obstructive suppurative pancreatic ductitis secondary to intraductal stones


Department of Gastroenterology, M.S.Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India

Date of Submission31-Aug-2020
Date of Decision18-Sep-2020
Date of Acceptance30-Sep-2020
Date of Web Publication23-Mar-2021

Correspondence Address:
Avinash Bhat Balekuduru
Department of Gastroenterology, M. S. Ramaiah Hospitals, Bengaluru - 560 054, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ghep.ghep_19_20

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  Abstract 


Pancreatic sepsis secondary to infected necrosis or pancreatic abscess is a well-known clinical entity. Acute obstructive suppurative pancreatic ductitis (AOSPD) in the setting of chronic calcific pancreatitis is a rare complication that is seldom reported. We report two cases of AOSPD who underwent successful pancreatic endotherapy.

Keywords: Endoscopic retrograde pancreatography, infection, pancreas, pus, stent


How to cite this article:
Balekuduru AB, Sagar BS, Subbaraj SB. Acute obstructive suppurative pancreatic ductitis secondary to intraductal stones. Gastroenterol Hepatol Endosc Pract 2021;1:66-8

How to cite this URL:
Balekuduru AB, Sagar BS, Subbaraj SB. Acute obstructive suppurative pancreatic ductitis secondary to intraductal stones. Gastroenterol Hepatol Endosc Pract [serial online] 2021 [cited 2021 Apr 22];1:66-8. Available from: http://www.ghepjournal.com/text.asp?2021/1/2/66/311733




  Introduction Top


Chronic pancreatitis is characterized by chronic, progressive pancreatic inflammation and scarring, irreversibly damaging the pancreas and resulting in pain, and loss of exocrine and endocrine function.[1] Acute obstructive suppurative pancreatic ductitis (AOSPD) was defined as acute suppuration of the pancreatic duct without a concurrent pancreatic abscess or infected necrosis/pseudocyst.[2] The diagnosis is confirmed by the finding of pancreatic duct obstruction either due to stone or malignancy on endoscopic retrograde pancreatography (ERP) with evidence of pancreatic duct infection, such as a positive pancreatic juice culture or recognition of purulent pancreatic juice.[2] AOSPD can be effectively treated by either endoscopic or surgical drainage.[3]

In this report, we describe two cases of AOSPD who underwent successful endoscopic drainage. With our briefcase review, we emphasize the importance of early detection of AOSPD in chronic pancreatitis.


  Case Report Top


Case 1

A 48-year-old female, known case of chronic pancreatitis and Type 3c diabetes was referred for abdominal pain, fever, and leukocytosis (total count of 16,000 cells/mm3). She had a previous history in another hospital of a failed attempt at ERP for a stone in the head of the pancreas. ERP and pancreatic sphincterotomy were done. Pancreaticogram revealed an 8 mm dilated main pancreatic duct (MPD) with multiple filling defects. Balloon sweep retrieved pus and stones and two 5Fr 7 cm single pigtail stents were placed [Figure 1]. She became asymptomatic, and the stents were removed after 6 months.
Figure 1: (a) Pus from the ampulla (arrow); (b) balloon sweep retrieved stones and pus; (c) fluoroscopy images showing dilated main pancreatic duct, (d) balloon inflated and (e) double PD stent placement (arrow)

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Case 2

A 67-year-old man, known case of Type 2 diabetes mellitus for 15 years, presented with fever and multiple episodes of bilious vomiting of 2 days' duration. Physical examination and laboratory parameters were unremarkable except for tachycardia and leukocytosis (total count of 11,000 cells/mm3). Abdominal contrast-enhanced computed tomography showed intraductal stones with dilatation of the MPD and atrophic parenchyma [Figure 2]. There was no pancreatic mass, pseudocyst, or abscess. At ERP, the major papilla was normal but a stone was impacted in the minor papilla. Direct needle-knife sphincterotomy on the bulging minor papilla was performed followed by the release of the stone. Pus was seen flowing from the minor papilla but no culture was obtained. Balloon sweep of the MPD was done followed by placement of 5Fr, 7 cm single pigtail stent. The minor papilla was not cannulated [Figure 3] and [Figure 4]. He underwent endoscopic stent removal after 1 month. Magnetic resonance imaging was performed which revealed complete pancreas divisum [Figure 2].
Figure 2: (a and b) Contrast-enhanced computed tomography image before endoscopic retrograde pancreatography demonstrates a marked pancreatic ductal dilatation with intraductal calcifications (white arrow) and parenchymal atrophy; (c and d) magnetic resonance cholangiopancreatography image post endoscopic retrograde cholangiopancreatography demonstrated complete pancreas divisum

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Figure 3: (a) Impacted stone at minor papilla (arrow)-(cephalad and anterior) from normal major papilla with stone impaction; (b) precut sphincterotomy in cephalad direction (arrow); (c) pus from minor papilla; (d) main pancreatic duct stent placement

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Figure 4: (a) Fluoroscopy image showing deep main pancreatic duct cannulation from minor papilla; (b) Fluoroscopy image showing the placement of pancreatic duct stent

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AOSPD was diagnosed in both cases by purulent discharge at the time of endoscopic retrograde cholangiopancreatography without evidence of any infected necrotic tissue or a coexisting pancreatic abscess on imaging. Both the patients were advised to be on a low-fat diet and pancreatic lipase 25,000 U thrice a day. They responded to ciprofloxacin for 10 days and endoscopic drainage. Following stent removal, they were asymptomatic at 6 months follow-up.


  Discussion Top


AOSPD presentation and severity of the illness can vary significantly. Abdominal pain, systemic inflammatory response syndrome (SIRS), and septic shock have been reported.[3] Both our patients had SIRS features at the time of diagnosis.

The pathogenesis of AOSPD is not completely understood. Possible hypotheses include a hematogenous or enteric spread of the intestinal flora for AOSPD. Sphincterotomy (might allow enteric bacterial reflux into pancreatic duct), diabetes mellitus (impairment in neutrophil activation), ductal obstruction (stone, stricture, and malignancy), autoimmune pancreatitis, and chronic pancreatitis (impaired antibacterial activity/decreased quantity of pancreatic secretions) may contribute to the development of AOSPD.[3],[4] Chroinc pancreatitis with intraductal obstruction, diabetes mellitus in both the patients and prior sphincterotomy in the first case were predisposing factors.

AOSPD in chronic pancreatitis should be differentiated from acute on chronic pancreatitis. In AOSPD, inflammation is located in the pancreatic duct presenting with fever, elevated C-reactive peptide, and larger stone (7 mm) in the pancreatic head with greater MPD dilation (7 mm) requiring antibiotics and effective pancreatic drainage. In comparison, pancreatic parenchymal inflammation with higher amylase, pancreatic enlargement, and peripancreatic fat stranding on computed tomography and aggressive intravenous hydration are administered for acute on chronic pancreatitis. AOSPD is an uncommon counterpart in the pancreatic duct of more common acute suppurative biliary cholangitis.[4]

The first case was of AOSPD in chronic pancreatitis with failed ERP and the second case was in chronic pancreatitis due to pancreas divisum which were successfully treated with pancreatic sphincterotomy and stenting. The diagnosis of AOSPD is performed by the identification of pus at the pancreatic duct on ERP/surgery in the absence of evidence of other pathologies, such as infected pseudocyst, necrosis, or abscess.[4],[5] AOSPD should be considered in the differential diagnosis of acute on chronic pancreatitis as effective endotherapy is curative.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Conwell DL, Lee LS, Yadav D, Longnecker DS, Miller FH, Mortele KJ, et al. American pancreatic association practice guidelines in chronic pancreatitis: Evidence-based report on diagnostic guidelines. Pancreas 2014;43:1143-62.  Back to cited text no. 1
    
2.
Shimizuguchi R, Kikuyama M, Kamisawa T, Kuruma S, Chiba K. Acute obstructive suppurative pancreatic ductitis (AOSPD) in pancreatic cancer treated by nasopancreatic drainage. Clin J Gastroenterol 2018;11:315-9.  Back to cited text no. 2
    
3.
Inoue T, Ito K, Ishii N, Kobayashi Y, Yoneda M. Acute Obstructive suppurative pancreatic ductitis associated with type 1 autoimmune pancreatitis. Pancreas 2017;46:e24-5.  Back to cited text no. 3
    
4.
Kondo H, Naitoh I, Okumura F, Nakazawa T, Hayashi K, Miyabe K, et al. Clinical features of acute obstructive suppurative pancreatic ductitis: A retrospective review of 20 cases. J Gastroenterol Hepatol 2016;31:1366-73.  Back to cited text no. 4
    
5.
Wali E, Koo P, Packer CD. Acute obstructive suppurative pancreatic ductitis in an asymptomatic patient. Case Rep Med 2015;2015:1-4.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Case Report
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