We report the case of a 68-year-old woman with a previous duodenal adenoma resection
who underwent esophagogastroduodenoscopy, during which endoscopic biopsy of a hypertrophied
minor duodenal papilla was performed with a standard biopsy forceps. The exam was
otherwise normal and she was discharged with no pain or discomfort.
Eight hours after the procedure, the patient developed intense abdominal pain, which
necessitated urgent admission 6 hours later. Laboratory tests showed that the patient’s
lipase level was 4106 U/L (normal range, 13 to 60 U/L) and her glucose level was 263 mg/dL,
with no other abnormalities. An abdominal computed tomography (CT) scan showed Balthazar’s
grade E pancreatitis with 70 % necrosis, associated with multifocal partial thrombosis
of the splenic vein.
Laboratory follow-up, done later the same day, showed a C-reactive protein level of
135 mg/L (normal range, < 5 mg/L), decreased ionized calcium concentration at 0.93 mmol/L
(normal range, 1.15 to 1,3 mmol/L) and hyperlactatemia at 20 mg/dL (normal range,
4 to 14 mg/dL), which got worse the same day. The patient developed multiorgan failure,
leading to admission to the Intensive Care Unit (ICU). Other etiologies of acute pancreatitis,
such as biliary stones, hypertriglyceridemia and alcohol consumption, were excluded.
Another CT scan 48 hours after the onset of the patient’s symptoms revealed worsening
of the pancreatic and peripancreatic collections as well as extensive splenic vein
thrombosis and multiple arterial vasospasms. Such a presentation is characteristic
of severe acute pancreatitis, according to Revised Atlanta Classification for Acute
Pancreatitis [1]. Multiorgan failure that persists for more than 48 hours is a predictor of high
and early mortality [2]. The patient had a Ranson’s score of 8, which corresponded with a 100 % risk of
mortality [3]. Unfortunately, despite appropriate care in the ICU, the patient died 4 days after
admission.
To our knowledge, this is the first case of fatal necrotizing acute pancreatitis following
a minor papilla biopsy. Two severe cases following biopsy of the minor papilla have
been reported in the literature [4]
[5], for which an almost identical clinical picture of abrupt onset only a few hours
after biopsy was described. Those patients were discharged from the hospital after
several weeks of care [4]
[5], in contrast to our patient who died. In both cases in the literature, the patients
presented with pancreas divisum. Such an anatomical variation was not identified in
our patent, although it was highly suspected.
Conclusions
In conclusion, even though complications due to endoscopic biopsies are relatively
rare, the dramatic developments encountered with our patient clearly underscore the
need to draw the attention of endoscopists to the possible risks associated with biopsies
of the papilla, especially if the minor papilla is targeted. Perhaps a pancreas divisum
should be excluded before performing minor papilla biopsies, or if the procedure is
judged to be mandatory, prophylaxis for pancreatitis, as is done prior to endoscopic
retrograde cholangiopancreatography – namely, hyperhydration or intrarectal administration
of nonsteroidal anti-inflammatory drugs administration – should be provided.
