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An Unexpected Cause of Pancreatitis.

Department of Gastroenterology, Norfolk and Norwich University Hospital, Norwich, UK 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 Question: A 71-year-old retired farmer presented to the emergency department with a 1-week history of jaundice and epigastric pain. There was no nausea, vomiting, or diarrhea. He had no previous abdominal complaints or surgery. He was a nonsmoker, had minimal alcohol intake, and has never used intravenous drugs. He did not have any recent foreign travel or infectious contacts. On admission, the bilirubin was acutely elevated at 101 mmol/L (normal, 0-22) with a direct bilirubin of 80 mmol/L. He had an alkaline phosphatase of 322 U/L, alanine transaminase of 767 U/L, and an amylase of 758 U/L, with increased inflammatory markers (white cell count, 17.0 10 L; C-reactive protein, 42 mg/L). The initial clinical impression was gallstone pancreatitis. Computed tomography confirmed pancreatitis and a left portal vein thrombus (Figure A). The patient developed an acutely swollen and painful right arm in hospital. A Doppler ultrasound scan showed an incompressible thrombus in the right brachial and axillary vein. An ultrasound scan of the abdominal revealed multiple gallstones in the gallbladder with a normal caliber common bile duct. Magnetic resonance cholangiopancreatography confirmed gallstones with some mild thickening of the common bile duct, suggesting cholangitis (Figure B). Intravenous tazocin was started. Despite this, the patient deteriorated, with blood tests suggesting increasing cholestatic jaundice. An endoscopic retrograde cholangiopancreatography was performed. Endoscopic ultrasound examination was avoided owing to the evidence of a large duodenal diverticulum on magnetic resonance cholangiopancreatography (Figure C). On endoscopic retrograde cholangiopancreatography, an edematous ampulla was seen, with biopsies showing nonspecific inflammation. An 8.5-mm balloon trawl in the common bile duct did not show any stones or debris. A hepatologic opinion was sought after an initial acute pancreatitis screen did not elucidate a cause. A diagnostic test was performed. What diagnostic test was performed? What is the unifying diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.