Severe acute pancreatitis following endoscopic biopsy of the minor duodenal papilla.

month history of moderate right upper quadrant abdominal pain. Abdominal ultrasonography revealed multiple solid liver nodules. Computed tomography (CT) of the thorax, abdomen, and pelvis confirmed liver metastases with no obvious primary tumor. Serum biochemistry showed only a mild increase in g-glutamyl transpeptidase. Carcinoembryonic antigen and CA19 –9 were increased to 60 – 80 times the normal values. Esophagogastroduodenoscopy revealed Helicobacter pylori-positive erosive gastritis and duodenal mucosal hyperplasia after biopsy of a suspiciously enlarged duodenal papilla. At the same time colonoscopy found the primary tumor – a 20-mm ulcerated adenocarcinoma in the left colon. Four hours after the endoscopy procedures, the patient complained of abdominal pain. Serum amylases, lipases, and Creactive protein were increased to 20 –30 times the normal values. CT scan showed grade E severe acute pancreatitis (Balthazar score) (l" Figs. 1 and 2) [1]. The Ranson score was 6 at 48 hours after admission [2]. Magnetic resonance cholangiopancreatography diagnosed a complete pancreas divisum (l" Fig. 3). After 4 weeks of intensive care the patient resumed normal alimentation. At 6 weeks a CT scan showed a large pseudocyst at the level of the pancreatic body and tail (l" Fig. 4) and progression of liver metastasis. The patient was unresponsive to systemic chemotherapy. Two weeks later (8 weeks after the acute pancreatitis) the patient died from right atrial compression secondary to liver metastases. An asymptomatic rise in amylase concentration can be observed after 30 % of papilla biopsies [3]. A single case of mild pancreatitis was reported after papilla biopsy in a patient with Gardner’s syndrome [4]. Papillary edema due to biopsy may obstruct the pancreatic duct causing pancreatitis; this probably happens more Severe acute pancreatitis following endoscopic biopsy of the minor duodenal papilla