A 46-year-old previously fit lady was admitted with acute pancreatitis. She had no history of gallstones. She was not on any medications and consumed minimal amounts of alcohol. On subsequent investigations as to the causative factor, she was found at ultrasound to have an air-fluid filled cystic structure posterior to the head of pancreas which was compressing the common bile duct. Further magnetic resonance imaging and computer tomography scans showed that this cystic lesion was located around the ampulla of Vater. A diagnosis of a perivaterian abscess was made. At endoscopy, a large contained abscess was seen which was successfully drained. She made a full and uneventful recovery

Bertaud, S.

Dindyal, S.

Pastides, P.

Sarker, S. K.

English

PubMed

P. Pastides

S. Bertaud

S. K. Sarker

S. Dindyal

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Case Reports in Medicine

Acute Pancreatitis Secondary to a Perivaterian Duodenal Diverticular Abscess

A 46-year-old previously fit lady was admitted with acute pancreatitis. She had no history of gallstones. She was not on any medications and consumed minimal amounts of alcohol. On subsequent investigations as to the causative factor, she was found at ultrasound to have an air-fluid filled cystic structure posterior to the head of pancreas which was compressing the common bile duct. Further magnetic resonance imaging and computer tomography scans showed that this cystic lesion was located around the ampulla of Vater. A diagnosis of a perivaterian abscess was made. At endoscopy, a large contained abscess was seen which was successfully drained. She made a full and uneventful recovery.</jats:p

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Hindawi Publishing CorporationCase Reports in MedicineVolume 2010, Article ID 527141, 3 pagesdoi:10.1155/2010/527141Case ReportAcute Pancreatitis Secondary toa Perivaterian Duodenal Diverticular AbscessP. Pastides, S. Bertaud, S. K. Sarker, and S. DindyalDepartment of General Surgery, The Whittington Hospital NHS Trust, Magdala Avenue, London N19 5NF, UKCorrespondence should be addressed to P. Pastides, ppastides@hotmail.comReceived 22 August 2010; Accepted 16 November 2010Academic Editor: Indraneel BhattacharyyaCopyright © 2010 P. Pastides et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.A 46-year-old previously fit lady was admitted with acute pancreatitis. She had no history of gallstones. She was not on anymedications and consumed minimal amounts of alcohol. On subsequent investigations as to the causative factor, she was foundat ultrasound to have an air-fluid filled cystic structure posterior to the head of pancreas which was compressing the commonbile duct. Further magnetic resonance imaging and computer tomography scans showed that this cystic lesion was located aroundthe ampulla of Vater. A diagnosis of a perivaterian abscess was made. At endoscopy, a large contained abscess was seen which wassuccessfully drained. She made a full and uneventful recovery.1. IntroductionWe present a case of acute pancreatitis caused by a duodenaldiverticular abscess occluding her ampulla of Vater. This casereport is the first documented case in the literature of acutepancreatitis caused by a perivaterian duodenal diverticularabscess.2. Case PresentationA thirty-eight-year-old female presented to our emergencydepartment with one-day history of acute onset epigastricpain. It was constant and sharp in nature and associated withseveral episodes of vomiting. There was no history of fevers,rigors, dysuria, or change in bowel habit. She gave a two-week history of preceding mild abdominal pain, particularlyafter eating. She was previously fit and well with no historyof gallstones, took no regular medications, and had no signif-icant past medical history. She had no known drug allergiesand was on no regular medication. She was a nonsmoker andconsumed around four units of alcohol per week.On inspection, she looked unwell. She was apyrexial andtachycardic. On palpation of her abdomen, she had markedepigastric tenderness and guarding. Her blood tests revealeda raised white cell count (16.5), bilirubin (26), ALT (165),AST (222), LDH (494) and amylase level of 2245. She wasdiagnosed with acute pancreatitis, scoring 2 on the Glasgowseverity score.An abdominal ultrasound demonstrated a dilated com-mon bile duct (11 mm) with a distended gallbladder with nogallstones or other pathology (Figure 1).A MRCP performed the following day confirmed a12.4 mm dilated bile duct with dilation of the intrahepaticbiliary tract. In addition, it revealed a “curious” cysticlesion, with an air-fluid level, lying posterior to the headof the pancreas at the level of the distal common bile andpancreatic duct, which appeared to be causing some extrinsiccompression (Figure 2).She began to improve clinically and haematologically(reduced leukocytosis) with oral antibiotics. However herbilirubin continued to rise, peaking at 58. She underwent aCT scan of her abdomen on her fourth day of admission.This showed a cystic or necrotic mass behind the head of thepancreas, representing an inflammatory lesion, phlegmon, orduodenal diverticular abscess (Figure 3).An ERCP on her sixth day postadmission revealed a10 cm duodenal diverticular abscess draining pus and bile,at the level of the major papilla (Figure 4). It appeared thatthe cause of her pancreatitis was extrinsic compression of thebile duct due to a perivaterian duodenal diverticular abscess.2 Case Reports in MedicinePFigure 1: Abdominal ultrasound showing a dilated common bileduct (11 mm).Figure 2: MRCP slice showing an air-fluid filled cyst (arrowed)posterior to the head of the pancreas.3. DiscussionThis is the first documented report of a perivaterian divertic-ular abscess causing acute pancreatitis due to compression ofthe ampulla of Vater.Duodenal diverticula occurs with a frequency of between5% and 25% [1]. The large variance in these figures is dueto the fact that they tend to be asymptomatic and mostlydiagnosed if they cause complications or at autopsy. Theyare mostly located around the posterior border in the secondpart of the duodenum. Those located around the ampulla ofVater, as described in this patient, are known as perivateriandiverticular abscesses [2].Recognised complications of these types of diverticulaeinclude mechanical obstruction and perforation leading toperitonitis, requiring urgent surgical intervention. Ulcera-tion giving rise to upper gastrointestinal bleeding has alsobeen reported and could be fatal if the erosion involves theaorta or a mesenteric vessel [3, 4].Radiological diagnosis of these abscesses can be diﬃcult.Since the commonest site of formation is at the second partof the duodenum, a large fluid-filled cystic lesion could easilybe diagnosed as a neoplasm of the pancreas arising from thehead of the pancreas, which is the common site of pancreaticFigure 3: CT scan slice showing the air-fluid filled cyst.(a)(b)Figure 4: Images from the ERCP showing a duodenal ulcer whichwas draining pus and bile.neoplasm formation. Computer tomography and magneticresonance imaging scans are useful to distinguish betweenthese two widely varying diagnoses by demonstrating char-acteristic air-fluid levels within these lesions [5, 6]. Uppergastrointestinal endoscopy has been shown in various studiesto be a useful diagnostic tool; however, if the diverticula areCase Reports in Medicine 3located in the third or fourth part of the duodenum, then thesensitivity decreases [7].It has been shown that there is an association betweenperiampullary diverticula, which can lead to abscess for-mation, and biliary duct stones. However a large studyshowed that there is no association between periampullarydiverticula and pancreatitis [8]. Thus in a patient suﬀeringfrom pancreatitis with dilated bile ducts but no gallstones,the diagnosis of perivaterian abscess should be considered.Our presented patient was successfully treated withendoscopic drainage of this abscess and made a full uncom-plicated recovery. She was seen four months postoperativelyin clinic with no reported problems. She is now beingroutinely followed up at our local tertiary hepatobiliarycentre. Endoscopic relief for similar cases has been reportedsuccessfully in several other cases [8, 9] and is an alternativeto more invasive procedures, with the advantage of fasterrecovery times for patients.4. ConclusionThis is the first documented case of a perivaterian duodenalabscess causing compression of the common bile andpancreatic duct leading to pancreatitis. Duodenal diverticulaare more common than previously thought, but case reportsare scarce as the majority are silent and cause no significantclinical manifestations. Care must be taken to diagnose thecondition correctly by using appropriate imaging modalities.Successful endoscopic treatment is possible and should beattempted in appropriate patients.Conflict of InterestsNone of the authors involved in this submission state anyconflict of interests.References[1] J. E. Lane, M. Ajjan, and S. Sedghi, “GI bleeding from duodenaldiverticula,” American Journal of Gastroenterology, vol. 96, no.9, p. 2799, 2001.[2] R. B. Cattell and T. J. Mudge, “The surgical significance ofduodenal diverticula,” The New England Journal of Medicine,vol. 246, pp. 317–324, 1952.[3] D. N. Lobo, T. W. Balfour, S. Y. Iftikhar, and B. J. Rowlands,“Periampullary diverticula and pancreaticobiliary disease,”British Journal of Surgery, vol. 86, no. 5, pp. 588–597, 1999.[4] S. A. Afridi, C. J. Fichtenbaum, and H. Taubin, “Review ofduodenal diverticula,” American Journal of Gastroenterology,vol. 86, no. 8, pp. 935–938, 1991.[5] N. C. Balci, A. Akinci, E. Aku¨n, and H. U. Klo¨r, “Juxtapapillarydiverticulum: findings on CT and MRI,” Clinical Imaging, vol.27, no. 2, pp. 82–88, 2003.[6] N. C. Balci, T. Noone, E. Aku¨n, A. Akinci, and H. U. Klo¨r,“Juxtapapillary diverticulum: findings on MRI,” Journal ofMagnetic Resonance Imaging, vol. 17, no. 4, pp. 487–492, 2003.[7] W. Y. Yin, H. T. Chen, S. M. Huang, H. H. Lin, and T. M. Chang,“Clinical analysis and literature review of massive duodenaldiverticular bleeding,” World Journal of Surgery, vol. 25, no. 7,pp. 848–855, 2001.[8] T. C. K. Tham and M. Kelly, “Association of periampullaryduodenal diverticula with bile duct stones and with technicalsuccess of endoscopic retrograde cholangiopancreatography,”Endoscopy, vol. 36, no. 12, pp. 1050–1053, 2004.[9] T. Eapen and K. R. Reddy, “Cholangitis and pancreatitisdue to a juxtapapillary duodenal diverticulum, endoscopicsphincterectomy is the other alternative in selected cases,” TheAmerican Journal of Gastroenterology, vol. 77, pp. 303–330,1982.Submit your manuscripts athttp://www.hindawi.comStem CellsInternationalHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014MEDIATORSINFLAMMATIONofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Behavioural NeurologyEndocrinologyInternational Journal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Disease MarkersHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014BioMed Research InternationalOncologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Oxidative Medicine and Cellular LongevityHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014PPAR ResearchThe Scientific World JournalHindawi Publishing Corporation http://www.hindawi.com Volume 2014Immunology ResearchHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Journal ofObesityJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014 Computational and  Mathematical Methods in MedicineOphthalmologyJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Diabetes ResearchJournal ofHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Hindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Research and TreatmentAIDSHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Gastroenterology Research and PracticeHindawi Publishing Corporationhttp://www.hindawi.com Volume 2014Parkinson’s DiseaseEvidence-Based Complementary and Alternative MedicineVolume 2014Hindawi Publishing Corporationhttp://www.hindawi.com

A f r i d i ,C .J .F i c h t e n b a u m ,a n dH .T a u b i n ,“ R e v i e wo f duodenal diverticula,”

Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography,”

B a l c i ,A .A k i n c i ,E .A k¨

B a l c i ,T .N o o n e ,E .A k ¨ u n ,A .A k i n c i ,a n dH

C a t t e l la n dT .J .M u d g e ,“ T h es u r g i c a ls i g n i ﬁ c a n c eo f duodenal diverticula,” The New England

Cholangitis and pancreatitis due to a juxtapapillary duodenal diverticulum, endoscopic sphincterectomy is the other alternative in selected cases,”

GI bleeding from duodenal diverticula,”

L o b o ,T .W .B a l f o u r ,S .Y .I f t i k h a r ,a n dB .J .R o w l a n d s , “Periampullary diverticula and pancreaticobiliary disease,”

Y in,H.T .Chen,S.M.H uang,H.H.Lin,andT .M.Chang, “Clinical analysis and literature review of massive duodenal diverticular bleeding,”

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3014833

Acute Pancreatitis Secondary to a Perivaterian Duodenal Diverticular Abscess

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