A Case of Acute Pancreatitis Following Endoscopic Biopsy of the Ampulla of Vater

Abstract

Ampullary tumors are diagnosed by endoscopic biopsy of the ampulla of Vater. We encountered a rare case of acute pancreatitis following endoscopic biopsy of the ampulla. A 53-year-old man referred to our hospital for detailed examination of a suspected tumor of the ampulla of Vater. We conducted endoscopic biopsy from the ampulla. He developed severe abdominal pain four hours after the procedure. The serum amylase and serum lipase were elevated and abdominal computed tomography (CT) revealed pancreatic enlargement and diffuse stranding of the peri-pancreatic fat, compatible with the findings of acute pancreatitis. We diagnosed the patient as having acute pancreatitis caused by endoscopic biopsy of the ampulla of Vater. Conservative therapy improved his condition, however, a large pancreatic walled-off necrosis (WON) developed. Therefore, we performed endoscopic ultrasonography (EUS)-guided cyst drainage on the 74th day after admission. The WON diminished gradually in size and the symptoms disappeared, and the patient was discharged in good physical condition on the 137th day after admission. In this case, the ampullary biopsy may have caused mucosal edema or intraductal hematoma, resulting in pancreatic duct obstruction. It is important for endoscopists both to be aware of this potential complication following endoscopic biopsy of the ampulla and to inform the patients about possible complications of this procedure.

Acute Pancreatitis Following Endoscopic Ampullary Biopsies without Attempted Cannulation of the Ampulla of Vater

“…The edema may have led to increased pancreatic duct pressure. This same mechanism is also proposed by Ishida et al [5] and Morales and Hixson [3], who reported cases of acute pancreatitis following endoscopic biopsy of the ampulla. Ishida et al [5] additionally mentioned that the rise in the pancreatic duct pressure must have been low and of short duration, as no dilation of the pancreatic duct was observed.…”

“…The third was also a case of severe pancreatitis with formation of a large pancreatic walled-off necrosis that was managed with ultrasonography-guided drainage [5]. …”

Endoscopic retrograde cholangiopancreatography with ampullary biopsyvsERCP alone: a matched-pairs controlled evaluation of outcomes and complications

“…The complication rate in both groups was consistent with the established complication rate with ERCP [ 6 , 7 , 13–15 ]. Another uncontrolled, smaller study [ 4 ], as well as case reports [ 9–11 ] on ampullary biopsy complications after ERCP, was in keeping with these findings. Our data agreed with the largest uncontrolled series reporting no complications with ampullary biopsies in a retrospective review of 62 patients undergoing ERCP for pancreatobiliary cancer or IgG-4 sclerosing cholangitis; however, post-procedure follow-up was not evaluated in that study [ 9 ].…”

“…Another uncontrolled, smaller study [ 4 ], as well as case reports [ 9–11 ] on ampullary biopsy complications after ERCP, was in keeping with these findings. Our data agreed with the largest uncontrolled series reporting no complications with ampullary biopsies in a retrospective review of 62 patients undergoing ERCP for pancreatobiliary cancer or IgG-4 sclerosing cholangitis; however, post-procedure follow-up was not evaluated in that study [ 9 ]. No study has evaluated ampullary biopsy during ERCP as an independent risk factor in the context of post-ERCP complications.…”

A case of severe necrotising pancreatitis following ampullary biopsy

“…Only two previous cases of pancreatitis following ampullary biopsy exist in the literature; in only one did the patient develop pancreatic necrosis. 4,5 In previous cases, the proposed pathophysiological basis for the development of pancreatitis after biopsy was pressure on the pancreas due to intramural or submucosal oedema/haematoma following the biopsy although this was not confirmed on imaging. This is also the likely mechanism in our case.…”