Cephalic Duodenopancreatectomy for Hyperalgic Duodenal Crohn's Disease Fistulized in the Pancreatic Gland

Abstract

Upper gastrointestinal (GI) tract involvement in adult Crohn's disease (CD) is rare and severe complications unusual. Stenosis has been reported, but gastroduodenal fistulae are seldom detected during surgery and most of the fistulae are cologastric or ileogastric. In complicated gastroduodenal CD, medical treatments are often effective and surgery is only considered in exceptional cases. We here report the unusual case of a 23-year-old patient with upper GI CD presenting a hyperalgic giant ulcer of the bulb fistulized in the pancreatic gland. The failure of steroids and two lines of combined treatment led us to a salvage surgical option. Abdominal exploration showed a plate stomach with an inflammatory bulboduodenal block. Cephalic duodenopancreatectomy and cholecystectomy were performed; histological analysis reported large fissuring pylorus ulceration with micro abscesses reaching the pancreas and the presence of non-caseating granulomas. Six months after the surgery, the patient had stopped antalgic treatment and did not have residual abdominal pain. He had gained 11 kg in weight and had no diarrhea with pancreatic enzymes. To our knowledge, we report the first case of an upper GI and fistulizing CD patient heavily treated with steroids and combined immunosuppressant agents requiring salvage cephalic duodenopancreatectomy.

Crohn’s disease of esophagus, stomach and duodenum

“…Gastroduodenal fistulas are uncommon and usually result from inflammatory activity in adjacent organs such as the transverse colon and ileocolonic anastomosis[ 26 , 57 ]. Duodenopancreatic fistula with refractory abdominal pain is rare[ 58 ]. Duodenal CD may be a cause of acute or chronic pancreatitis due to the inflammatory process and fibrosis in the region of the vater ampulla, with duodenopancreatic reflux or fistulas between the duodenum and the pancreatic duct[ 26 , 59 , 60 ].…”