Acute pancreatitis complicating Crohn's disease: mere coincidence or causality?

An example of acute pancreatitis developing five weeks after initial treatment with 5-aminosalicylic acid (5-ASA) and methylprednisolone for severe Crohn's disease is reported in a 37 year old female patient. She had undergone cholecystectomy for gall stones some years earlier. There was no evidence of acute or chronic pancreatitis. No morphological changes of the upper gastrointestinal tract were found except for some irregularity of the main pancreatic duct and the secondary ducts on endoscopic retrograde pancreatography. Rechallenge with 5-ASA did not induce recurrent pancreatitis or changes in pancreatic enzymes. This case report supports the concept of an association between acute pancreatitis and Crohn's disease.     

Pancreatic disorders in inflammatory bowel disease

An increased incidence of pancreatic disorders either acute pancreatitis or chronic pancreatitis has been rec-orded in patients with inflammatory bowel disease(IBD) compared to the general population.Although most of the pancreatitis in patients with IBD seem to be related to biliary lithiasis or drug induced,in some cases pancreatitis were defined as idiopathic,suggesting a direct pancreatic damage in IBD.Pancreatitis and IBD may have similar presentation therefore a pancreatic disease could not be recognized in patients with Crohn's disease and ulcerative colitis.This review will discuss the most common pancreatic diseases seen in patients with IBD.     

Idiopathic fibrosing pancreatitis and Crohn's disease: an interesting association

Idiopathic fibrosing pancreatitis is an uncommon condition in children and adolescents of unknown aetiology. This syndrome has been reported in 36 cases so far. To our knowledge none of these cases was definitively associated with Crohn's disease. In this report we describe a young female patient who developed Crohn's disease of the colon 5 years after having been diagnosed with idiopathic fibrosing pancreatitis. The differential diagnosis between this syndrome associated with Crohn's disease and pancreatic Crohn's disease or fibrosing colonopathy, an entity related to pancreatic enzyme therapy, is discussed.     

Crohn's Disease and Pancreatitis

Pancreatitis has rarely been reported as a complication of Crohn's disease. We report our experience with two cases of pancreatitis associated with Crohn's disease. In one, the pancreatitis occurred secondary to duodenal Crohn's disease involving the ampulla of Vater. Endoscopic retrograde pancreatography demonstrated involvement of the ampulla, with marked dilation and delayed drainage of the pancreatic duct, suggesting mechanical obstruction. In the second patient, Crohn's disease was localized to the ileum and colon. We conclude that duodenal Crohn's can cause pancreatitis, and this may, in some cases, be on an obstructive basis. In addition, non-duodenal Crohn's disease can be associated with pancreatitis as well. In a patient with a history of Crohn's disease presenting with an atypical exacerbation, pancreatitis should be considered.     

Acute Pancreatitis as a Complication of Crohn''s Disease

Two cases of Crohn's disease coincidental with acute pancreatitis are described. Both patients were diagnosed as suffering from acute pancreatitis by hyperamlasemia and ultrasonography. Both had received a previous diagnosis of Crohn's ileocolitis. Crohn's disease was active in one patient at the onset of pancreatitis but was inactive in the other. We saw no factor that was obviously responsible for the pancreatitis in these patients. We also review other cases of Crohn's disease accompanied with pancreatitis that have been reported previously in the literature. In six cases, no cause was established for the pancreatitis, other than the Crohn's disease itself. We assume that pancreatitis, although rare, may be one of the extra-intestinal complications of Crohn's disease.     

Pancreatitis and duodenopancreatic reflux in Crohn's disease. Case report and review of the literature

A 21-year-old woman with duodenal Crohn's disease developed pancreatitis many years after radiographic evidence of duodenopancreatic reflux. We review the 17 previously reported cases of non-drug-induced recurrent pancreatitis associated with Crohn's disease and discuss possible pathogenetic mechanisms. Pancreatitis should be considered in any Crohn's disease patient with filling of the pancreatic duct on barium study of the upper gastrointestinal tract.     

Idiopathic pancreatitis associated with inflammatory bowel disease

The list of extraintestinal manifestations of inflammatory bowel diseases does not classically include pancreatitis and pancreatic insufficiency. We report here six cases of unexplained pancreatitis associated with inflammatory bowel disease (five patients with Crohn's disease, one with indeterminate colitis). None of the classical etiologies for pancreatitis was found in our patients; moreover none of them had duodenal localization of Crohn's disease or sclerosing cholangitis, two conditions in which pancreatitis associated with inflammatory bowel disease has been previously described. Pancreatitis was painless (or was associated with moderate and atypical abdominal pain) in four of our six cases; no pancreatic calcification was found in any case; in three patients a total or subtotal exocrine pancreatic insufficiency was evidenced. Endoscopic retrograde pancreatography performed in four subjects showed normal or minimally altered pancreatic ducts even in those with severe pancreatic insufficiency. These cases emphasize the existence of a probably nonfortuitous association of inflammatory bowel disease with pancreatitis. Its recognition could make a significant contribution in the management of inflammatory bowel disease.     

Diagnostic difficulty in a Case of Heterotopic Pancreatic Tissue of the Ileum

We describe a case of heterotopic pancreatic tissue of the ileum causing acute gastrointestinal tract bleeding. It was initially clearly demonstrated as an ileal polyp preoperatively by radiologic means. Exploratory surgery was performed, and the segment of ileum containing the mass was resected. Histopathologic examination of the lesion revealed heterotopic pancreatic tissue of Heinrich type II. There was no histological evidence of acute or chronic pancreatitis, but erosion was confirmed at the tip of the mass. Even symptomatic heterotopic pancreatic tissue of the ileum may give difficult diagnostic problems. The present case is reported to show the possibility of diagnosing rare abnormalities of the ileum.     

Acute pancreatitis in patients with Crohn's disease: clinical features and outcomes

BACKGROUND: Acute pancreatitis has occasionally been associated with Crohn's disease (CD), but whether a causal association exists remains unclear. We sought to determine the frequency of etiologies in a consecutive series of patients with CD with acute pancreatitis. METHODS: A centralized diagnostic index was used to identify all patients with CD with acute pancreatitis that were evaluated at Mayo Clinic Rochester between 1976 and 2001. Both diagnoses were made or confirmed at our institution. Records were abstracted for demographics, presenting symptoms, diagnostic tests, risk factors of pancreatitis, treatment, and follow-up. RESULTS: Forty-eight patients with CD with pancreatitis were identified. The median age at diagnosis of acute pancreatitis was 47 years (range, 31-91 yr). Forty-six (96%) met biochemical criteria for acute pancreatitis. The most sensitive radiographic tests were abdominal computed tomography (70%) and abdominal ultrasound (46%). The etiology of pancreatitis was considered to be gallstones (21%), significant alcohol intake (15%), use of purine analogs (13%), duodenal Crohn's involvement (12%), postendoscopic retrograde cholangiopancreatography complications (10%), postoperative complications (12%), use of other medications (4%) and idiopathic (8%). The median length of hospitalization was 7 days (range, 0-40 d). Ten patients (21%) had recurrence of acute pancreatitis. Three patients (6%) were subsequently diagnosed with pancreatic cancer. CONCLUSIONS: A definite etiology could be identified in most patients with CD with acute pancreatitis. Gallstones and alcohol accounted for more than one third of cases, whereas CD, either because of duodenal involvement or medications used for its treatment, accounted for more than one quarter of the cases. A small proportion of patients remained idiopathic.     

Crohn's disease of the duodenum presented as pancreatitis due to persimmon bezoar

Pancreatitis due to Crohn's disease of the duodenum is very rare. It is the result of either reflux of duodenal content into the pancreatic duct or stenosis due to direct involvement of the ampullary region with Crohn's disease. The patient described had isolated Crohn's disease of the duodenum; pancreatitis was the result of persimmon bezoar's constricting the ampullary region.     

Hyperamylasemia in inflammatory bowel disease

We determined the prevalance and significance of hyperamylasemia in 180 patients with idiopathic inflammatory bowel disease (IBD) (83 with ulcerative colitis, and 97 with Crohn's disease). Serum total amylase and pancreatic and salivary isoamylase activity were measured in all patients. In all patients with hyperamylasemia, we measured isoamylase activity by cellulose acetate electrophoresis and lipase activity, assayed for the presence of macroamylase, and carried out pancreatic ultrasound examination and barium studies of the upper gastrointestinal tract. Eight of 97 patients with Crohn's disease (8%) had hyperamylasemia; 4 of them had an elevated pancreatic isoamylase and 2 a raised lipase activity. All patients with hyperamylasemia had normal ultrasonographic scans of the pancreas and no evidence of duodenal involvement on barium meal. None had macroamylasemia. We found no relationship of hyperamylasemia to disease site, activity, and duration or therapy and no patient developed clinical evidence of pancreatitis. We conclude that a small but important number of patients with Crohn's disease have hyperamylasemia not associated with overt pancreatitis. In the absence of appropriate indications, it requires no investigation.     

Pancreatic function in Crohn's disease.

We investigated exocrine pancreatic function in a population of patients with Crohn's disease in order to correlate the pancreatic function with clinical and laboratory variables. A total of 143 patients affected by Crohn's disease and 115 control subjects were studied. All had a Lundh meal test. As a group patients with Crohn's disease had significantly decreased activity of both amylase (p less than 0.02) and lipase (p less than 0.001) in duodenal aspirates. In patients with Crohn's disease enzyme activities were not correlated to duration of disease or to extent or localisation of previous bowel resection. The lowest enzyme values were found in patients with the most extensive bowel involvement, and they were significantly lower (p less than 0.05) than in patients with disease confined to the terminal ileum. The differences between enzyme values in other subgroups of patients were not significant. For the patient group as a whole no correlation was found between disease activity and enzyme values, but for the most uniform group of patients, those with terminal ileitis, pancreatic function was significantly lower (p less than 0.05) in patients with moderate and severe disease compared with patients with mild disease. Thus at least two factors seem to be responsible for impaired pancreatic function in Crohn's disease: firstly disease activity and secondly localisation or extent of disease.     

Acute pancreatitis associated with primary hyperparathyroidism]

A case of acute pancreatitis associated with primary hyperparathyroidism is reported. There was none of usual causes of pancreatitis, which did not recur following the removal of a parathyroid adenoma. There are over one hundred of cases of acute or chronic pancreatitis associated with hyperparathyroidism in the literature, suggesting a causal relationship between the two entities. The pancreatic disease has been attributed either to the hypercalcemia or to the excess of circulating parathyroid hormone. However, some authors have recently questioned any link between these two diseases.     

Metronidazole-induced acute pancreatitis.

Three cases of metronidazole-induced acute pancreatitis have been reported recently in three women who were being treated for nonspecific vaginitis. We report the fourth such case in a 63-year-old woman with long-standing Crohn's disease who developed acute pancreatitis that was temporally associated with the initiation of metronidazole therapy for a rectovaginal fistula. No other risk factors for pancreatitis were identified except for possibly Crohn's disease itself. We review the literature with regard to metronidazole-induced acute pancreatitis and suggest a possible mechanism. Metronidazole should be considered as a possible cause of acute pancreatitis, and its use should be discontinued if no other risk factor is found.     

Risk of acute pancreatitis in patients with chronic inflammatory bowel disease. A Danish 16-year nationwide follow-up study

BACKGROUND: There are few epidemiologic data about the risk of acute pancreatitis in chronic inflammatory bowel diseases; we therefore wanted to estimate the risk of a first episode of acute pancreatitis in patients with Crohn's disease and ulcerative colitis in the total Danish population. METHODS: The study included all patients discharged from Danish hospitals with a diagnosis of Crohn's disease or ulcerative colitis registered in the Danish National Registry of Patients in the period from 1977 to 1992. The first episode of acute pancreatitis was identified in the cohort. The observed number of patients with acute pancreatitis was compared with expected numbers on the basis of age, sex, and calendar-specific incidence rates in the general population. RESULTS: Overall, 15,526 patients were discharged and followed up for 112,824 person-years. The standardized incidence ratio (SIR) for acute pancreatitis was increased both in patients with Crohn's disease (SIR = 4.3; 95% confidence interval (CI), 2.9-6.1) and in those with ulcerative colitis (SIR= 2.1; 95% CI, 1.6-2.8). CONCLUSION: Patients with chronic inflammatory bowel disease seem to be at increased risk of acute pancreatitis. Further validation and refinement of this registration-based study are needed.     

Crohn's disease of the duodenum with spontaneous reflux into the pancreatic duct

A patient with Crohn's disease which involved the duodenum presented with recurrent pancreatitis. His upper gastrointestinal series demonstrated spontaneous reflux of barium into the pancreatic duct. The literature is reviewed and a probable mechanism for this very unusual occurrence is suggested.     

Crohn disease-associated pancreatitis: is there a new extra-intestinal manifestation of the disease?

We report the case of a 23-year old woman suffering from Crohn's ileocolitis for 14 years who died of a prolonged shock followed by hyperglycaemia. The post-mortem examination showed an acute pancreatitis. There was no hint for Crohn's disease of the duodenum or primary sclerosing cholangitis (PSC). Unexplained Pancreatitis coincident with Crohn's disease might be a possible extraintestinal manifestation of the disease. However such association remains speculative at the moment. Further studies based on morphological, functional, immunological and epidemiological data are required. Review of the literature and our own data show the necessity to look attentive for other causes of acute pancreatitis associated with Crohn's disease (PSC, pancreas divisum, drug induced-pancreatitis).     

Pancreatitis associated with Crohn''s disease: a premalignant state for cystadenocarcinoma of pancreas?

We report a 74-yr-old woman with Crohn's disease and acute pancreatitis who, 3 yr after resolution of the latter, developed cystadenocarcinoma of the pancreas. No drug, toxin, or other etiologies including contiguous duodenal involvement were identified as responsible for the pancreatitis, suggesting that pancreatitis was an extraintestinal manifestation of her Crohn's disease. Could Crohn's-associated pancreatitis be a premalignant state for cystadenocarcinoma of the pancreas?     

The specificity of peptide-PABA-test (author's transl)]

Exocrine pancreatic function was determined by oral administration of N-benzoyl-L-tyrosyl-p-aminobenzoic acid (peptic-PABA-test) in 120 controls, 74 patients with chronic pancreatitis, 35 patients with acute pancreatitis 2--6 weeks after recovery, 201 patients with a variety of gastro-intestinal diseases and in 10 patients with anorexia nervosa. In the control group, 70% +/- 18% of the oral administered dose of PABA was found within 6 hours in the urine. In contrast the group of chronic pancreatic patients excreted only 40% +/- 13% over the same period. "False negative" PABA excretion was found in 11 (9%) of the 120 persons with no pancreas disease. "False positive" PABA excretion was found in 13 (17,5%) of the 74 patients with chronic pancreatitis. The test was not influenced by age or sex. After stomach resection or cholecystectomy and in patients with ulcus duodeni, chronic hepatitis, functional diarrhea, Crohn's disease, colitis ulcerosa and acute pancreatitis 2--6 weeks after recovery the peptide-PABA-test was not distored. Diminished PABA excretion was encountered in some patients with toxic liver disease, inflammatory disease of the small intensine like M. Whipple, celiac disease and unspecific enteritis and in a few patients with cholelithiasis. Low PABA excretion was found in early all patients with partial small intestinal resection, terminal liver cirrhosis or liver metastasis with ascites and in all patients with anorexia nervosa.     

Reversible bilateral optic neuritis after Infliximab discontinuation in a patient with Crohn's disease

A relationship between inflammatory bowel disease and multiple sclerosis is supported by a higher than expected coexistence of these diseases among families and individuals.A 32 year-old male with Crohn's disease of the terminal ileum diagnosed 4 years ago and HLA-B27 negative bilateral sacroiliitis diagnosed 2 years ago, was admitted in our hospital because of an acute episode of blurred vision. In addition the patient complained for urine incontinence. Before this admission the patient was administered methylprednisolone and Infliximab induction treatment. During admission the diagnosis of multiple sclerosis-associated bilateral optic neuritis was made and Infliximab was discontinued. The patient was started on therapy with interferon-beta for multiple sclerosis, prednizolone and azathioprine for Crohn's disease and oxybutynin hydrochloride for urine incontinence. After 8 weeks of Infliximab discontinuation patient recovered totally from optic neuritis.This is a rare case of totally reversible bilateral optic neuritis associated with multiple sclerosis in a patient with Crohn's disease and sacroiliitis receiving also Infliximab induction therapy.