University of Texas Health Science Center San Antonio, TX
Andrea DeCino, MD, Laura Rosenkranz, MD; University of Texas Health Science Center, San Antonio, TX
Introduction: ERCP related complications occur at an incidence of 15-30%. Stent induced ductal perforations are rare (0.01-0.1% of ERCPs). We present the fortunate discovery of a pancreatic NET (neuroendocrine tumor) heralded by the unfortunate events of hemosuccus pancreatitis (HP) and ductal and parenchymal perforations.
Methods: A 38-year-old Hispanic woman with Recurrent Acute Pancreatitis and Pancreatic Divisum who previously underwent related endotherapy at an outside institution, presented with severe abdominal pain. Contrasted CT, MRCP, and EUS revealed two focal strictures in the dorsal pancreatic duct. No parenchymal lesions were noted. ERCP was performed with placement of a pancreatic duct stent bridging both strictures.
Three weeks following the procedure, the patient presented with syncope, hematemesis, and hematochezia. Physical exam was notable for epigastric tenderness to palpation. Lipase was 2840 IU/L and hemoglobin was 8.4 G/dL.
No source of bleeding was identified on either upper or lower endoscopy. On CT angiogram, intraductal stent was visualized without adjacent pseudocyst, pseudoaneurysm, or evidence of pancreatitis. This time, ERCP revealed a trivial amount of blood oozing from the minor ampulla, which was treated with injection of diluted Epinephrine (Fig A). The existing pancreatic stent was removed in its entirety, and a new pancreatic stent was placed over the guidewire. Within several days, the patient developed severe abdominal pain associated with significant rise in amylase and lipase, and a CT scan revealed pancreatic duct rupture with stent extension into the peritoneum (Fig B and C). The patient later underwent distal pancreatectomy with pancreaticojejunostomy. The explanted pancreatic tail contained a well differentiated 2.2cm NET. Over the next four years, the patient remained tumor free with no evidence of metastatic disease. Discussion: We speculate our patient's NET, undetected by all imaging modalities utilized, was the culprit of the two pancreatic duct strictures and caused obstruction of the PD, leading to deviation of stent trajectory, even though placed over the guidewire, and ultimately perforation of the duct and the pancreatic parenchyma.
Our patient's source of bleeding was felt to be hemosuccus pancreaticus, as no other source of bleeding was identified. HP is undetected on endoscopy in 60% of patients. NETs may manifest clinically with recurrent pancreatitis and HP, as evidenced in our patient's case.
Fig A. Slow mucosal bleed at the minor ampulla during ERCP
Fig B. Axial image of pancreatic stent extension into the peritoneum by contrast-enhanced computed abdominal tomography
Fig C. Coronal image of pancreatic stent extension into the peritoneum by contrast-enhanced computed abdominal tomography
Disclosures: Andrea DeCino indicated no relevant financial relationships. Laura Rosenkranz indicated no relevant financial relationships.