West Virginia University, Charleston Division Charleston, WV, United States
Adil Memon, MD1, Ronald Gwinn, 1, Suzanne Kemper, MPH2, Shawn Chillag, MD1 1West Virginia University, Charleston Division, Charleston, WV; 2CHERI, Health Services and Outcomes Research, Charlesrton, WV
Introduction: Pancreatitis, a frequent cause of hospitalization, with the vast majority from 2 or 3 etiologies. Amongst the most frequent causes are alcohol use and gallstones of the common bile duct. Two unusual cases are presented with discussion. The primary lesson is to consider causes other than alcohol and biliary disease in the etiology. A fundamental mechanism for pancreatic injury from pressure, internal or external, is proposed.
Case Description/Methods: CASE 1
A 75-year-old man presented with nausea, vomiting, right upper abdomen/flank pain. He had history of right ureteral and bladder urothelial carcinoma with prior radiation and surgery. lipase levels were elevated over 3X of normal. CT scan of abdomen reported hydronephrosis with its upper pole compressing the duodenum (Figure 1). Placement of a nephrostomy tube, rapid symptom relief and a decline in lipase occurred.
CASE 2 A 74-year-old woman had chronic abdominal pain, early satiety, vomiting and marked abdominal distension with diffuse tenderness. Lipase was 1851uL. CT Imaging revealed a markedly distended stomach from pyloric stenosis (Figure 2a) with a compressed pancreas (Figure 2b). Nasogastric drainage resulted in rapid symptom relief. Endoscopy identified impassable pyloric stricture with antral ulcerations. The pylorus could not be easily entered until a balloon dilation was performed to 11 mm. Lipase trended down.
Discussion: The pancreas is very sensitive to pressure. Compression pancreatitis is a rare cause that is not frequently reported. Mechanism of injury is proposed to be secondary to pressure causing direct injury of the acinar cells. Recent experimental trials in rat models have shown that pancreatic acinar cells express the mechanoreceptor Piezo1 which are activated with pressure within the gland causes calcium influx leading to cell death. Blockade of Piezo1 receptor may prevent pancreatitis. There have been other reported cases of external compression of the pancreatic drainage system and pancreas, from intragastric balloon insertions or duodenal hematomas. This is the first reported case of pancreatitis related to massive gastric distension from pyloric stenosis. Unusual and rare causes such as these should be considered in the differential as prompt mechanical intervention should be applied just as for gallstone pancreatitis. Could further research into mechanoreceptors such as Piezo1 and related molecular blockade in humans prevent pancreatitis?
Figure: Compression Pancreatitis
Adil Memon indicated no relevant financial relationships.
Ronald Gwinn indicated no relevant financial relationships.
Suzanne Kemper indicated no relevant financial relationships.
Shawn Chillag indicated no relevant financial relationships.
Adil Memon, MD1, Ronald Gwinn, 1, Suzanne Kemper, MPH2, Shawn Chillag, MD1. P0068 - Pressure Pancreatitis - Two Unusual Cases and a Different Way of Thinking of Causation, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.