Why do people with Crohn's disease develop chronic pancreatitis? Case study

Guide

Scholars from the Sixth Affiliated Hospital of Sun Yat-sen University reported a case
of chronic pancreatitis in a patient with Crohn's disease caused by a rare cause.

Case introduction

The patient, a 40-year-old male, was admitted to the hospital
with intermittent abdominal pain, vomiting, and weight loss.
He has a 10-year history of Crohn's disease (CD) and undergoes right hemicolectomy for intestinal obstruction, followed by azathioprine maintenance therapy
.
Emergency admission to the hospital with recurrent intestinal obstruction 6 months ago with CT enterogram showing duodenal ileo-sigmoid intestinal fistula (figure A) with pancreatic enlargement (figure B).

Glucocorticoids and antibiotics are effective in improving symptoms, but intermittent epigastric pain with episodes of vomiting occurs after gradual discontinuation of glucocorticoids, and antibiotics
are given intermittently to relieve symptoms.

On admission, abdominal CT shows changes associated with chronic pancreatitis; Multiple pancreatic calcifications with ductal dilation were observed (panel C).

Patients had elevated blood amylase and C-reactive protein levels (812 U/L and 64 mg/L, respectively) and IgG4 and other autoantibodies are negative
.

Figure A~C

Q: What could be the cause of chronic pancreatitis in a patient?

The answer is revealed: duodenum-ileo-colonic fistula

Reviewing the CT enterogram results of the patient, we found that the descending transverse lumen above the duodenal fistula was dilated (figure D), the gastroscopy showed edema and stenosis in the descending duodenum, and there was fecal overflow at the duodenal fistula (Fig.
E
).

After considering the patient's clinical presentation, laboratory findings, and history, we concluded that in the past 6 months, due to intestinal fistula and duodenal obstruction, fecal fluid has flowed retrograde into the descending duodenal segment and pancreatic duct, resulting in a recurrence
of acute pancreatitis.

Symptoms of acute pancreatitis mimic those of intestinal obstruction and intestinal fistula, causing patients to neglect their symptoms
.
At the same time, recurrent pancreatitis develops into chronic pancreatitis
.

To treat this patient, a nasojejunal feeding tube
was placed under the guidance of digital subtraction angiography.
After the insertion of gavage, no more abdominal pain, vomiting, and amylase levels returned to normal
.
Ultimately, surgery confirmed intestinal stenosis at the duodenal fistula with multiple calcifications of the pancreas (Figure F
).
Urox-en-Y anastomosis is performed and the fistula intestinal segment
is removed.
Vedelizumab was given postoperatively, and no recurrence
of chronic pancreatitis was found at follow-up.

Pancreatitis can occur in patients with inflammatory bowel disease, but acute pancreatitis is more common
than chronic pancreatitis.

This patient developed irreversible chronic pancreatitis within 6 months due to duodenal fistula, and its symptoms were masked by the inherent symptoms of CD, resulting in delayed diagnosis, so prompt clinical management
was required.