Clin Endosc.  2019 Sep;52(5):510-515. 10.5946/ce.2018.191.

Duodenal Stricture due to Necrotizing Pancreatitis following Endoscopic Ultrasound-Guided Ethanol Ablation of a Pancreatic Cyst: A Case Report

• Chun JW
• Lee SH
• Choi JH
• Paik WH
• Ryu JK
• Kim YT

• KMID: 2464675
• DOI: http://doi.org/10.5946/ce.2018.191

Abstract

The frequency of incidental detection of pancreatic cystic lesions (PCLs) is increasing because of the frequent use of cross-sectional imaging. The appropriate treatment for PCLs is challenging, and endoscopic ultrasound-guided ablation for PCLs has been reported in several studies. Although the feasibility and efficacy of this therapeutic modality have been shown, the safety issues associated with the procedure are still a concern. We present a case of a 61-year-old man who underwent ultrasound-guided ethanol ablation for PCL and needed repeated endoscopic balloon dilatation for severe duodenal stricture caused by necrotizing pancreatitis after the cyst ablation therapy.

Keyword

Pancreatic cyst; Duodenal obstruction; Pancreatitis, acute necrotizing; Endosonography

MeSH Terms

Constriction, Pathologic*
Dilatation
Duodenal Obstruction
Endosonography
Ethanol*
Humans
Middle Aged
Pancreatic Cyst*
Pancreatitis*
Pancreatitis, Acute Necrotizing
Ethanol

Figure

• 

  Fig. 1. Imaging evaluations of pancreatic cyst lesion. (A) Initial computed tomography (CT) scan revealed a 2.2-cm branch duct-intraductal papillary mucinous neoplasm in the uncinate process of the pancreas (arrow); (B) Initial endoscopic ultrasonography findings indicated a 2-cm unilocular cyst in the uncinate process without a definite mural nodule or pancreatic duct dilatation; (C) A follow-up CT showed a 3.5-cm cystic lesion with exophytic portion in the uncinate process, increased in size (arrow); (D) Magnetic resonance cholangiopancreatography revealed a 3.6-cm pleomorphic cystic lesion in the pancreas head with pancreatic duct communication and without main pancreatic duct dilatation or solid mural nodule (arrow).

• 

  Fig. 2. Abdominal computed tomography (CT) findings. (A) Pancreatic swelling with extensive peripancreatic infiltration and fluid collection suggesting acute interstitial edematous pancreatitis; (B) Hypoenhancement of the pancreas with extensive areas of necrosis showing necrotizing pancreatitis; (C) A follow-up CT after 6 weeks revealed walled-off pancreatic necrosis; (D) Third duodenal portion narrowing (arrow) associated with upstream dilatation of the duodenum and stomach, suggesting gastric outlet obstruction.

• 

  Fig. 3. Endoscopic balloon dilation (EBD) of the duodenal stricture. (A) Endoscopic ultrasonography (EUS) showing peripancreatic necrosis and aspiration attempts (arrow); (B) Part of walled-off necrosis was drained by EUS-guided aspiration using 19-gauge needle (arrow); (C) The stricture observed in the second part of the duodenum was not passed by the duodenoscope. The guidewire was passed to the third portion and EBD with the diameter of 20 mm was performed.; (D) The fluoroscopy showing dye passed through the third portion of duodenum, but not adequate. (E) After one week from first EBD, luminal narrowing was found in the second and third portions of the duodenum. (F) The second EBD was attempted. (G) Duodenoscope passage was still difficult due to narrowed lumen after a week. (H) Dye passage was confirmed after third EBD. (I, J) The fourth EBD was performed 3 times for 3 minutes, and the stricture was alleviated. (K, L) The improved state of stricture was confirmed after the 5th EBD.

• 

  Fig. 4. Computed tomography (CT) images after resolution of procedure-related adverse events. (A) Abdominal CT scan performed 1 month after the last discharge, showed interval regression of pancreatitis and no duodenal obstruction (arrow); (B) Complete remission of pancreatic cystic lesion was revealed by the follow-up CT scan performed 9 months after cyst ablation (arrow).

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