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Biliary Stenosis and Gastric Outlet Obstruction: Complications After Acute Pancreatitis
Motokazu Sugimoto*1, Greggory S. Flint1, John C. Kirkham2, Cody Boyce2, Tyler Harris2, Sean Carr2, David Sonntag2, Brent D. Nelson2, Joshua Barton1, Louis W. Traverso1
1Center for Pancreatic and Liver Disease, St. Luke's Health System, Boise, ID; 2Radiology, St. Luke's Health System, Boise, ID
Introduction: Common bile duct (CBD) stenosis and gastric outlet obstruction (GOO) during acute pancreatitis are not often reported although these conditions have been recognized with chronic pancreatitis. The aim of this study was to observe the frequency, duration, and treatment of CBD stenosis and GOO.
Methods: Between June 2010 and June 2014, 871 patients were hospitalized with clinical diagnosis of acute pancreatitis at the St. Luke's Health System. Of those 139 cases had pancreatic and/or peripancreatic collections by CT scan and were included in our study. Severity was evaluated using the CT severity index (CTSI) scoring system. Percutaneous catheter drainage (PCD) was performed in 52 patients with persistent or enlarging collections by CT scan, systemic inflammatory response syndrome, organ failure, and/or refractory abdominal pain. All patients were followed until resolution with median follow-up of 483 days [range, 47-1355] after index discharge. CBD stenosis and GOO was defined clinically and radiographically. In these patients with pancreatic and/or peripancreatic collections, the clinical and pathological findings were compared between those who did and did not develop CBD stenosis and/or GOO.
Results: Of the 139 cases there were 13 cases with CBD stenosis and/or GOO (9%) - 7 with CBD stenosis-only, 2 with GOO-only, and 4 with both CBD stenosis and GOO. Comparing these 13 cases to the 126 patients without CBD stenosis or GOO the former had higher CTSI scores (P < 0.001), higher incidence of pancreatic head necrosis (P < 0.001), and higher incidence of portal vein occlusion (P = 0.002). They required PCD more frequently (P < 0.001). For those treated with PCD, amylase-rich drain fluid and culture-positive drain fluid were observed more often (P < 0.001 and P = 0.006, respectively).
CBD stenosis occurred 65 days [11-231] after onset, whereas GOO occurred 88 days [22-117] after onset. In 11 the patients with CBD stenosis, 6 were treated with endoscopic stenting and 5 underwent percutaneous transhepatic biliary drainage. Median duration of biliary decompression was 180 days [36-231]. All 6 patients with GOO underwent percutaneous gastric drainage for a median of 117 days [41-176]. Five patients had simultaneous jejunal feeding. All 13 cases recovered from these inflammatory complications without surgical intervention.
Conclusions: The anatomic proximity of the CBD and the duodenum to the severe inflammatory process of acute pancreatitis results in the late onset of reversible inflammatory stenosis. Especially in patients with pancreatic head necrosis, development of these complications should be anticipated. Percutaneous and endoscopic methods successfully managed these complications although prolonged decompression was required.
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