An unusual cause of pancreatitis

Clinical presentation

A 67 year old woman had experienced more than 10 episodes of acute pancreatitis in five years. She was referred to our hospital for recurrent acute pancreatitis despite prior endoscopic papillotomy and laparoscopic cholecystectomy. She denied consumptions of alcohol or herbal medications. No other family member had a similar illness.

On physical examination neither jaundice nor abdominal tenderness was noted. There was no palpable abdominal mass. Laboratory values were as follows: amylase 100 U/l (<220), lipase 36 U/l (<190), triglycerides 120 mg/dl (<200), and calcium 2.37 mmol/l (2.02–2.6). Liver function tests and tumour markers were within normal limits.

Magnetic resonance cholangiopancreatography was performed (fig 1) and the findings were confirmed by endoscopic retrograde cholangiopancreatography (ERCP). At ERCP, the major papilla was not widely open but the minor papilla was prominent. The major papilla was first cannulated and opacified and the minor papilla was subsequently cannulated and opacified (fig 2).

Figure 1 Magnetic resonance cholangiopancreatography of a 67 year old woman.

Figure 2 Endoscopic retrograde cholangiopancreatography with sequential opacification at the major papilla and then at the minor papilla.

Question

What accounts for her recurrent attacks of pancreatitis?

See page 171 for answer

This case is submitted by:

Supplementary figure 1 (Endoscopic view of the major papilla. Note the lack of profuse mucus at the orifice in this case) and supplementary figure 2 (endoscopic view of the minor papilla), can be viewed on the Gut website at http://www.gutjnl.com/supplemental.