Acute pancreatitis associated with peroral double-balloon enteroscopy: a case report.

Abstract

A 58-year-old Japanese man had tarry stool and severe anemia. Neither upper nor lower gastrointestinal (GI) endoscopy showed any localized lesions. Thus, the source of his GI bleeding was suspected to be in the small intestine, and he underwent peroral double-balloon enteroscopy (DBE) using EN-450T5 (Fujinon-Toshiba ES System Co., Tokyo, Japan). There were no lesions considered to be the source of GI bleeding. After the procedure, the patient began to experience abdominal pain. Laboratory tests revealed hyperamylasemia and abdominal computed tomography revealed an inflammation of the pancreas and the peripancreas. He was thus diagnosed to have acute pancreatitis. Conservative treatments resulted in both clinical and laboratory amelioration. He had no history of alcohol ingestion, gallstone disease or pancreatitis. Magnetic resonance cholangiopancreatography demonstrated no structural alterations and no stones in the pancreatobiliary ductal system. As his abdominal pain started after the procedure, his acute pancreatitis was thus thought to have been related to the peroral DBE. This is the first reported case of acute pancreatitis probably associated with peroral DBE.

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INTRODUCTION
The small intestine is located quite far from both the
mouth and the anus, and thus it has been diffi cult to be
examined by endoscopy until recently. However, capsule
endoscopy and double-balloon enteroscopy (DBE), new
methods of enteroscopy, have been introduced in recent
years which have now made the observation of the entire
small intestine possible.
DBE is a novel technique which was developed by
Yamamoto et al, in Japan[1-3], and is spreading also in other
countries. Both a 200-cm enteroscope and a 145-cm over-
tube which have a soft latex balloon at their tips are in-
cluded in the system. Both balloons can be infl ated or de-
fl ated by a balloon-pump controller which thus allows for
a shortening of the proximal intestine, thus allowing the
enteroscope to be inserted into the deep small intestine.
Currently, two different diameter enteroscopes, EN-
450P5/20 (Fujinon-Toshiba ES System Co., Tokyo, Japan)
with an outer diameter of 8.5 mm (an overtube with an
outer diameter of 12.2 mm) and EN-450T5 with an outer
diameter of 9.4 mm (an overtube with an outer diameter
of 13.2 mm) are available. With a larger accessory channel,
EN-450T5 allows the performance of a variety of entero-
scopic treatments including argon plasma coagulation/ab-
lation, coagulation/biopsy (hot biopsy) and balloon dilata-
tion. The indications of DBE are for the diagnosis and the
treatment of small intestinal diseases. DBE is quite useful
for the diagnosis of the origin of obscure gastrointestinal
(GI) bleeding in the small intestine and for the endoscopic
evaluation and histopathological diagnosis from the biopsy
samples of small intestinal lesions such as ulcers, tumors
and strictures. It is also useful for the treatment of small
intestinal diseases, for example, the management of active
GI bleeding and polypectomy of the small intestinal
polyps. The technique of DBE is considered to be safe
as only few complications related to sedation and original
diseases　have been reported previously[4,5].
In this paper, we report a case that developed acute
pancreatitis after peroral DBE. To our knowledge, this is
the fi rst report which describes a case of acute pancreatitis
probably associated with peroral DBE.
CASE REPORT
Acute pancreatitis associated with peroral double-balloon
enteroscopy: A case report
Kuniomi Honda, Takahiro Mizutani, Kazuhiko Nakamura, Naomi Higuchi, Kenji Kanayama, Yorinobu Sumida,
Shigetaka Yoshinaga, Soichi Itaba, Hirotada Akiho, Ken Kawabe, Yoshiyuki Arita, Tetsuhide Ito
www.wjgnet.com
Kuniomi Honda, Takahiro Mizutani, Kazuhiko Nakamura,
Naomi Higuchi, Kenji Kanayama, Yorinobu Sumida, Shige-
taka Yoshinaga, Soichi Itaba, Hirotada Akiho, Ken Kawabe,
Yoshiyuki Arita, Tetsuhide Ito, Department of Medicine and
Bioregulatory Science, Graduate School of Medical Sciences, Ky-
ushu University, Fukuoka, Japan
Correspondence to: Kazuhiko Nakamura, M.D., Ph.D., Depart-
ment of Medicine and Bioregulatory Science, Graduate School of
Medical Sciences, Kyushu University, 3-1-1, Maidashi, Higashi-
ku, Fukuoka 812-8582,
Japan. knakamur@intmed3.med.kyushu-u.ac.jp
Telephone: +81-92-6425286 Fax: +81-92-6425287
Received: 2005-09-13 Accepted: 2005-10-26
Abstract
A 58-year-old Japanese man had tarry stool and se-
vere anemia. Neither upper nor lower gastrointestinal
(GI) endoscopy showed any localized lesions. Thus, the
source of his GI bleeding was suspected to be in the
small intestine, and he underwent peroral double-balloon
enteroscopy (DBE) using EN-450T5 (Fujinon-Toshiba
ES System Co., Tokyo, Japan). There were no lesions
considered to be the source of GI bleeding. After the
procedure, the patient began to experience abdominal
pain. Laboratory tests revealed hyperamylasemia and
abdominal computed tomography revealed an infl amma-
tion of the pancreas and the peripancreas. He was thus
diagnosed to have acute pancreatitis. Conservative treat-
ments resulted in both clinical and laboratory ameliora-
tion. He had no history of alcohol ingestion, gallstone
disease or pancreatitis. Magnetic resonance cholangio-
pancreatography demonstrated no structural alterations
and no stones in the pancreatobiliary ductal system. As
his abdominal pain started after the procedure, his acute
pancreatitis was thus thought to have been related to
the peroral DBE. This is the fi rst reported case of acute
pancreatitis probably associated with peroral DBE.
© 2006 The WJG Press. All rights reserved.
Key words: Enteroscopy; Small intestine; Pancreatitis;
complication
Honda K, Mizutani T, Nakamura K, Higuchi N, Kanayama K,
Sumida Y, Yoshinaga S, Itaba S, Akiho H, Kawabe K, Arita
Y, Ito T. Acute pancreatitis associated with peroral double-
balloon enteroscopy: A case report. World J Gastroenterol
2006; 12(11): 1802-1804
PO Box 2345, Beijing 100023, China World J Gastroenterol 2006 March 21; 12(11): 1802-1804
www.wjgnet.com World Journal of Gastroenterology ISSN 1007-9327
wjg@wjgnet.com © 2006 The WJG Press. All rights reserved.

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CASE REPORT
A 58-year-old Japanese man had tarry stool and syncope
and was hospitalized by ambulance during the previous
month. Since laboratory tests revealed severe anemia
(hemoglobin level: 77 g/L, normal 140-180 g/L), he
received red blood cell transfusion. Neither upper nor
lower gastrointestinal GI endoscopy showed any localized
lesions. Barium meal radiography of the small intestine
and computed tomography (CT) also failed to show any
lesions. As a result, the source of his GI bleeding was sus-
pected to be a small lesion in the small intestine such as
angiodysplasia, small ulcer or erosion, and he was thus re-
ferred to our hospital. Thirty days had already passed from
the day when he had tarry stool and his hemoglobin level
recovered up to 114 g/L. On the day of his admission,
written informed consent was obtained from him and he
underwent peroral DBE using EN-450T5. The total time
of the procedure was 100 min. At the most distal site,
the small intestinal mucosa was marked with a tattoo by a
submucosal injection of sterilized ink through an injection
catheter. There was a small submucosal tumor, which
had a yellowish surface with white specks, located in the
upper jejunum (Figure 1), which was considered to be a
lymphangioma because of its typical image. But it was not
considered to be the source of GI bleeding because there
was no ulceration or erosion on its surface. After fi nishing
the procedure, the patient began to experience abdominal
pain. An abdominal examination revealed moderate epi-
gastric tenderness and silent bowel sounds. His laboratory
findings were as follows: white blood cells, 13 100/μL
(normal 3 500-9 000 /μL); C-reactive protein, 2.37 mg/dL
(normal < 0.10 mg/dL); serum amylase, 702 U/L (normal
50-159 U/L). Abdominal CT revealed an infl ammation of
the pancreas and the peripancreas (Figure 2). He was thus
diagnosed to have acute pancreatitis. The patient was treat-
ed by total parenteral nutrition with intravenous rich fl uids
and gabexate. These treatments resulted in both clinical
and laboratory amelioration and he started oral intake on
day 16. Since then, his condition was good and he under-
went peranal DBE on day 26. No lesions were observed
on the anal side of the small intestine although the mark
with a tattoo was not detected. It probably disappeared
since it has been 26 d from the day of peroral DBE.
Honda K et al. pancreatitis due to double-balloon enteroscopy 1803
www.wjgnet.com
Hence, his GI bleeding source remained unknown. He was
discharged on day 30. His hospitalization was extended for
more than 10 d because of pancreatitis after peroral DBE.
The grade of his pancreatitis was diagnosed as severe
according to the criteria of Cotton et al [6].
He had no history of alcohol ingestion, gallstone dis-
ease or pancreatitis. Magnetic resonance cholangiopancrea-
tography on day 18 demonstrated no structural alterations
and no stones in the pancreatobiliary ductal system. As
his abdominal pain started after the procedure, his acute
pancreatitis was thus thought to have been related to the
peroral DBE.
DISCUSSION
Newly developed methods of enteroscopy, capsule
endoscopy and DBE, are quite useful for the detection of
the origin of GI bleeding in the small intestine. Capsule
endoscopy causes minimum discomfort to patients
because the patients are free after loading a recorder
and taking a capsule orally. But in Japan, experience
with capsule endoscopy is limited as it has not yet been
approved for the clinical use at the present time and
thus it can be used in only limited facilities as clinical
studies. DBE is currently available in Japan. We therefore
performed DBE in this case but we could not fi nd a lesion
which caused GI bleeding. We might have a greater chance
to find a responsible lesion if we could perform DBE
when the patient had a actve bleeding. We chose EN-
450T5 as we considered the possibility of the treatment of
a lesion with hemorrhage by argon plasma coagulation and
hemostatic clipping. The patient unexpectedly developed
acute pancreatitis after the DBE procedure.
Regarding the safety of DBE, May et al [4] reported that
the only complications observed were related to sedation
in 248 enteroscpies (including 153 peroral enteroscopies).
Yamamoto et al[5] demonstrated that two complications,
mainly associated with the original diseases, occurred
among 178 procedures (including 89 peroral enterosco-
pies). One was multiple perforations occurred in a patient
with intestinal lymphoma who received chemotherapy
and the other was in a patient who was discovered to have
Crohn’s disease and had postoperative fever and abdomi-
Figure 1 Peroral double-balloon enteroscopy revealed a small yellowish
submucosal tumor with white specks on the surface in the upper jejunum.
Figure 2 Abdominal CT showed infl ammation and swelling of the pancreas, and
a blurring of the fat planes in both the peripancreas and the left anterior pararenal
space.

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nal pain. In the above two studies, EN-450P5/20 was
used and no instances of acute pancreatitis were reported.
Up to now, we have performed peroral DBE using EN-
450P5/20 on 13 cases (one case reached to the ascending
colon), and no previous cases demonstrated pancreatitis.
This was the first case in which we performed peroral
DBE using EN-450T5. The thicker diameter of EN-
450T5 might therefore be associated with the development
of pancreatitis.
A few cases developing pancreatitis have been reported
as a complication of upper or lower GI endoscopy
without ampullary cannulation[7-9] although GI endoscopy
is not known to be associated with an increased risk for
pancreatitis. The underlying mechanism of pancreatitis in
these cases is unclear. In case of upper GI endoscopy, it
was possible that trauma to the papilla during duodenal
intubation might have led to edema of the papilla and
subsequent pancreatitis. In case of colonoscopy, it was
possible that overinsufflation of the colon might have
caused pressure of the pancreas or compression of the
colonoscope against the spine might have caused a direct
trauma to the pancreas. The mechanisms of developing
pancreatitis associated with peroral DBE were thought to
be as follows: the one may be a pancreatic duct obstruction
due to the direct oppression of the papilla by an overtube
and the other may be an increase in the intralumenal
pressure of the duodenum by a thick overtube and
shortening technique.
Here we reported a case of acute pancreatitis that was
thought to be associated with DBE. This case indicates
that, when peroral DBE is performed, especially with
EN-450T5, we have to keep in mind the possibility of
developing pancreatitis. And if a patient complained a
strong abdominal pain during and after the procedure, we
have to rule out acute pancreatitis by examining serum
amylase level and abdominal CT as soon as possible.
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S- Editor Wang J L- Editor Zhang JZ E- Editor Ma WH
1804 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol March 21, 2006 Volume 12 Number 11