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CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 11  |  Page : 3752-3754  

Acute pancreatitis as an initial presentation of Crohn's disease: A case report


Gastroenterology Division, Department of Medicine, College of Medicine, King Fahad Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

Date of Submission09-Sep-2019
Date of Decision16-Sep-2019
Date of Acceptance30-Sep-2019
Date of Web Publication15-Nov-2019

Correspondence Address:
Dr. Norah Mohammed Almarri
Department of Medicine, Gastroenterology Section, King Fahad University Hospital, Dammam 34445
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_753_19

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  Abstract 


Acute pancreatitis (AP) is not commonly known to be an extra-intestinal manifestations of Crohn's disease (CD). Several cases have been reported discussing the relation of AP with CD. However, no specific etiological factors for pancreatitis were found, which appears to support the possibility of a relationship between AP and CD. We report a 30-year-old male present with generalized abdominal pain associated with watery diarrhea. Diagnosis of AP was made. A CT abdomen showed pancreatic inflammation with a terminal ileum thickening. Colonoscopy with multiple biopsy was done for the patient, which confirmed the diagnosis of CD. The patient started on adalimumab for 6 months, showed good response, and became symptomatically free. No recurrent attacks after 2 years of follow-up. The association between AP and CD is not yet clear. Therefore, patients presenting with idiopathic pancreatitis should be investigated to rule out the coexistence of IBD for better outcome.

Keywords: Acute pancreatitis, autoimmune pancreatitis, Crohn's disease, extra-intestinal manifestation, inflammatory bowel disease


How to cite this article:
Almarri NM, Alobaidli AJ, Almarhabi AA, Alshammari MA. Acute pancreatitis as an initial presentation of Crohn's disease: A case report. J Family Med Prim Care 2019;8:3752-4

How to cite this URL:
Almarri NM, Alobaidli AJ, Almarhabi AA, Alshammari MA. Acute pancreatitis as an initial presentation of Crohn's disease: A case report. J Family Med Prim Care [serial online] 2019 [cited 2019 Dec 5];8:3752-4. Available from: http://www.jfmpc.com/text.asp?2019/8/11/3752/270948




  Introduction Top


Crohn's disease (CD) has many established extra-intestinal manifestations; however, acute pancreatitis (AP) is not commonly known to be among them.[1] Several cases have been reported discussing the relation of AP with CD. In these cases, no specific etiological factors for pancreatitis were found, which appears to support the possibility of a relationship between AP and CD.[1] A retrospective case series study done in Israel over a 10-year period found that only 2.17% of pediatric patients and 0.06% of adult patients presented with AP as first presentation of inflammatory bowel disease (IBD).[2] Understanding the relationship between the two disease entities is vital to successful management of patients presented with both conditions. We report here a case of acute pancreatitis presenting as the first extra-intestinal manifestation of CD.


  Case History Top


This is a case of a 30-year-old male who presented with a 2-week history of watery diarrhea associated with generalized abdominal pain. On physical examination, there was epigastric tenderness. Laboratory results showed that lipase and amylase levels were three times above the upper limit of normal (lipase >2000 U/L, amylase 971 U/L), and a C-reactive protein level of 68.2 mg/dl [Table 1]. Viral and autoimmune studies were normal. Abdominal ultrasound and magnetic resonance cholangiopancreatography (MRCP) findings were unremarkable. Diagnosis of AP was made.
Table 1: Laboratory Results Upon Admission

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A computed tomography (CT) scan showed terminal ileum thickening [Figure 1]. A colonoscopy was then done for the patient, which revealed moderate inflammation in the terminal ileum [Figure 2]. Multiple biopsies were taken, and the histopathological features were consistent with CD of mild-to-moderate disease activity. Treatment was started with an induction dose of 160 mg subcutaneous adalimumab (HUMIRA®), then 40 mg subcutaneously every 2 weeks for 6 months. Since the onset of treatment, he reported good response and became symptomatically free. No recurrent attacks after 2 years of follow-up.
Figure 1: CT scan of a terminal ileum thickness

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Figure 2: Colonoscopy; inflamed terminal ileum

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  Discussion Top


Multiple factors may affect the occurrence of AP in CD, including medications used for treatment of the disease itself.[3] In this case, factors that may trigger AP were investigated and excluded such as alcohol intake, biliary causes, hypertriglyceridemia, hypercalcemia, viral causes, and medications.

Several theories have been suggested to explain the pathophysiology of AP in CD. For example, in cases of duodenal CD, AP is most likely due to duodenal-pancreatic duct fistulas.[4] When there is no duodenal involvement, autoimmune causes were suggested to contribute to the occurrence of pancreatitis in CD.[5] There has been a reported prevalence of autoantibodies against the exocrine glands of the pancreas in 20–30% of CD patients.[6] However, evidence that links the presence of autoantibodies and pancreatitis development in CD patients is still lacking.[1]

Autoimmune pancreatitis (AIP) is another distinctive disease of pancreatic involvement, classified to type 1 and type 2. Although both types are under the same disease entity, it's been noticed that type 2 has more strong association with IBD, being AP as the common case presentation of type 2 AIP.[7]

The diagnosis of type 1 AIP depends on the serological level of IgG4, whereas type 2 needs to be confirmed by histopathological samples, as there is no definitive serological marker for it.[7] Nevertheless, the absence of increased IgG4 levels, such as in our case, makes it difficult to confirm the diagnosis of AIP, and because no pancreatic tissue biopsy was taken, type 2 could not be confirmed either.

After reviewing several studies, it can be suggested that AP, although rare, can present as the first manifestation of CD.[8],[9] According to a recent literature review, it has been recommended to manage patients with pancreatitis related CD with infliximab as well as periodic gallstone screening.[1] In our patient, adalimumab was used as it was available. There is no evidence to suggest against its use, both drugs are known to have a similar response and are effective in achieving maintenance.[10] It gave good results in terms of symptom resolution and disease activity control. We believe either one of these drugs can be used in such presentation.


  Conclusion Top


The association between AP and CD is not yet established. Therefore, as primary care physician, we have to be aware about all rare presentations of IBD. Thorough examination and investigation is crucial in all patients presenting with idiopathic pancreatitis to rule out the coexistence diseases, as it will help to conduct the right management. This case report supports the hypothesis that AP can precede the clinical manifestations of underlying IBD. Further studies need to be conducted to confirm this relationship.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jasdanwala S, Babyatsky M. Crohn's disease and acute pancreatitis. A review of literature. JOP 2015;16:136-42.  Back to cited text no. 1
    
2.
Broide E, Dotan I, Weiss B, Wilschanski M, Yerushalmi B, Klar A, et al. Idiopathic pancreatitis preceding the diagnosis of inflammatory bowel disease is more frequent in pediatric patients. J Pediatr Gastroenterol Nutr 2011;52:714-7.  Back to cited text no. 2
    
3.
Pitchumoni CS, Rubin A, Das K. Pancreatitis in inflammatory bowel diseases. J Clin Gastroenterol 2010;44:246-53.  Back to cited text no. 3
    
4.
Pimentel AM, Rocha R, Santana GO. Crohn's disease of esophagus, stomach and duodenum. World J Gastrointest Pharmacol Ther 2019;10:35-49.  Back to cited text no. 4
    
5.
Moubax K, Mana F, Urbain D. Crohn's disease presenting with acute pancreatitis. Acta Gastroenterol Belg 2014;77:357-8.  Back to cited text no. 5
    
6.
Soubieres AA, Poullis A. Emerging role of novel biomarkers in the diagnosis of inflammatory bowel disease. World J Gastrointest Pharmacol Ther 2016;7:41-50.  Back to cited text no. 6
    
7.
Lee YS, Kim N, Son JH, Kim JW, Bae WK, Kim K, et al. Type 2 autoimmune pancreatitis with Crohn's disease. Intern Med 2018;57:2957-62.  Back to cited text no. 7
    
8.
Fousekis FS, Theopistos VI, Katsanos KH, Christodoulou DK. Pancreatic involvement in inflammatory bowel disease: A review. J Clin Med Res 2018;10:743-51.  Back to cited text no. 8
    
9.
Annese V. A review of extraintestinal manifestations and complications of inflammatory bowel disease. Saudi J Med Med Sci 2019;7:66-73  Back to cited text no. 9
    
10.
Barreiro-de Acosta M, Gisbert JP. Editorial: Relative efficacy of infliximab and adalimumab in Crohn's disease in an Australian and New Zealand cohort. Aliment Pharmacol Ther ;45:855-6.  Back to cited text no. 10
    


    Figures

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    Tables

  [Table 1]



 

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