Acute pancreatitis due to an impacted juxtapapillary duodenal diverticulum.

A 58-year-old woman presented with severe abdominal pain. Laboratory findings showed markedly raised amylase and lipase concentrations at 1169IU/L and 5040IU/L respectively. She denied any alcohol consumption. Triglyceride and calcium levels were within the normal range. An abdominal computed tomography (CT) scan showed a round, 2.7-cm, low density, mass-like lesionwith a central area of air density in the second part of the duodenum (●" Fig.1). Esophagogastroduodenoscopy (EGD) revealed a bezoar impacted in a juxtapapillary duodenal diverticulum (JPDD;●" Fig.2). The hard phytobezoar was broken up and removed using grasping forceps. After the bezoarhadbeen removed, her pancreatitis improved. A subsequent endoscopic retrograde cholangiopancreatography (ERCP) showed that the JPDD was located caudally to the papilla with the papillary orifice hardly visible, being located deep inside on the ceiling of the diverticulum. No biliary sludge or stones were noted. A sphincterotomy was performed to prevent recurrence of the pancreatitis (●" Fig.3). JPDDs are usually located on the cephalic side of the major papilla and may be associated with biliary stasis or relapsing pancreatitis [1–4]. Food or bezoar impaction in a JPDD is known to cause biliary obstruction; however, pancreatitis due to bezoar impaction in a JPDD has never been reported, although there are reports of pancreatitis due to impaction of a large bezoar in the duodenal lumen itself [5]. The reason for this seems to be the anatomical proximity of the common type of JPDD to the bile duct rather than the pancreatic duct (●" Fig.4). In this report, bezoar impaction in a rare caudally located type of JPDD caused acute pancreatitis. This is a rare cause of acute pancreatitis and an unusual clinical manifestation of a JPDD caused by its location.