A rare cause of biliary obstruction and pancreatitis

The prevalence of duodenal diverticula varies considerably in the literature, between 3-24% [1,2]. They are acquired extraluminal outpouchings of the mucosal wall through the muscularis propria and their incidence increases with age. While most duodenal diverticula do not cause major symptoms, they are increasingly recognized as causes of pancreaticobiliary disease. Food bezoar in a juxtapapillary duodenal diverticulum (JPDD) causing pancreaticobiliary obstruction is rare, with the first of such case reported in 1977 [3]. We present a case of food bezoar in JPDD causing pancreatitis, severe pancreaticobiliary duct obstruction and dilation--mimicking as neoplasm-that was successfully diagnosed and treated endoscopically. A 60-year-old female presented with two months of right upper quadrant abdominal (RUQ) pain radiating to the back with associated jaundice, nausea, vomiting, pruritus and clay colored stools. Physical exam was significant for jaundice, epigastric and RUQ tenderness without guarding. Vital signs were normal and afebrile. Laboratory testing revealed leukocyte count of 8,800 mm3, lipase of 1085 U/L, alanine aminotransferase 164 IU/L, total/direct bilirubin of 10.8/8.9 mg/dL and alkaline phosphatase of 523 IU/L. Abdominal ultrasound showed common bile duct (CBD) dilation to 17 mm and was without choledocholithiasis. CT of abdomen showed a 3.8 cm pancreatic head mass causing significant biliary ductal dilatation as well as pancreatic ductal dilatation (Fig. 1). Esophagogastroduodenoscopy (EGD) revealed large periampullary diverticula with impacted bezoar that was disimpacted with flushes and Roth Net (Fig. 2). Endoscopic ultrasound performed post disimpaction demonstrated aforementioned ductal dilatation on CT and diverticula, but without pancreatic head mass, choledocholithiasis, or panLETTER TO THE EDITOR