Acute pancreatitis is a common entity treated by all general surgeons, gastroenterologists, and internists. It can go from mild abdominal pain to a severe disease which can end in death due to the systemic inflammatory response syndrome. The most frequent etiology is gallstones followed by ethanol ingestion. However, there are a lot of possible causes of acute pancreatitis:
ERCP
Trauma
Neoplasms
Pancreas divisum
Medications (ex. furosemide)
Hyperlipidemia
Hypercalcemia
Infectious agents (viruses, bacteria, biliary parasites)
Genetic causes (ex. cystic fibrosis)
Autoimmune pancreatitis
Vasculitis
Pregnancy
Recently I found an interesting case report talking about one infrequent cause of acute pancreatitis. This paper was published in 2018 by Dr. Neel Core et al from Australia. They report the case of an obese patient (BMI 41) who resorted to the emergency department because of abdominal pain in the day after being endoscopically inserted with an intragastric balloon (IGB). Blood tests revealed an elevated serum lipase (> 3 times the reference), and an abdominal CT scan demonstrated pancreatitis and free intra-peritoneal fluid. According to the authors, the CT scan also showed a stranding tail of the pancreas due to compression by the IGB. Since there were no other causes for pancreatitis (no gallstones, no trauma, no alcohol ingestion, normal autoimmune screens, normal triglycerides, no history of ERCP, no family history of pancreatitis, no medication), the pancreas compression by the ICG was diagnosed as the cause of acute pancreatitis. After removal of the IGB, the patient improved.
By compressing the pancreas, an IGB can cause acute pancreatitis.
IGB has a severe complications rate of 10,5%. Death has also been reported from gastric perforation or aspiration. Acute pancreatitis is a rare complication from the IGB, it can occur 1 day to 11 months after balloon insertion and has only 13 case reports. Acute pancreatitis is caused by a pancreas compression by the IGB, or by a dislodgment of the catheter (depending on the type of IGB) into the duodenum. Removal of the IGB results in a dramatic improvement. In some cases, the IGB could not be removed endoscopically, and a laparotomy was necessary either for IGB retrieval or to exclude full-thickness gastric wall ischemia on endoscopy. Do you think all reported cases were mild pancreatitis? Wrong. From the 13 cases reported four patients had severe pancreatitis, some of them with pancreatic necrosis. How can such a minimally invasive procedure cause so much damage? Unbelievable, but it is the reality.
I believe these reports are very important since many patients and even doctors think some procedures have no complications. Additionally, some doctors while trying to use their skills and techniques to treat some diseases, fail to recognize that severe complications can arise from any minimally invasive procedure. All patients must be informed that even the easiest and simplest procedure can have severe adverse events. The authors conclude by saying “pancreatitis associated with IGB insertion is a rare but increasingly recognized clinical entity”. This means that all doctors must know this possible complication since prompt removal of the IGB will cause immediate patient improvement.
Link to PubMed:
Dr. Carlos Eduardo Costa Almeida
General Surgeon