European Journal of Internal Medicine 97 (2022) 101–102

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European Journal of Internal Medicine

journal homepage: www.elsevier.com/locate/ejim

Internal Medicine Flashcard

Acute abdominal pain following esophagogastroduodenoscopy✰,✰✰

Takashi Oshima, Hiroyuki Yano, Mitsuyo Kinjo *
Department of Medicine, Okinawa Chubu Hospital, Okinawa, Japan

1. Introduction dilation of the lower esophagus, stomach, and duodenum. The duo­
denum was compressed between the superior mesenteric artery (SMA)
A 48-year-old man developed abdominal pain and vomiting twelve and abdominal aorta. (Fig. B)
hours after esophagogastroduodenoscopy. He had lost 4.4 kg while What is the diagnosis?
being treated for a gluteal muscle abscess two months prior, and then
underwent surgery for gastric perforation one month prior to admission. 2. Diagnosis
His-postoperative course was uneventful and endoscopy showed a
healed benign gastric ulcer. His-past medical history included schizo­ Acute pancreatitis triggered by endoscopic insufflation.
phrenia and poorly controlled type 1 diabetes. Prescribed medications
included insulin and vonoprazan. He did not smoke or drink alcohol.
3. Discussion
His-vital signs were unremarkable. BMI was 14.3 kg/m2. Patient was
in moderate distress. Abdominal examination revealed tenderness in
Prompt decompression of duodenal hypertension by nasogastric
epigastrium, without rebound or guarding. Lipase and amylase were
suction with no oral intake and intravenous fluid rapidly relieved his
elevated at 2004 U/L (range 13–49) and 847 U/L (range 44–132).
abdominal pain. His-pancreatic enzymes normalized. This patient, who
Electrolyte level and triglycerides were normal. Contrast enhanced
likely had pre-existing diabetic dysmotility, developed critically
computed tomography of abdomen demonstrated a swollen pancreatic
increased intraluminal pressure in the duodenum when air was intro­
head with minimal fluid collection without cholelithiasis (Fig. A) and
duced during upper endoscopy. He regained his weight after two months

Fig. A. Swollen pancreatic head (yellow arrow) with minimal fluid collection and no gallstones. B. Horizontal duodenum was compressed (white arrow) by the
superior mesenteric artery (yellow arrow) and abdominal aorta (blue arrow).

✰
Funding source: None. ✰✰ Declarations of interest: None.
* Corresponding author.
E-mail address: kinjomitsuyo@gmail.com (M. Kinjo).

https://doi.org/10.1016/j.ejim.2022.01.006
Received 24 October 2021; Accepted 1 January 2022
Available online 7 January 2022
0953-6205/© 2022 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
T. Oshima et al.
of nutritional support and did well without recurrent pancreatitis.
The temporal relationship to endoscopy in the absence of other eti­
ologies such as cholelithiasis or alcoholism implicated the procedure.
Duodenal hypertension is an uncommon cause of acute pancreatitis.
Mechanical obstruction or impaired intestinal peristalsis (e.g. diabetes)
predisposes to elevated duodenal pressure, which can be provoked by
SMA syndrome, duodenal loop obstruction after gastric surgery, and
double-balloon enteroscopy [1,2]. Increased intraluminal pressure in
the duodenum and pancreatic duct led to reflux of pancreatic enzymes
into the pancreatic duct, resulting in acute pancreatitis[1].
Several cases of acute pancreatitis following upper and/or lower
endoscopy have been described[3]. Pancreatitis is presumed to be
caused by direct trauma or gas insufflation in duodenum or in pancreas,
leading to inflammatory response. Acute pancreatitis shortly after upper
endoscopy is a rare complication of endoscopy that should be considered
when other common etiologies of pancreatitis are absent.
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European Journal of Internal Medicine 97 (2022) 101–102
Acknowledgment
We would like to thank Dr. Lisa Rucker (General Internal Medicine,
Jacobi Medical Center, NY) and Dr. Rita McGill (Nephrology, University
of Chicago) for kind English correction of this manuscript. We also thank
Dr. Tetsushi Higa (Medicine, Okinawa Chubu Hospital) for patient
management.
References
[1] Groenen MJ, Moreels TG, Orlent H, Haringsma J, Kuipers EJ. Acute pancreatitis
after double-balloon enteroscopy–An old pathogenetic theory revisited as a result of
using a new endoscopic tool. Endoscopy 2006;38:82–5.
[2] Sihuay-Diburga DJ, Accarino-Garaventa A, Vilaseca-Montplet J, Azpiroz-Vidaur F.
Acute pancreatitis and superior mesenteric artery syndrome. Rev Esp Enferm Dig
2013;105:626–8.
[3] Nwafo NA. Acute pancreatitis following oesophagogastroduodenoscopy. BMJ Case
Rep 2017;2017:bcr2017222272.