Aggravated pancreatitis after performing a colonoscopy

A 44-year-old man with alcoholism and diabetes complained of epigastric pain radiating to his back for 1 day. Fever or signs of toxicity were not reported. He visited our emergency department with the following vital signs: body temperature, 36.0°C; pulse rate, 91 beats/min; respiratory rate, 18 breaths/min; blood pressure, 137/90 mmHg, and peripheral oxygen saturation, 97% under room air. Laboratory examination revealed leukocytosis (11,410/μL of blood) and mildly elevated aspartate aminotransferase (52 IU/L). An abdominal computed tomography (CT) scan revealed acute pancreatitis, with the CT severity index being C without necrosis (Figure 1A), and a rectosigmoid tumor (Figure 1B). The BISAP score was zero. The patient was admitted and treated conservatively with bowel rest, intravenous fluids, and analgesics. All symptoms improved on the third day after admission, and the patient tolerated a clear liquid diet. Colonoscopy was arranged 7 days after the initial attack of acute pancreatitis for pathological sampling of the rectosigmoid tumor, and the patient received standard bowel preparation prior to the procedure.

During the procedure, an abdominal pressure maneuver was performed around the sigmoid colon and splenic flexure. However, the colonoscopy could only be advanced to the hepatic flexure due to unbearable pain and intolerance to the abdominal pressure maneuver. The rectosigmoid tumor was biopsied (Figure 1C). After colonoscopy, his abdominal pain progressed within a few hours, and then fever occurred. Follow-up abdominal CT excluded an obstructive bowel gas pattern or evidence of free air; however, previous pancreatitis deteriorated and necrosis was shown (Figure 1D); blood tests revealed significantly elevated amylase and lipase levels. Therefore, the patient was transferred to the intensive care unit and gradually recovered with proper treatment.

In this case, the patient had alcoholism-related acute pancreatitis, which greatly improved symptomatically at the time of colonoscopy. However, the symptoms, CT findings, and elevated lipase levels suggested severe deterioration of the disease immediately after the procedure. Only a few cases of acute pancreatitis attributed to colonoscopy have been reported,^1-4 and currently, there is no discussion regarding aggravated acute pancreatitis after colonoscopy in patients just recovering from the disease. Previous studies have proposed mechanical or barotrauma (from excessive insufflation or abdominal pressure) to the pancreas while moving the endoscope through the bowel as a possible cause of acute pancreatitis after colonoscopy owing to the anatomical proximity of the splenic flexure to the pancreatic body and tail.^{2, 5} This was likely the cause of the deteriorated pancreatitis in the present case, especially considering the technical difficulty of the procedure as well as the inflammatory and swollen status of the pancreas at the time of admission. However, dehydration induced by the bowel prepare process can also be taken as a possible cause of the exacerbated pancreatitis. We conclude that colonoscopy should be avoided in patients with recent acute pancreatitis, even in those with significantly improved symptoms. Further studies are needed to evaluate the proper duration of time or a safe range of lipase levels and infection parameters for performing colonoscopy after acute pancreatitis.

The authors declare no conflicts of interest.

The patient signed informed consent forms before the commencement of the study.