Acute pancreatitis and duodenobiliary fistula - a rare complication of Crohn's disease

History: A 53-year-old man with long-standing Crohn's disease presented with recurrent abdominal pain and vomiting; lipase levels were elevated. Investigations and diagnosis: At admission ultrasound demonstrated a swollen head of the pancreas, dilated pancreatic and intrahepatic bile ducts and peripancreatic fluid. At upper gastrointestinal endoscopy a 10 mm bleeding ulcer was identified, which histologically proved to be epitheloid cell-containing granulomas. A fistula connecting to the hepatocholedochal duct was identified at the floor of the ulcer. Helicobacter pylori was not demonstrated. Treatment and course: After sphincterotomy of the papilla of Vater concrements were extracted and a stent was implanted into the common bile duct. Ultimately a total of five stents were consecutively implanted via the major papilla, closing the fistula. After three years all stents were removed and pancreatitis did not recur. Conclusion: The differential diagnosis of abdominal pain in patients with Crohn's disease is often difficult and should include fistulas of the upper gastrointestinal tract which may be treated endoscopically.