Pancreatic panniculitis associated with periampullary duodenal diverticulum

Tanja Tirnanić; Tatjana  Radević; Andrea Djordjević; Nenad  Petrov; Željko Mijušković

doi:10.2298/VSP230626043T

Tanja Tirnanić Military Medical Academy, *Clinic for Dermatovenerology, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Tatjana Radević Military Medical Academy, Clinic for Dermatovenerology, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Andrea Djordjević Military Medical Academy, Clinic for Dermatovenerology, Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia
Nenad Petrov University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia; Military Medical Academy Institute of Pathology and Forensic Medicine, Belgrade, Serbia
Željko Mijušković Military Medical Academy, Clinic for Dermatovenerology Belgrade, Serbia; University of Defence, Faculty of Medicine of the Military Medical Academy, Belgrade, Serbia

DOI: https://doi.org/10.2298/VSP230626043T

Keywords: diagnosis, diverticulum, endoscopy, gastrointestinal, histological techniques, pancreatin, pancreatitis, panniculitis, tomography, x-ray computed

Abstract

Introduction. Pancreatic panniculitis (PP) is a rare type of lobular panniculitis that manifests as painful erythematous nodules on the skin of the lower extremities. Subcutaneous fat necrosis caused by the release of pancreatic enzymes is the underlying cause of the disease, affecting around 2–3% of patients with pancreatic diseases. Case report. We present a case of a 58-year-old male patient who was admitted to our clinic due to the appearance of painful erythematous nodules on the lower extremities and trunk. Laboratory results revealed increased levels of pancreatic enzymes, amylase, and lipase, as well as heightened levels of glucose and inflammation markers. The histological analysis of the skin lesion biopsy revealed the presence of predominantly lobular panniculitis in the hypodermis, with areas of fatty tissue necrosis/saponification and remnants of adipocytes (“ghost cells”). Abdominal computed tomography scan demonstrated periampullary diverticulum (PD) of the duodenum, with no signs of pancreatitis or other pancreatic abnormalities. Esophagogastroduodenoscopy showed a wide opening of PD in the D2 segment of the duodenum. The patient was successfully treated with pancreatin therapy, resulting in a significant reduction of skin lesions and decreased levels of pancreatic enzymes. Conclusion. Duodenal PDs can be the cause of PP, most likely due to the pressure they exert on the pancreatic duct, which can lead to elevated values of pancreatic enzymes. Depending on the individual characteristics of the patient, symptomatic duodenal PD may be treated with operative or non-operative measures. Treatment of PP primarily involves addressing any underlying medical condition.

References

Sánchez RB, Bustos BD, Bel PH, Aguilar AT, De Miquel VA. Pancreatic panniculitis. A review of 7 cases. Piel 2012; 27(7): 367–71. (Spanish)

García-Romero D, Vanaclocha F. Pancreatic panniculitis. Dermatol Clin 2008; 26(4): 465–70.

Requena L, Sánchez Yus E. Panniculitis. Part II. Mostly lobular panniculitis. J Am Acad Dermatol 2001; 45(3): 325–61; quiz 362–4.

Naeyaert C, de Clerck F, De Wilde V. Pancreatic panniculitis as a paraneoplastic phenomenon of a pancreatic acinar cell carci-noma. Acta Clin Belg 2016; 71(6): 448–50.

Martínez-Escribano JA, Pedro F, Sabater V, Quacedo E, Navarro V, Aliaga A. Acute exanthem and pancreatic panniculitis in a patient with primary HIV infection and haemophagocytic syn-drome. Br J Dermatol 1996; 134(4): 804–7.

Koh WL, Tay YK, Ng VW. Pancreatic Panniculitis Sans Pan-creatitis in a Patient with Diabetic Ketoacidosis. Ann Acad Med Singap 2017; 46(6): 252–3.

Milani-Nejad N, Johnson AG, Chung CG. Nonpancreatic Pancreatic Panniculitis: An Incidental Finding in Individuals without Pancreatic Disease? A Case Series and Review of the Literature. J Clin Aesthet Dermatol 2021; 14(4): 28–30.

Corazza M, Salmi R, Strumia R. Pancreatic panniculitis as a first sign of liver carcinoma. Acta Derm Venereol 2003; 83(3): 230–1.

Goyal A, Jain M, Rehberg K, Goodman W, Gertner E. Pancreatic panniculitis in active systemic lupus erythematosus. J Cutan Pathol 2019; 46(9): 688–90.

Rizwan MM, Singh H, Chandar V, Zulfiqar M, Singh V. Duode-nal diverticulum and associated pancreatitis: case report with brief review of literature. World J Gastrointest Endosc 2011; 3(3): 62–3.

Uomo G, Manes G, Ragozzino A, Cavallera A, Rabitti PG. Peri-ampullary extraluminal duodenal diverticula and acute pancreatitis: an underestimated etiological association. Am J Gastroenterol 1996; 91(6): 1186–8.

Chen Q, Zhang Y, Tang Z, Yu M, Liu Z, Zhou X, et al. The role of periampullary diverticulum on the incidence of pancreati-cobiliary diseases and the outcome of endoscopic retrograde cholangiopancreatography. Arch Med Sci 2020; 17(4): 905–14.

Clavien PA, Hauser H, Meyer P, Rohner A. Value of contrast-enhanced computerized tomography in the early diagnosis and prognosis of acute pancreatitis. Am J Surg 1988; 155(3): 457–66.

Rongioletti F, Caputo V. Pancreatic panniculitis. G Ital Dermatol Venereol 2013; 148(4): 419–25.

Hudson-Peacock MJ, Regnard CF, Farr PM. Liquefying panniculi-tis associated with acinous carcinoma of the pancreas respond-ing to octreotide. J R Soc Med 1994; 87(6): 361–2.

Chait JS, Galli LD, Clark CJ. Indications for Operative Man-agement of Complicated Duodenal Diverticula: A Review. Am Surg 2023; 89(7): 3043–6.