+Model
ARTICLE IN PRESS
CLINRE-775; No. of Pages 2
Clinics and Research in Hepatology and Gastroenterology (2015) xxx, xxx.e1—xxx.e2
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LETTER TO THE EDITOR Loperamide-induced recurrent acute pancreatitis Dear Editor, Acute pancreatitis is among the most frequent gastrointestinal disorders and has numerous etiologies [1]. Drug-induced acute pancreatitis is responsible for only 0.1—2% of cases. Loperamide is an opiate with peripheral action, used in the treatment of diarrhea. Herein, we report a rare case of recurrent acute pancreatitis induced by the intake of loperamide. A 65-year-old woman with a history of laparoscopic cholecystectomy and one episode of acute pancreatitis presented to our emergency center for abdominal pain and mild diarrhea for which she had taken loperamide. The patient had already been admitted to our division for acute pancreatitis of unknown etiology 4 months earlier. She declined any alcohol consumption and had a negative family history for pancreatitis. Abdominal palpation showed epigastric tenderness while lab tests revealed elevated serum amylase and lipase, 472 U/L and 1531 U/L, respectively. Liver function tests were also elevated: aspartate transaminase 208 U/L, alanine transaminase 128 U/L, alkaline phosphatase 123 U/L, ␥-GT 149 U/L. White cell count, C-reactive protein, calcium, triglycerides and IgG4 were unremarkable. An abdominal ultrasound confirmed status post-cholecystectomy, no bile duct dilation and no other relevant lesion. An axial intravenously contrast-enhanced CT-image performed during her prior admission demonstrated a well-defined pancreatic gland and homogeneous parenchyma (arrows) without interstitial or peripancreatic edema: acute pancreatitis of type A according to Balthazar et al. [2] (Fig. 1); therefore we did not repeat this imaging during the second episode. Since loperamide was discontinued, patient condition improved and she was released 5 days after admission. A pancreatic magnetic resonance imaging (MRI) including MR-cholangiopancreatography was performed on an outpatient basis, showing a well-defined homogeneously hypointense pancreatic gland without any sign of acute inflammation. The principal pancreatic duct (arrow) was thin and regular. The MRI confidently excluded common bile duct lithiasis or any other underlying morphological cause for acute pancreatitis (Fig. 2).
Gallstones and alcohol are responsible for 35—40% and 30% of acute pancreatitis, respectively [1] http://www. uptodate.com/contents/etiology-of-acute-pancreatitis/ abstract/14. In this case, both causes could be confidently excluded based on the history of the patient and on imaging studies. By thoroughly reviewing her history, the intake of loperamide was the most relevant element that specifically coincided with the onset of both episodes, giving rise to the diagnosis of loperamide-induced acute pancreatitis. She reported a loperamide-intake of 6 mg/d, during 2 days, for mild diarrhea. Since loperamide was discontinued, patient condition improved and she did not present any recurrence, with a follow-up of 16 months. The World Health Organization (WHO) edited a list of 525 drugs suspected to induce acute pancreatitis as a possible side effect. Although drug-induced acute pancreatitis is considered as a relatively rare entity accounting for only 0.1% to 2% of cases, it may presumably be underdiagnosed in some cases and classified as of ‘‘unknown etiology’’ [3], like for the first episode in the present case. We performed a review of
Figure 1 Axial intravenously contrast-enhanced computed tomography (CT)-image demonstrates a well-defined pancreatic gland and homogeneous parenchyma (arrows) without interstitial neither peripancreatic edema. Acute pancreatitis of type A according to Balthazar et al. [2].
http://dx.doi.org/10.1016/j.clinre.2015.06.008 2210-7401/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Labgaa I, et al. Loperamide-induced recurrent acute pancreatitis. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.06.008
+Model CLINRE-775; No. of Pages 2
ARTICLE IN PRESS
xxx.e2
Letter to the editor
References
Figure 2 Axial T2-weighted magnetic resonance images (MRI) show a well-defined homogeneously hypointense pancreatic gland without any sign of acute inflammation. The principal pancreatic duct (arrow) is thin and regular.
[1] Forsmark CE, Baillie J, Practice AGAIC, Economics C, Board AGAIG. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007;132(5):2022—44. [2] Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174(2):331—6. [3] Spanier BW, Tuynman HA, van der Hulst RW, Dijkgraaf MG, Bruno MJ. Acute pancreatitis and concomitant use of pancreatitisassociated drugs. Am J Gastroenterol 2011;106(12): 2183—8. [4] Lee HM, Villa AF, Caudrelier S, Garnier R. Can loperamide cause acute pancreatitis? Pancreas 2011;40(5):780—1. [5] Vidarsdottir H, Vidarsdottir H, Moller PH, Bjornsson ES. Loperamide-induced acute pancreatitis. Case Rep Gastrointest Med 2013;2013:517414. [6] Howaizi M, Sbai-Idrissi MS, Baillet P. Loperamide-induced acute pancreatitis. Gastroenterol Clin Biol 2000;24(5):589—91 [Pancréatite aiguë secondaire à la prise de loperamide]. [7] Epelde F, Boada L, Tost J. Pancreatitis caused by loperamide overdose. Ann Pharmacother 1996;30(11):1339.
Ismaïl Labgaa a,∗ Emilie Uldry a Christopher Doerig b Sabine Schmidt c Nicolas Demartines a Nermin Halkic a a Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland b Division of Gastroenterology and Hepatology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland c Department of Radiology and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
the literature for loperamide-induced acute pancreatitis, disclosing only 4 other cases [4—7]. The present report is the first describing two consecutive episodes of acute pancreatitis induced by loperamide. In conclusion, loperamide-induced acute pancreatitis is a rare disorder that may concern doctors from a wide spectrum of specialties: gastroenterology, emergency, general or hepatobiliary surgery, internal medicine and family medicine. Involved doctors should consider it and integrate it in their differential diagnosis of acute pancreatitis.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Source of fundings: none. Consent: written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
∗
Corresponding author at: Department of Visceral Surgery, University of Lausanne (CHUV), rue du Bugnon 46, 1011 Lausanne, Switzerland. Tel.: +1 646 549 0930; fax: +1 212 824 2574. E-mail address: [email protected] (I. Labgaa)
Please cite this article in press as: Labgaa I, et al. Loperamide-induced recurrent acute pancreatitis. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.06.008
ARTICLE IN PRESS
CLINRE-775; No. of Pages 2
Clinics and Research in Hepatology and Gastroenterology (2015) xxx, xxx.e1—xxx.e2
Available online at
ScienceDirect www.sciencedirect.com
LETTER TO THE EDITOR Loperamide-induced recurrent acute pancreatitis Dear Editor, Acute pancreatitis is among the most frequent gastrointestinal disorders and has numerous etiologies [1]. Drug-induced acute pancreatitis is responsible for only 0.1—2% of cases. Loperamide is an opiate with peripheral action, used in the treatment of diarrhea. Herein, we report a rare case of recurrent acute pancreatitis induced by the intake of loperamide. A 65-year-old woman with a history of laparoscopic cholecystectomy and one episode of acute pancreatitis presented to our emergency center for abdominal pain and mild diarrhea for which she had taken loperamide. The patient had already been admitted to our division for acute pancreatitis of unknown etiology 4 months earlier. She declined any alcohol consumption and had a negative family history for pancreatitis. Abdominal palpation showed epigastric tenderness while lab tests revealed elevated serum amylase and lipase, 472 U/L and 1531 U/L, respectively. Liver function tests were also elevated: aspartate transaminase 208 U/L, alanine transaminase 128 U/L, alkaline phosphatase 123 U/L, ␥-GT 149 U/L. White cell count, C-reactive protein, calcium, triglycerides and IgG4 were unremarkable. An abdominal ultrasound confirmed status post-cholecystectomy, no bile duct dilation and no other relevant lesion. An axial intravenously contrast-enhanced CT-image performed during her prior admission demonstrated a well-defined pancreatic gland and homogeneous parenchyma (arrows) without interstitial or peripancreatic edema: acute pancreatitis of type A according to Balthazar et al. [2] (Fig. 1); therefore we did not repeat this imaging during the second episode. Since loperamide was discontinued, patient condition improved and she was released 5 days after admission. A pancreatic magnetic resonance imaging (MRI) including MR-cholangiopancreatography was performed on an outpatient basis, showing a well-defined homogeneously hypointense pancreatic gland without any sign of acute inflammation. The principal pancreatic duct (arrow) was thin and regular. The MRI confidently excluded common bile duct lithiasis or any other underlying morphological cause for acute pancreatitis (Fig. 2).
Gallstones and alcohol are responsible for 35—40% and 30% of acute pancreatitis, respectively [1] http://www. uptodate.com/contents/etiology-of-acute-pancreatitis/ abstract/14. In this case, both causes could be confidently excluded based on the history of the patient and on imaging studies. By thoroughly reviewing her history, the intake of loperamide was the most relevant element that specifically coincided with the onset of both episodes, giving rise to the diagnosis of loperamide-induced acute pancreatitis. She reported a loperamide-intake of 6 mg/d, during 2 days, for mild diarrhea. Since loperamide was discontinued, patient condition improved and she did not present any recurrence, with a follow-up of 16 months. The World Health Organization (WHO) edited a list of 525 drugs suspected to induce acute pancreatitis as a possible side effect. Although drug-induced acute pancreatitis is considered as a relatively rare entity accounting for only 0.1% to 2% of cases, it may presumably be underdiagnosed in some cases and classified as of ‘‘unknown etiology’’ [3], like for the first episode in the present case. We performed a review of
Figure 1 Axial intravenously contrast-enhanced computed tomography (CT)-image demonstrates a well-defined pancreatic gland and homogeneous parenchyma (arrows) without interstitial neither peripancreatic edema. Acute pancreatitis of type A according to Balthazar et al. [2].
http://dx.doi.org/10.1016/j.clinre.2015.06.008 2210-7401/© 2015 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Labgaa I, et al. Loperamide-induced recurrent acute pancreatitis. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.06.008
+Model CLINRE-775; No. of Pages 2
ARTICLE IN PRESS
xxx.e2
Letter to the editor
References
Figure 2 Axial T2-weighted magnetic resonance images (MRI) show a well-defined homogeneously hypointense pancreatic gland without any sign of acute inflammation. The principal pancreatic duct (arrow) is thin and regular.
[1] Forsmark CE, Baillie J, Practice AGAIC, Economics C, Board AGAIG. AGA Institute technical review on acute pancreatitis. Gastroenterology 2007;132(5):2022—44. [2] Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174(2):331—6. [3] Spanier BW, Tuynman HA, van der Hulst RW, Dijkgraaf MG, Bruno MJ. Acute pancreatitis and concomitant use of pancreatitisassociated drugs. Am J Gastroenterol 2011;106(12): 2183—8. [4] Lee HM, Villa AF, Caudrelier S, Garnier R. Can loperamide cause acute pancreatitis? Pancreas 2011;40(5):780—1. [5] Vidarsdottir H, Vidarsdottir H, Moller PH, Bjornsson ES. Loperamide-induced acute pancreatitis. Case Rep Gastrointest Med 2013;2013:517414. [6] Howaizi M, Sbai-Idrissi MS, Baillet P. Loperamide-induced acute pancreatitis. Gastroenterol Clin Biol 2000;24(5):589—91 [Pancréatite aiguë secondaire à la prise de loperamide]. [7] Epelde F, Boada L, Tost J. Pancreatitis caused by loperamide overdose. Ann Pharmacother 1996;30(11):1339.
Ismaïl Labgaa a,∗ Emilie Uldry a Christopher Doerig b Sabine Schmidt c Nicolas Demartines a Nermin Halkic a a Department of Visceral Surgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland b Division of Gastroenterology and Hepatology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland c Department of Radiology and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
the literature for loperamide-induced acute pancreatitis, disclosing only 4 other cases [4—7]. The present report is the first describing two consecutive episodes of acute pancreatitis induced by loperamide. In conclusion, loperamide-induced acute pancreatitis is a rare disorder that may concern doctors from a wide spectrum of specialties: gastroenterology, emergency, general or hepatobiliary surgery, internal medicine and family medicine. Involved doctors should consider it and integrate it in their differential diagnosis of acute pancreatitis.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Source of fundings: none. Consent: written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
∗
Corresponding author at: Department of Visceral Surgery, University of Lausanne (CHUV), rue du Bugnon 46, 1011 Lausanne, Switzerland. Tel.: +1 646 549 0930; fax: +1 212 824 2574. E-mail address: [email protected] (I. Labgaa)
Please cite this article in press as: Labgaa I, et al. Loperamide-induced recurrent acute pancreatitis. Clin Res Hepatol Gastroenterol (2015), http://dx.doi.org/10.1016/j.clinre.2015.06.008
