A Rare Cause of Acute Pancreatitis Authors: Chintan Gandhi, MD; Tavleen Bhatia, MD; Jay Dadhania, MD The Children’s Hospital at Saint Peter’s University Hospital, New Brunswick, New Jersey CT abdomen with contrast: Enlarged pancreas with multiple nodules in duodenum, jejunum and ileum with significant mesenteric and retroperitoneal lymphadenopathy (Fig 1). Introduction: Discussion: Increased incidence of acute pancreatitis in children Common etiologies include biliary disorders, idiopathic, trauma and medications No reports of leukemia presenting as acute pancreatitis in pediatric population. Reporting a case of acute pancreatitis caused by extra-medullary acute myeloid leukemia (AML) Acute pancreatitis, as per Atlanta Classification, requires two of the following three features: 1) abdominal pain suggestive strongly of acute pancreatitis, 2) serum amylase and/or Lipase activity at least 3 times greater than the upper limit of normal, and 3) characteristic findings of acute pancreatitis on trans-abdominal USG or CT. Acute pancreatitis in this case presumed to be due to obstruction of pancreatic ampulla by extra medullary AML nodules. Complete resolution of pancreatitis clinically as well as radiologically after chemotherapy supports our assumption Most cases of acute pancreatitis are self limiting without significant morbidity; however, it is essential to look for an underlying cause and treat it to prevent recurrence. This case signifies the importance of finding the underlying etiology of pancreatitis and treating it. Fig. 2 EGD showing mass protruding in 2nd and 3rd part of duodenum Case Report: Endoscopy: Several masses protruding in duodenum in the vicinity of ampulla of duodenum (Fig 2). Duodenal Biopsy: Mucosa with mononuclear infiltrate, mixed with eosinophils s/o myeloid sarcoma/leukemia. Additional Studies: Lymph node and bone marrow biopsy showed increased leukemic cells with 19% blast cells s/o AML. Follow up: After chemotherapy, patient improved significantly and pancreatitis resolved with normal levels of Lipase and normal appearance pancreas on repeat CT(Fig 3). Clinical History : 10 year-old-boy presented with acute onset epigastric pain and vomiting on and off for one month. Developed bilious vomiting on 2nd day of admission. Associated symptoms: Lethargy and 8-pound weight loss in one month. History of similar episode two weeks prior to this admission. Family history: Positive for parental consanguinity, autoimmune diseases. No family history of pancreatitis or metabolic disorder. Labs: Normal CBC, electrolytes and amylase. Elevated LFTs (Bilirubin 2.8 with direct bilirubin of 1, AST 150, ALT 194, Alk Phos 469) and Lipase 1089. Imaging: Abdominal USG: Diffusely enlarged pancreas suggestive of acute pancreatitis and no signs of biliary obstruction or gall stone. Upper GI series: Numerous filling defects in second and third portion of duodenum References: Rajeshwari B. et al. Acute myeloid leukemia presenting as obstructive jaundice. Indian Journal of Pediatrics 2012 May;49(5):414-6 Xin-Ping Li et al. Isolated pancreatic granulocytic sarcoma: A case report and review of the literature. World J Gastroenterol 2011 January 28;17(4):540-542 F. Ravandi-Kashani et al. Granulocytic sarcoma of the pancreas: a report of two cases and literature review. Clin. Lab. Haem.1999, 21:219-224 Fig. 1 CT scan abdomen showing Fig. 3 showing normal pancreas after enlarge pancreatitis chemotherapy