Celiac Disease and papillary stenosis

Introduction Celiac Disease is a genetically predetermined chronic inflammation characteristically affecting the proximal small bowel. Whilst pancreatitis has been seen in celiac disease ,no specific etiology has been identified. We have encountered three patients with celiac disease and papilla of vater stenosis. Methods: We reviewed the records of all patients undergoing ERCP at the University of Iowa who had a diagnosis of papillary dysfunction. 170/239 patients had a fixed papillary stenosis. Of these 3/170 had a diagnosis of celiac disease. Case one: 56 y.o. male with known celiac disease, presented with a two year history of idiopathic pancreatitis primarily on business trips. He was on a gluten free diet (GFD) with intermittent non-compliance while traveling. ERCP demonstrated normal biliary and pancreatitic ducts. Biliary manometry demonstrated papillary stenosis with marked inflammation on biopsy. No further episodes on rigid GFD. Case Two: 60 y.o. female presented with acute pancreatitis. ERCP revealed papillary stenosis and was treated with papillotomy. Patient subsequently presented with T-cell small bowel lymphoma. Celiac disease was later confirmed with biopsy and serology. Case three: 56 y.o. female with postprandial biliary pain . She underwent ERCP which revealed duodenal ulceration, papillary stenosis and underwent a papillotomy. 18 months later, the patient presented with lactose intolerance and a diagnosis of celiac disease was made with biopsy and serology. Discussion; These 3 cases illustrate the association of papillary stenosis with celiac disease at a rate greater than chance(1.8 %). It is likely that the mucosal inflammation seen in celiac disease involving the papilla in the duodenum is the likely etiotogic factor involved in these cases The finding of improvement following reduction of inflammation on a GFD, make this postulate even more likely. Whilst this retrospective survey revealed coexistence of 2% of papillary stenosis cases seen in one medical center, celiac disease should be considered as a potential etiotogic factor in papillary stenosis. A prospective search may reveal further undiagnosed cases.