When One Scope Reveals Three Diagnoses

Clinical case: when one scope reveals three diagnoses. A 38-year-old woman. Acute pancreatitis grade A, with acute cholangitis and lower CBD stone on MRCP. On CT, there was also an asymptomatic ileal intussusception. Sent for ERCP. But endoscopy told a much bigger story. Entering the duodenum, the mucosa stopped me - scalloped folds, fissuring, mosaic pattern.Classic signs of coeliac disease. Minimize then the papilla: bulky, obstructed. Cannulation with a guidewire on sphincterotome. Contrast injection revealed a defect in the lower CBD. Sphincterotomy performed. Bile and small debris cleared. Duodenal biopsies taken. Three findings. One unifying diagnosis. 

The Connection Coeliac disease can cause:

→ Papillary stenosis → ductal obstruction → acute pancreatitis

→ Lymphoid hyperplasia in the small bowel → lead point → intussusception (often transient, no surgery needed)

→ Villous atrophy visible endoscopically, even when the indication was purely biliary.

The bulky papilla wasn't idiopathic. The pancreatitis wasn't idiopathic. And the intussusception? Likely the same immune-mediated process at work in the gut wall. 

Practical Pearls

• Always inspect the duodenal mucosa during ERCP — you are already there

• Biopsy both the bulb and the second portion to maximize diagnostic yield

• In adults with idiopathic pancreatitis + papillary stenosis, think coeliac

• Gluten-free diet can resolve the intussusception - no surgery, no intervention

• Exclude adenocarcinoma as a lead point, especially in adults with severe villous atrophy 

Endoscopy is not just a therapeutic tool. It is a diagnostic window - if you choose to look.