Inferior Vena Cava Thrombosis in Acute Pancreatitis: A Rare Vascular Complication

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Introduction: The systemic complications of acute pancreatitis are myriad and are mostly a consequence of systemic inflammatory response. Isolated portal and superior mesenteric vein thrombosis are well recognized complications of acute pancreatitis, while thrombosis involving the inferior vena cava (IVC) is extremely rare. Case Report: A 79-year-old male with history of chronic alcoholism presented with upper abdominal pain of 3 weeks' duration. Initial evaluation revealed epigastric tenderness and a serum lipase level of 1,041 U/L. Abdominal computerized tomography showed inflammatory stranding in the pancreatic head, 7-mm pancreatic duct calculus, and punctate calcifications in the pancreatic body suggestive of acute on chronic pancreatitis. He also had a pancreatic pseudocyst and 3.4-cm thrombosis in the IVC above the level of right renal vein with 60% luminal obstruction. He was started on intravenous heparin. He developed abdominal distension and a fall in the hematocrit in the next 2 days. Repeat imaging revealed hemorrhage into the pseudocyst with probable rupture into the peritoneal cavity. Anticoagulation was stopped and he was conservatively managed with blood transfusion. An IVC filter was placed. The workup for hypercoagulabe state including factor V Leiden mutation, prothrombin gene mutation, and activity of protein C, protein S, and antithrombin III was unremarkable. An ERCP done later showed pancreatic duct stricture with calculus that was not amenable to endoscopic treatment. He is on followup and is doing symptomatically well. Discussion: Venous thrombosis occurring outside the splanchnic circulation is very rarely described in pancreatitis. Release of pancreatic proteolytic enzymes due to acute inflammation is the most likely mechanism responsible for thrombosis of the splenic, portal, and superior mesenteric veins. IVC thrombosis can result from systemic inflammatory response with hypercoagulable state or a pancreatic cyst that compresses or penetrates the IVC. Pulmonary thromboembolism is a potential cause of mortality and morbidity in patients with IVC thrombosis, hence early recognition of this complication is vital. There are isolated reports of patients with acute pancreatitis and extra-splanchnic venous thrombosis who have been successfully treated with anticoagulation. In the setting of a pancreatic pseudocyst, anticoagulation is fraught with danger as it can result in hemorrhage into the cyst as described in our case. IVC filter placement is a good alternative in patients who cannot undergo anticoagulation or develop bleeding after anticoagulation. Literature regarding the optimal strategy and the duration of anticoagulation in these patients is minimal.