S1941 Acute Pancreatitis Following a Lower Extremity Angioplasty

Abstract

Introduction: Acute pancreatitis affects a significant population globally. Usual etiologies are gallstones, alcohol, hypertriglyceridemia, medications; less frequent are trauma, hypercalcemia, infections, toxins, ischemia, anatomic anomalies, vasculitis, and idiopathic. Pancreatitis post coronary intervention is an uncommon cause with only 19 published cases in the last two decades. Being cognizant of this etiology is important given the increasing number of patients undergoing angiography. Case Description/Methods: An 81-year-old female with hypertension, diabetes, peripheral arterial disease, prior cholecystectomy underwent left lower extremity angioplasty at an outside center. Within a few hours, she started having severe epigastric pain radiating to her back, nausea, vomiting and loose bloody stool. She presented to the emergency department 24 hours after symptom onset. Epigastric tenderness was present on exam. Labs revealed leukocytosis (24,450/µL),elevated lipase (1410 U/L), elevated creatinine (1.3 mg/dL), lactate (3.1 mmol/L), calcium 9.4 mg/dL and triglycerides 161 mg/dL. Incidentally, found to be positive for COVID-19. Normal common bile duct diameter seen on sonogram. CT angiogram of the abdomen/pelvis showed acute pancreatitis, duodenal and central small bowel enteritis (Figure). She was not on any medications known to cause pancreatitis and denied alcohol use. Patient improved with analgesics and intravenous fluids. She had no recurrence of bloody stools and hemoglobin remained stable. On day 4, she was able to tolerate a regular diet, and leukocyte count and creatinine normalized. Patient did not have any COVID respiratory symptoms, and was discharged. Discussion: Given the temporal association to angioplasty and no other identifiable cause, acute pancreatitis was presumed to be due to the contrast used during angioplasty. Other possibilities included cholesterol embolism but no peripheral signs of cholesterol embolism were seen. Patient was an asymptomatic COVID-19 case. Although, there are case series of pancreatitis due to COVID, those were found in very sick symptomatic patients. On review of literature, cholesterol embolism was identified as a definite cause only on autopsy or laparotomy (Table). Other possible mechanisms are: high viscosity of the contrast media leading to ischemia and necrosis, contrast causing NF-κB activation followed by epithelial damage, and vasospasm. Pancreatitis after coronary angiography is rare, nonetheless, an important differential especially if there is a temporal relationship.Figure 1.: CT scan (abdomen) of our patient demonstrating acute pancreatitis. Table 1. - Current literature reports on acute pancreatitis after coronary angiography/angioplasty S. NO. YEAR AUTHOR PROCEDURE ETIOLOGY TIME BETWEEN PROCEDURE AND SYMPTOM ONSET CONTRAST USED VOLUME OF CONTRAST(mL) 1 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy 14 hours Not Mentioned 80-160 2 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy Immediately Not Mentioned 80-160 3 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 4 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 5 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 6 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 7 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 8 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 9 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 10 1994 Orvar et al1 Angiography Contrast-Induced Not Mentioned Not Mentioned 80-160 11 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy Not Mentioned Not Mentioned 80-160 12 1994 Orvar et al1 Angiography Cholesterol emboli detected on autopsy Not Mentioned Not Mentioned 80-160 13 2013 Gorges et al2 Angiography Contrast-Induced 1 hour Iopamidol 120 14 2014 Abstract 343, Journal of Hospital Medicine3 Angioplasty Contrast-Induced Not Mentioned Not Mentioned Not Mentioned 15 2017 Hajimaghsoudi et al4 Angiography Contrast-Induced 48 hours Visipaque(Iodixanol) 100 16 2020 Rafiq et al5 Angioplasty Contrast-Induced Immediately Ioversal 150 17 2020 Mui et al6 Angioplasty Contrast-Induced Immediately Omnipaque(Iohexol) 120 A total of 19 cases were identified. However, only seventeen cases have been shown in the table. Due to inability to get permission for reuse, the remaining 2 cases have not been shown. 1 - Orvar K, Johlin FC. Atheromatous embolization resulting in acute pancreatitis after cardiac catheterization and angiographic studies. Arch Intern Med 1994;154:1755–61 2 - Gorges R, Ghalayini W, Zughaib M. A case of contrast-induced pancreatitis following cardiac catheterization. J Invasive Cardiol 2013;25:E203–4. 3 - An Unusual Source of Abdominal Pain.Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev.. Abstract 343 Journal of Hospital Medicine, Volume 9, Suppl 2. https://shmabstracts.org/abstract/an-unusual-source-of-abdominal-pain/ 4 - Hajimaghsoudi M, Zeinali F, Mansouri M, et al. Acute necrotizing pancreatitis following coronary artery angiography: a case report. ARYA Atheroscler 2017;13:156–8. 5 - S1558 A Rare Case of Pancreatitis Secondary to Coronary Angiogram Dye. Rafiq, Rehan; Rafiq, Ahmad.The American Journal of Gastroenterology: October 2020 - Volume 115 - Issue - p S791doi: 10.14309/01.ajg.0000708280.94586.25 6 - Mui JJ, Shamavonian R, Thien KCP. Acute pancreatitis following coronary angiography: case report and review of contrast-induced pancreatitis. Int Surg J 2020;7:870-2