The Wrath of Pancreatic Enzymes: A Rare Case of Hematuria

Abstract

Acute pancreatitis (AP) is a common gastrointestinal disease associated with many local complications including peripancreatic fluid collections, pseudocysts and necrosis. We present an unusual complication of AP: destruction of the ureter from pancreatic enzymes.A 60-year-old male with a history of former tobacco and alcohol abuse presented to the ED with a 3-day history of periumbilical pain and 1-day of hematuria. Vital signs on admission were within normal limits, physical exam was notable for periumbilical and suprapubic tenderness. Urinalysis showed a significant amount of blood, >100 rbc/hpf, 100mg/dl of protein. Lipase was 259 IU/L. Computed tomography (CT) without contrast showed significant peri-pancreatic stranding around the body and tail of the pancreas with small calcifications in the head. Subsequent CT urogram with contrast showed necrotizing tissue in the body of pancreas, a fluid collection adjacent to the left ureter and evidence of a ruptured left calyx without hydroureteronephrosis. A left ureteral stent and nephrostomy tube were placed. Patients course was complicated by DIC and ARDS, he was discharged 10 days later without any further episodes of hematuria. This case demonstrated multiple complications of severe pancreatitis including a rare manifestation of direct visceral damage. Pancreatic inflammation can have a local effect with involvement of the perirenal fascia in 82% of patients with severe pancreatitis. Release of proteolytic enzymes into the peripancreatic fat is suspected to cause inflammation of the retroperitoneal fascial planes. This local inflammation is noted as perirenal fat stranding on CT imaging. However, progression of this inflammation into direct ureteral damage is exceedingly rare and rupture is usually associated with hydronephrosis and ureteral obstruction. According to a 2009 review, only 27 cases have been reported in the literature. Our case is unique as there is ureteral injury causing rupture but no evidence of hydronephrosis on imaging. Furthermore, the majority of cases with hydronephrosis and ureteral injury are on the right side. Due to the evidence of calcifications in the pancreas on imaging, it is suspected that our patient had acute on chronic pancreatitis causing direct proteolytic injury to the ureter without any concurrent obstruction or hydronephrosis. The case serves as a reminder that two presenting complaints are often correlated to an underlying pathophysiology.1246_A.tif Figure 1: Severe pancreatitis with necrosis1246_B.tif Figure 2: Coronal MIP showing evidence of extravasation of contrast from ureter