Complication Of Chronic Pancreatitis Research Articles

The Occurrence of a Pseudoaneurysm of the Hepatic Artery within the Thrombosed Portal Vein of a Patient with Chronic Pancreatitis: A Case Report

A pseudoaneurysm is an uncommon but important life threatening complication of chronic pancreatitis. The arteries most commonly affected by a pseudoaneurysm are (in decreasing percent occurrence), the splenic (40%), gastroduodenal (30%), pancreaticoduodenal (20%), gastric (5%), hepatic (2%), and others (superior mesenteric, jejunal, ileocecal, and aorta) (1-3%). Thrombosis of the splenic or portal vein is another important complication of chronic pancreatitis. In this case report, we present a rare complication in the form of a right hepatic artery pseudoaneurysm which developed within the thrombosed right portal vein of a 35-year-old woman afflicted with chronic pancreatitis.

Pseudoanévrisme de l’artère hépatique : complication rare au cours de l’histoire naturelle de la pancréatite chronique: À propos de deux cas

Bleeding from a pseudoaneurysm is a rare complication of chronic pancreatitis. We present two cases of ruptured pseudoaneurysms of the hepatic arteries. The first case involved a pancreatic pseudocyst that ruptured in the duodenum and the second resulted in an intrahepatic hematoma that compressed the bile tract causing secondary hemobilia. Angiographic embolization was the primary treatment in both cases, with surgery for the first patient and later radiological drainage in the second. The hemorrhage was controlled in both cases despite the severe prognosis and high mortality in these cases.

Islet Autotransplantation Restores Normal Glucose Tolerance in a Patient With Chronic Pancreatitis

Impaired glucose tolerance is a frequent complication of chronic pancreatitis (CP) that over time leads to diabetes (1). Intractable abdominal pain from CP that can no longer be managed by oral pancreatic enzymes and by narcotic analgesics is treated by surgery. To avoid diabetes onset following pancreatectomy, combined islet autotransplantation has been offered to the patients who suffered from CP in Leicester, U.K., since 1994 (2,3) (http://hpb.org.uk/hpbunitspecialist.php?page_id=11). Here, we present a case report of a patient that suffered from CP and had an abnormal oral glucose tolerance test (OGTT) …

Chronic pancreatitis complicated by pancreaticopericardial fistula

Pancreaticopericardial fistula is an extremely rare complication of chronic pancreatitis with few reported cases. A 45‐year‐old man with a history of chronic pancreatitis presented with dyspnoea and chest pain. On examination, there were signs of pyrexia, tachycardia, tachypnoea and hypotension. Computed tomography and magnetic resonance imaging demonstrated a fistulous tract arising from the tail of the pancreas and extending through the diaphragmatic hiatus into the posterior mediastinum and the pericardial sac. Initial conservative treatment with antibiotics, octreotide (a somatostatin analogue), and nasojejunal feeding led to resolution of the fistula. The patient subsequently underwent an elective Roux‐en‐Y pancreaticojejunostomy 1 month later. The operation was performed without complication and he has remained symptom free during follow‐up. We present this rare complication of chronic pancreatitis and review the relevant literature.

Mechanisms and Emerging Treatments of the Metabolic Complications of Chronic Pancreatitis

Exocrine and endocrine abnormalities in chronic pancreatitis contribute to the morbidity and mortality risks of the disease. Complications of exocrine insufficiency include malabsorption, vitamin deficiency syndromes, and weight loss. Oral enzyme replacement therapy is usually effective if attention is paid to factors that affect the bioavailability of enzyme preparations. Complications of endocrine insufficiency can be more difficult to treat due in part to an incomplete knowledge of their etiology. This review focuses on the endocrine aspects of chronic pancreatitis and highlights the observations of our laboratory on the pathogenesis of the metabolic complications of the disease. In addition to decreased insulin secretory capacity, pancreatogenic (or apancreatic) diabetes is characterized by decreased or absent glucagon and pancreatic polypeptide (PP) secretion, a loss of hepatic insulin receptor (IR) expression/availability, and an impairment in hepatic IR function (phosphorylation and endocytosis). Diminished hepatic IR expression in chronic pancreatitis appears to be because of PP deficiency; laboratory animals and patients with PP deficiency demonstrate decreased hepatic IR availability that is reversed by prolonged (8-hour) PP administration. The impairment in hepatic IR function appears independent of PP deficiency but is reversed by prolonged (28-day) treatment with the insulinotropic/insulinomimetic hormone glucagon-like peptide 1. The endocytosis of hepatic IR is linked to the endocytosis of the glucose transporter 2 from the hepatocyte plasma membrane, and studies suggest that the 2 plasma membrane-bound proteins are complexed noncovalently to function and translocate as a unit after insulin binding to the hepatic IR. The process appears vigorous and sensitive enough to account for a significant reduction in hepatic glucose output and may represent a major mechanism for insulin regulation of hepatic glucose production. The regulatory mechanisms of PP-mediated hepatic IR expression and combined IR and GLUT2 endocytosis after insulin binding are defective in chronic pancreatitis and contribute to the apancreatic diabetes, which characterizes this disease.

Endoscopic treatment of pancreatic fistulas

Aims: Pancreatic fistula is a serious complication of acute and chronic pancreatitis or pancreatic trauma and surgery. Its management is still controversial. Patients and methods: 8 patients with pancreatic fistula were treated endoscopically over a period of 5 years. 5 patients were presented with pancreatic ascites following pancreatic tail resection (2 cases), nephrectomy (1 case), blunt abdominal trauma (1 case) and necrosectomy due to acute necrotic pancreatitis (1 case). In 1 patient pancreatic ascites and left pleural effusion developed after splenectomy and in 1 patient pleural effusion occurred as a complication of chronic pancreatitis; 1 patient had an external fistula associated with pancreatic tail pseudocyst following distal pancreatectomy. The level of amylase in the aspirated fluids were consistently elevated. The mean fistula output volume was 150ml/day. ERCP identified leaks. Dual or pancreatic sphincterotomy, pancreatic stent or nasopancreatic drain placement was performed to lower the pancreatic duct pressure and bypass the ductal disruption. Results: Dual or pancreatic sphincterotomy was effective for the 5 patients in whom the ductal injury originated from the tail of the pancreas and hence could not be bypassed (splenectomy, nephrectomy, abdominal trauma, two postoperative fistulas). These patients had no strictures in the main pancreatic duct. Their fistulas closed within 3 weeks, except for one patient whose fistula closed after 12 weeks. Pancreatic stent or nasopancreatic drain placement was performed in 3 patients with chronic pancreatitis and main pancreatic duct stricture to bypass the disruption. Only in one of the patients it was effective, leading to closure of the fistula. Endoscopic therapy was unsuccessful in 2 patients in spite of pancreatic stent, enteral nutrition and use of octreotide. They required surgery. There was no serious complication or procedure-related mortality. Conclusion: Endoscopic treatment is an effective and safe method for pancreatic fistulas, especially for patients without strictures in the main pancreatic duct.

Pancreaticopleural Fistula

Purpose: Pancreaticopleural fistula (PPF) is a rare entity in which pancreatic secretions drain directly into the pleural cavity. A case is described herein of PPF in a patient with chronic pancreatitis. A 43-year-old male presented with a 4-week history of dysnea, chest pain, cough and a history of alcoholism. On examination he had features of pleural effusion that was confirmed by chest X-ray showing a large left sided pleural effusion. Lab analysis revealed a serum amylase of 651 IU/L (reference range: 0–150 IU/L). A CT scan showed a large left pleural effusion and atrophic pancreas with pseudocysts. Pleural aspiration was done six times without resolution of the effusion. Pleural fluid analysis showed an amylase of 11,990 IU/L. The patient was diagnosed with a PPF and started on octreotide. An ERCP showed an irregular pancreatic duct and a leak from the distal pancreatic duct into the left pleural cavity; a 12 cm 7 Fr pancreatic stent was inserted across the area of disruption. He was discharged on octreotide and a repeat chest X-ray showed no pleural effusion. The patient's pancreatic stent was removed and he is doing well. PPF is a rare complication of chronic pancreatitis. Pleural effusions from pancreatitis are due to irritation of the diaphragm. In contrast, PPF is thought to result from direct pancreatic duct fistulazition, or by pseudocyst passage through diaphragmatic defects. Pleural effusions tend to be recurrent, and analysis of the pleural aspirate reveals a much higher amylase in the setting of PPF as compared to pleural effusions due to pancreatitis. Although an algorithm for evaluation of suspected pancreaticopleural fistula remains to be established, computed tomography has traditionally been the initial imaging modality of choice despite only identifying fistulas less than half the time. ERCP, although invasive, is more sensitive in demonstrating fistulas than CT (79% vs. 43%) and allows for therapeutic intervention at that time3. MRCP may be a promising imaging modality for the future, but remains to be evaluated. A recent review showed that 100% of patients treated with pancreatic stents had complete resolution compared with 0–33% of those who were managed alone with a chest tube, TPN, and octreotide. The authors recommended early endoscopic intervention. Chest tube placement is reserved for those with respiratory compromise. Surgery should only be contemplated as a last resort.

Spontaneous Internal Pancreatic Fistula Presenting with Persistent Pleural Effusion

A 50 year old male patient presented with unexplained shortness of breath for one month. He had no known co- morbidities. His social history was significant for excessive alcohol consumption. Physical exam revealed decreased breath sounds on the right side with dullness to percussion. No abdominal tenderness was noted. Chest radiograph revealed a large right sided pleural effusion, which reformed shortly after pleurocentesis. Magnetic resonance pancreatography (MRP) showed changes of chronic pancreatitis with outpouching from the main pancreatic duct, raising the suspicion a pancreaticopleural fistula. Pleural fluid amylase level was elevated at 43920 U/L. Endoscopic retrograde cholangiopancreatography (ERCP) revealed irregular pancreatic duct with significant contrast leak from the tail, communicating with the right hemi-thorax (Fig 1). Due to significant disruption of pancreatic duct, the decision was made to proceed with distal pancreatectomy. Surgical pathology revealed a 2 cm size fistula originating from the distal pancreatic duct. The patient had an uneventful recovery from surgery.Figure 1Discussion: Internal pancreatic fistulas are uncommon complications of chronic pancreatitis. In most cases, the diagnosis can be made from CT scan, ERCP and MRP, where disruption of the main pancreatic duct is noted. Medical therapy options, including total parenteral nutrition, chest tube placement, octereotide, and nasopancreatic drain, have resulted in resolution of the fistula in 1/3 of the cases described previously. Pancreatic duct stenting has proven to be successful in some cases if done early in the course of the disease. Approximately 50% of the cases described in literature had to undergo surgery, with distal pancreatectomy being the most common resection performed. This choice of treatment is usually considered once medical treatment fails, or in cases where medical therapy is considered less effective, as in the cases of complete ductal disruption. Our patient had significant distal pancreatic duct disruption on top of extensive chronic pancreatitis, making the surgical option more practical. [figure 1]

Pharmacological management of pain in chronic pancreatitis

Pain is the major presenting symptom of chronic pancreatitis. Patients with chronic pancreatitis experience substantial impairments in health-related quality of life. Pain may be considered as the most important factor affecting the quality of life. The pathogenesis of pancreatic pain is poorly understood. The cause of pain in chronic pancreatitis is probably multifactorial. This article discusses the various hypotheses that have been suggested to underlie pain. Special attention is paid to the concept of autonomous central sensitisation and hyperalgesia as a cause of pain. Strict abstinence from alcohol is the first step of chronic pancreatic pain management. As a second step, it is important to exclude treatable complications of chronic pancreatitis, such as pseudocysts. Symptomatic treatment with analgesics is often unavoidable in patients with chronic pancreatitis. Acetaminophen, non-steroidal anti-inflammatory drugs and eventually opioids are suitable. Several trials have been performed with pancreatic enzymes, but a meta-analysis demonstrated no significant benefit in terms of pain relief. The treatment of chronic pancreatic pain requires a multidisciplinary approach that tailors the various therapeutic options to meet the need of the individual patient.

Biliary Pancreatic Portal Fistula as a Complication of Chronic Pancreatitis

In this study we describe an unusual complication in a patient suffering from chronic calcifying pancreatitis. The patient had a fistula between the common bile duct, the pancreatic duct, and the portal vein. He received supportive medical treatment and achieved long-term survival. A review of the literature including diagnosis, treatment and outcome of this rare complication is presented.

Right Hemithoracic Pseudocyst with Splenic Artery Aneurysm: Two Rare Complications of Uncommon Disease

Pleural involvement is an uncommon but well recognized complication of chronic pancreatitis [1], mainly in the form of pleural effusion affecting the left hemithorax. Pancreatic pseudocyst extending to the posterior mediastinum with or without communication with the pleural space is another rare form of this involvement. The treatment of chronic pancreatic pleural effusions and pancreatic pseudocysts generally starts with a conservative approach including bowel rest, drainage of the pleural effusion by repeated thoracentesis or a chest tube, and total parenteral nutrition (TPN) for a period of time determined by the clinical course. Other treatment modalities including percutaneous drainage, endoscopic retrograde cholangiopancreatogram (ERCP) with stenting of the pancreatic duct and surgical drainage are used if conservative approaches fail. We report a patient with a complicated pancreatic pseudocyst who showed an involvement of the posterior mediastinum and right pleural space, with conspectus sparing of the left hemithorax. The patient had a prolonged and complicated course that included recurrence of the pseudocyst with oral feedings and the development of a splenic artery aneurysm. Some of the above findings have been reported separately as uncommon complications of chronic pancreatitis and pancreatic pseudcyst, but to our knowledge a single case with all these complications was not published in the English literature.

Stenosis of the common bile duct in chronic pancreatitis.

The incidence of common bile duct stenosis in patients with chronic pancreatitis was studied in a consecutive series of patients admitted for endoscopic retrograde cholangiopancreatography (ERCP). Thirty-six out of 79 patients (46 per cent) with moderate or advanced chronic pancreatitis as defined by radiological criteria were found to have a stenosis of the intrapancreatic portion of the common bile duct. There were no age or sex differences between the patients with and without biliary stenosis, but significantly more patients with stenosis had advanced chronic pancreatitis. In about two-thirds of the patients the stenosis was smooth, symmetrical and tapering. In the remaining cases, a shorter stricture of the hour-glass type was found. A complete obstruction was never seen. About one-half of the patients with bile duct stenosis were icteric at the time of the investigation. The jaundice resolved spontaneously in all but 1 patient in 3-42 (median 14) days. Stenosis of the common bile duct is a frequent complication of chronic pancreatitis, but biliary-enteric bypass operation seems to be unnecessary in the great majority of the patients.

Alcohol and cigarettes: Partners in crime in chronic pancreatitis

Alcohol and cigarettes: Partners in crime in chronic pancreatitis

Pancreaticothoracic fistulas: imaging findings in five patients

Pancreaticothoracic fistulas are a rare complication of chronic pancreatitis. This study evaluated the imaging findings in patients with pancreaticothoracic fistulas. We retrospectively reviewed the medical records and radiographic images in five patients with pancreaticothoracic fistulas diagnosed at our institution during the previous 6 years. Data from radiography, endoscopic retrograde cholangiopancreatography (ERCP), computed tomography (CT), magnetic resonance cholangiopancreatography, and drainage catheter studies were evaluated. Persistent pleural effusions were present on the radiographs of all patients. ERCP was performed in three patients. Contrast material was injected into drainage catheters placed in a pancreatic pseudocyst in one patient and a pancreatic abscess in another patient. Pancreaticothoracic fistulas were demonstrated on all of these studies. One patient had a CT study immediately after ERCP and another patient had a CT study immediately after contrast material was injected through a drainage catheter placed percutaneously in a pseudocyst. CT demonstrated the full extent of the pancreaticothoracic fistula in both patients. Pancreaticothoracic fistulas are rare and may require multiple imaging modalities to establish a diagnosis.

Intrasplenic pancreatic abscess successfully treated by endoscopic transpapillary drainage through the minor papilla

Intrasplenic pancreatic pseudocyst and abscess are rare complications of chronic pancreatitis, and conventional treatment is surgery.1-7 Based on our literature search, we could find no published reports on the endoscopic management of intrasplenic pancreatic abscess. We report a 35-year-old alcoholic man with chronic calcific pancreatitis, complete pancreas divisum, and intrasplenic pancreatic abscess, successfully managed by nasopancreatic drainage through the minor papilla followed by minor papilla sphincterotomy and stent placement.

Endoscopic Therapy for Chronic Pancreatitis

When endoscopic therapy is used for the treatment of patients with painful chronic pancreatitis, extracorporeal shock wave lithotripsy (ESWL) can be proposed as a first-line approach when obstructive ductal stone(s) induce upstream dilation of the main pancreatic duct. Stone fragmentation by ESWL is followed by endoscopic ductal drainage using pancreatic sphincterotomy, fragmented stone(s) extraction, and pancreatic stenting in case of ductal stricture. After completion of endoscopic pancreatic ductal drainage, long-term clinical benefit can be expected for two thirds of the patients. Best clinical results are associated with absence or cessation of smoking and with early treatment in the course of chronic pancreatitis, while alcohol abuse increases the risks of diabetes, steatorrhea and mortality. The complications of chronic pancreatitis are mainly the development of pseudocyst secondary to the downstream ductal obstruction, and biliary obstruction caused by fibrotic changes in the head of the pancreas. Successful endoscopic pseudocyst drainage is currently obtained in most patients, and carries a low complication rate. Biliary stenting is a safe and effective technique for the short-term treatment of symptomatic bile duct stricture due to chronic pancreatitis, but permanent resolution is obtained in only 25% of cases. In conclusion, endoscopic management is now considered to be the preferred interventional treatment of chronic pancreatitis, for patients selected on the basis of the anatomical changes caused by the disease. This treatment is generally safe, minimally invasive, often effective for years, does not prevent further surgery, and can be repeated.

Percutaneous Thrombin Injection to Complete SMA Pseudoaneurysm Exclusion After Failing of Endograft Placement

Visceral aneurysms are potentially life-threatening vascular lesions. Superior mesenteric artery (SMA) pseudoaneurysms are a rare but well-recognized complication of chronic pancreatitis. Open surgical repair of such an aneurysm, especially in patients after previous surgical treatment, might be dangerous and risky. Stent graft implantation makes SMA pseudoaneurysm exclusion possible and therefore avoids a major abdominal operation. Percutaneous direct thrombin injection is also one of the methods of treating aneurysms in this area. We report a first case of percutaneous ultrasound-guided thrombin injection to complete SMA pseudoaneurysm exclusion after an unsuccessful endograft placement. Six-month follow-up did not demonstrate any signs of aneurysm recurrence.

Common Bile Duct Strictures Due to Chronic Pancreatitis Managed by Self-Expandable-Metal Stents (SEMS): Results of a Long-Term Follow-Up Study

Background: Common bile duct (CBD) strictures are a common complication of chronic pancreatitis (CP). Successful dilation of these strictures by insertion of an increasing number of plastic stents is not effective as in the setting of postoperative bile duct stenoses. Aim: To evaluate long-term results of the management of CP-related CBD strictures by SEMS. Methods: From 1990 to 2002, 24 patients (21 M, mean age 48 yrs) with a symptomatic CP-related CBD stricture refractory to plastic stenting that refused surgery, were treated by placement of a biliary SEMS at our institution. Seven (29%) patients had pancreatic calcifications. All patients had a minimum follow-up of 2 years, and SEMS patency was assessed. Results: Eighteen (75%) uncovered SEMS were inserted. Eight (33%) patients still had a functioning SEMS after a mean period of 52 months (range 26-121). Sixteen (66%) patients developed a SEMS malfunction after a mean period of 39 months (range 5-103). Follow-up of patent covered SEMS was 35 months (range 33-37) while that for uncovered SEMS was 61 months (range 26-121). Patency of clogged SEMS according to stent features is summarized in the Table. Conclusions: Placement of SEMS in CBD strictures secondary to CP could be a valid alternative to surgery. Covered stents were placed only during recent years and longer follow-up is necessary to compare covered and uncovered SEMS in this kind of biliary stenoses.

Pseudocyst rupture into the portal vein diagnosed with MRI

We report on the first documented case of rupture of a pancreatic pseudocyst into the portal vein diagnosed with MRI.

Internal Pancreatic Fistulas

Internal pancreatic fistulas (IPF) are an uncommon but well-recognized complication of chronic pancreatitis (CP) that are associated with significant morbidity and mortality. Because of their low incidence, management is still controversial. The aims of this study are to report the 8-year experience with IPF management in a Brazil University-affiliated hospital and to propose a management algorithm. A centralized diagnostic index was used to retrospectively identify all patients with IPF admitted to a teaching hospital from 1995 to 2003. The patient's medical records were reviewed for clinical features, diagnostic work-up, treatment strategies, response to therapy, and the length of hospital stay. All patients underwent contrast-enhanced computed tomography of the abdomen and endoscopic retrograde cholangiopancreatography, to guide the therapeutic modality to be offered. Conservative therapy included withholding of oral feedings in conjunction with total parenteral nutrition, octreotide subcutaneously, and multiple paracentesis or thoracentesis. Interventional therapy was either endoscopic or surgical. IPF was identified in 11 (7.3%) of 150 patients with CP. They ranged in age from 24 to 47 years (mean 36.1), with a male to female ratio of 10:1. All patients had underlying alcoholic CP. The presentation was pancreatic ascites in 9 patients and pleural effusion in 2 cases. Five patients were undergoing the conservative treatment, all presenting main pancreatic duct (MPD) dilatation; endoscopic placement of transpapillary pancreatic duct stent was performed in 4 patients who presented partial MPD stricture or disruption; surgical therapy was performed in 2 patients exhibiting complete MPD obstruction or disruption. Stents were removed 3 to 6 weeks after initial placement. IPF resolved in 10 of 11 patients (90.9%) within 6 weeks. The resolution of IPF was faster (13 +/- 5 vs. 25 +/- 13 days, P < 0.01) and the length of hospital stay was significantly shorter (17.2 +/- 5.6 vs. 31.2 +/- 4.4 days, P < 0.01) in patients subject to interventional treatment compared with those treated conservatively. There was 1 death due to sepsis in a patient managed conservatively; no death was recorded in the interventional therapy group. There was no recurrence of IPF at a mean follow-up of 38 months. Our results suggest that interventional therapy should be considered the best approach for the management of IPF in patients presenting MPD disruption or obstruction. Conservative therapy must be reserved for those showing MPD dilatation without ductal disruption or stricture. Early interventional therapy reduced hospital stay and convalescence, which likely resulted in lower healthcare overall costs.