Rare Complication Of Acute Pancreatitis Research Articles

1264 Mediastinal Pancreatic Pseudocyst With Expansion Into Bilateral Pleural Spaces

INTRODUCTION: Pseudocysts are a common complication of both acute and particularly chronic pancreatitis. Uncommonly, pseudocysts may communicate with thoracic cavities, including the mediastinum. We describe a case of acute pancreatitis complicated by a mediastinal pseudocyst with bilateral pleural space involvement. CASE DESCRIPTION/METHODS: A 51-year-old male with a history of alcohol abuse presented shortly after discharge from a prolonged hospitalization for his first lifetime episode of acute alcohol-induced pancreatitis. A CT of the chest ordered on admission for new onset respiratory distress demonstrated bilateral pleural effusions. Fluid analysis showed a right sided empyema and left sided aseptic exudative effusion. The right empyema resolved after chest tube placement but there was rapid recrudescence of a right pleural effusion after chest tube removal. Repeat fluid analysis was significant for a pancreatic specific amylase level of 2620. Repeat CT imaging demonstrated a posterior mediastinal fluid collection that arose from the pancreas, extended through the esophageal hiatus and was contiguous with new fluid collections in both pleural spaces and this was confirmed with MRCP. The mediastinal pseudocyst was deemed not amenable to endoscopic drainage so ERCP was performed with stent placement to the ventral pancreatic duct along with chest tube placement for the larger right sided fluid collection and subcutaneous octreotide administration, with eventual reduction of pseudocyst size. DISCUSSION: Mediastinal pseudocysts are a rare complication of acute pancreatitis more commonly seen in chronic pancreatitis, though exceedingly rare in general. It is theorized that mediastinal pseudocysts occur based on ease of pancreatic fluid movement. The pararenal and pelvic extraperitoneal spaces are typically the easiest spaces for this fluid to penetrate but conditions that create inflammatory fibrosis of these areas may make ascending flow into the mediastinum the path of least resistance. On CT scan and on MRCP, our patient had a mediastinal pseudocyst that communicated directly and inseparably with both the right and left pleural space. To our knowledge, this has not been previously seen in the limited case reports of mediastinal pseudocysts. Despite not being amenable to endoscopic drainage based on location, the use of octreotide coupled with pancreatic duct stenting proved effective in reducing the caliber of this mediastinal pseudocyst on interval imaging.

1435 Pancreaticoenteric Fistula: A Very Unique Complication of Acute Pancreatitis

INTRODUCTION: Pancreaticoenteric fistulas are a rare complication of acute pancreatitis. Spontaneous fistulation has been described in the literature in cases where acute pancreatitis is complicated with infection or necrosis. As a direct consequence to the fistula formation, direct vascular injury may occur, resulting in blood loss and rapid clinical deterioration. CASE DESCRIPTION/METHODS: A 77-year-old male with past medical history of essential hypertension, type 2 diabetes mellitus and coronary artery disease status post coronary artery bypass grafting in 2017 was brought to Emergency Room due to sudden onset right leg pain. He was admitted due to subacute limb ischemia and started on antiplatelet and anticoagulation medical therapy. Hospital course complicated with abdominal pain and four episodes of large volume port wine stools per rectum and significant drop in hemoglobin levels. After initial resuscitation measures, which include intravenous hydration and supportive blood products transfusions, patient was consulted to Gastroenterology service for evaluation and recommendations. Esophagoduodenoscopy revealed large clean base ulcerated lesion with an associated fistulous process in the first portion of the duodenum. No active bleeding nor blood remnants were noted. Abdominopelvic CT scan was immediately done and showed extensive devitalization of the pancreas along with large peripancreatic fluid collection with abundant internal gas suggestive of a contained perforation of duodenum. Interventional radiology and General surgery was consult. DISCUSSION: Spontaneous pancreaticoenteric fistula in the setting of pseudocysts formation secondary to necrotizing pancreatitis is a very rare and unique complication. Typical management is conservative, with medical therapy resulting in closure of the vast majority of fistulas. The infrequency with which pancreaticoenteric fistulas are encountered makes them a formidable diagnostic and treatment challenge. Even though it has been described in the literature, there still much to investigate regarding upper gastrointestinal fistulas and its associated vascular complications after acute pancreatitis.

1259 From Pancreatitis to Takotsubo: A Rare Complication of Acute Pancreatitis

INTRODUCTION: Takotsubo cardiomyopathy or stress cardiomyopathy (TCM) is a transient reversible form of cardiomyopathy. It is characterized by reduced ejection fraction and signs of myocardial ischemia and often precipitated by acute emotional or physical stressors. We present a rare case of TCM in a postmenopausal woman triggered by acute alcoholic pancreatitis. CASE DESCRIPTION/METHODS: A 57-year-old female with a history of alcohol abuse and diabetes mellitus presented to the emergency department with a two-day history of severe diffuse abdominal pain with radiation to the back. Associated symptoms included nausea and vomiting. Vital signs were within normal limits. Physical examination was significant for a mildly tender abdomen. Laboratory findings revealed leukocytosis of 14.6 and lipase of 882. All other chemistry and complete blood count labs were within normal limits. CT abdomen without contrast revealed peripancreatic fat stranding suggestive of acute pancreatitis. The patient was admitted for IV fluid resuscitation and pain management. On day 2 of admission, the patient became dyspneic and desaturated to 82% on room air. Stat chest x-ray showed flash pulmonary edema. Bedside ultrasound revealed a dilated IVC. Troponin (0.97) and BNP (1627) levels were elevated, concerning for acute heart failure exacerbation. EKG revealed no acute ischemic changes. The patient was aggressively diuresised with significant improvement in respiratory status. Transthoracic echocardiography (TTE) revealed a left ventricular ejection fraction (LVEF) of 40% with basal segment hyperkinesis but apical akinesis consistent with stress-induced cardiomyopathy. Follow up coronary angiography revealed normal coronary vessels. The patient was started on guideline-based heart failure therapy and was discharged to home in stable condition. A repeat TTE obtained 4 months later revealed unchanged LVEF and persistent apical akinesis in the setting of persistent alcohol use. Guideline directed therapy was continued and the patient was counseled on alcohol cessation. DISCUSSION: Acute pancreatitis induced TCM is rare. Our case further confirms the heterogenicity of TCM, including non-classical stressors such as alcohol abuse which may delay myocardial recovery.

1427 Minimally Invasive Treatment for Severe Acute Pancreatitis With Colonic Stenosis

INTRODUCTION: Colonic stenosis is a rare complication of acute pancreatitis (AP). It may be the consequence of inflammation and necrosis caused by AP. Early intervention is necessary, since the progression of colonic stenosis in AP leads to high mortality. We present a case of stenosis of right colic flexure in AP with total minimally invasive treatment. CASE DESCRIPTION/METHODS: A 73-year-old male patient with severe AP due to biliary lithiasis was transferred to our hospital because of recurrent infection and fever at the local hospital. The patient had upper and right lower quadrant abdominal pain at admission. Computed tomography (CT) revealed enveloping necrosis around pancreatic head and exudation of the ascending mesenteric side. CT-guided percutaneous catheter drainage was performed to relieve abdominal and peripancreatic abscess. One week after admission, the patient experienced acute onset severe dull pain in the lower right abdomen. CT showed closed loop ileus from ascending colon to transverse colon (Figure 1a). The colonoscopy revealed the stenosis of right colic flexure and adjacent part of transverse colon and the narrow section was 6 cm (Figure 2a). A fully covered intestinal stent (2 cm × 10 cm) was implanted under colonoscopy (Figure 2b, c). Postoperative CT revealed intestinal stent was in place (Figure 1b). The symptom was quickly controlled after implantation. Meanwhile, pancreatic duct stent was implanted to control the pancreatic fistula. The patient recovered smoothly with the supportive treatment and irrigation tubes were removed before discharge. After 2 months of discharge, CT presented a little necrosis around pancreas and colonic stenosis disappeared (Figure 1c). It was found that the stent had been extruded and right colonic flexure was slightly narrow by colonoscopy (Figure 2d). DISCUSSION: Colonic stenosis secondary to AP is uncommon. It may result from diffusion of inflammation by pancreatic enzymes and pancreatic necrosis. The anatomic relationship of the pancreas and large bowel is an important factor. In this case, stenosis of right colonic flexure is related with necrosis around pancreatic head. Colonic stenosis in AP can progress to colonic ischemia, necrosis and perforation, leading to very poor prognosis It needs operation and resection. Therefore, timely treatment is important. Here, we used total minimally invasive techniques, including implantation of pancreatic duct stent and colonic stent, to prevent detrimental consequence. The prognosis of the patient is good.

1377 Gastric Necrosis Associated With Necrotizing Pancreatitis

INTRODUCTION: Acute pancreatitis may lead to local complications and systemic toxicity. Gastric necrosis is a rare complication with only few cases reported in the literature. Herein we present a case of severe acute necrotizing pancreatitis acute complicated by gastric necrosis. CASE DESCRIPTION/METHODS: Our patient is a 42-year-old male with a history of idiopathic recurrent necrotizing pancreatitis who presented with severe epigastric abdominal pain, nausea and vomiting. Previous imaging revealed pancreatic necrosis in the body and head of the pancreas and extensive splanchnic thrombosis. Labs showed normal blood count, lipase and complete metabolic panel. CT of the abdomen during this admission revealed large volume ascites and total pancreatic necrosis and multiple areas of low attenuation in the expected location of the pancreatic head and body (Figure 1). Despite supportive care and antibiotics, he was unable to tolerate oral intake. On day 14 he developed hematemesis and hypotension. His hemoglobin dropped to 9.3 g/dL from 13.3 g/dL. An abdominal x-ray revealed a curvilinear lucency overlying the left lateral upper stomach suggestive of gastric pneumatosis. Upper endoscopy showed erythema, edema, and severe ulcerations with black necrotic mucosa in the inferior and posterior walls of the stomach. The anterior wall was relatively spared with clear demarcation of ischemic and viable mucosa (Figure 2). Gastric biopsies confirmed gastric necrosis. The patient's hemodynamic status worsened, and he required vasopressor support. Further interventions were deferred given his comorbidities and worsening hemodynamic status, and he was discharged to hospice care. DISCUSSION: Gastric necrosis is a rare complication of acute pancreatitis and occurs due to severe reduction in gastric mucosal blood flow. This can be secondary to thrombosis of large vessels such as the celiac trunk or attributed to microcirculatory vasospasm due to the release of thrombogenic and inflammatory mediators. The development of gastric necrosis leads to further clinical deterioration in a clinically ill patient. Despite its rarity, gastric necrosis should be suspected in the setting of severe pancreatitis in patients with signs of gastrointestinal bleeding and clinical deterioration.

Massive Bleeding From Inferior Mesenteric Vein With Hypovolemic Shock: A Rare Complication of Acute Pancreatitis

BackgroundAcute pancreatitis may cause massive intra-abdominal bleeding as vascular complications caused by the erosion of a major pancreatic or peripancreatic vessel. In terms of treatment, the differentiation between arterial bleeding and venous bleeding using abdominal computed tomography (CT) angiography is important. In addition, hypovolemic shock caused by bleeding from the inferior mesenteric vein (IMV) in acute pancreatitis has not been reported. Case ReportA 58-year-old man presented to our emergency department with complaints of abdominal pain of 10 hours’ duration. The pain had an abrupt onset and started with alcohol consumption. After performing initial laboratory tests and an abdominal CT scan, he was diagnosed with acute pancreatitis. However, he complained of severe abdominal pain and was drowsy 2 h later. Follow-up CT angiography revealed acute necrotizing pancreatitis with massive hemoperitoneum and hypovolemic shock. We also found active bleeding from the IMV. We did not consider emergency catheter angiography with embolization; instead, exploratory laparotomy and hematoma evacuation with IMV ligation was performed. He was discharged without complications 14 days later. Why Should an Emergency Physician Be Aware of This?Massive bleeding from the IMV accompanied by shock bowel syndrome is a rare complication of acute pancreatitis that can be confused with arterial bleeding. Emergency physicians should consider this diagnosis in acute pancreatitis as a possible cause of hypovolemic shock and anatomic course of the IMV and prevent fulminant shock by administering appropriate treatment.

Catastrophic Presentation of Pancreaticopleural Fistula

SESSION TITLE: Critical Care 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Pancreaticopleural fistula (PPF) is a rare complication of acute pancreatitis. It is difficult to diagnose and should be suspected in the appropriate setting. Treatment modalities are debated in medical literature. We present an acute catastrophic presentation of PPF with full recovery after conservative management. CASE PRESENTATION: 74 yo female presented to the ER with epigastric pain. Serum Lipase was 8042. CT abdomen suggested acute pancreatitis without common duct stone and was negative for pleural effusions. Patient was kept NPO and started on IV fluids and pain control. Next day, she developed acute chest pain and respiratory failure requiring mechanical ventilation. Chest X-Ray showed new moderate right pleural effusion. Thoracentesis drained 1000 mL of greenish exudative pleural fluid with Bilirubin 2.1 mg/dL, Amylase 6913 U/L and Lipase 8282 U/L which suggested an acute presentation of PPF. She suffered multi-organ failure requiring 4 vasopressors and Hemodialysis. Chest tube was inserted. Antibiotics and Octreotide 50 mcg IV Q8 hours were started. She gradually improved with conservative measures. She was extubated and chest tube removed after 11 days, then discharged after 21 days. DISCUSSION: PPF usual presentation is a pleural fluid analysis with elevated amylase or lipase. CT has sensitivity of 33-47% at identifying PPF. ERCP has better sensitivity at 46-78% with the advantage of being a diagnostic and therapeutic procedure. MRCP has highest sensitivity of 80%. Medical versus invasive treatment with ERCP or surgery is debated in current literature. Candidates for medical management with octreotide and thoracentesis or tube thoracostomy if needed are patients with normal or mildly dilated pancreatic duct. Octreotide is used to reduce the pancreatic exocrine function and promote fistula closure. Success rate of medical treatment is 31-65 %. Failed medical management is associated with increased morbidity. Placement of a stent using ERCP shunts pancreatic secretions and promotes healing. Patients with complete ductal obstruction may benefit from early surgical intervention. King et al success rate with early surgical intervention was 94%. Distal pancreatectomy followed by pancreaticojejunostomy were the most common surgeries reported. In our case, early intervention with tube thoracostomy, antibiotic treatment and octreotide had great impact on overall clinical improvement. CONCLUSIONS: PPF is a rare complication of acute pancreatitis that can manifest with pleural effusion and respiratory failure. Supportive care with drainage, antibiotics and octreotide can avoid the morbidities and mortalities associated with surgical interventions in selected cases. Reference #1: Ali T, et al. Pancreaticopleural Fistula. Pancreas. 2009;38(1):e26-e31 Reference #2: Aswani H, et al. Pancreaticopleural Fistula: A Review. Journal of Pancreas. 2015;16(1):90-94 Reference #3: King J, et al. Pancretic-pleural fistula is best managed by early operative intervention. Surgery. 2009;147(1):154-159 DISCLOSURE: The following authors have nothing to disclose: Margaret Tajak, Thomas Evely, Mahmoud Amarna, Camelia Chirculescu, Haytham Adada No Product/Research Disclosure Information

Non-Invasive Work-up and Conservative Management of Pancreaticopleural Fistula: A Case Series of 2 Patients With This Rare Complication of Acute Pancreatitis

Non-Invasive Work-up and Conservative Management of Pancreaticopleural Fistula: A Case Series of 2 Patients With This Rare Complication of Acute Pancreatitis

Emphysematous Pancreatitis in an Immunocompetent Patient

Emphysematous pancreatitis (EP) is a quite rare complication of acute pancreatitis (AP) but has a grave prognosis. Gas-forming organisms from the bowel may enter the pancreas to cause EP. Successful treatment requires aggressive management of the infection with early surgical debridement. We report a case of an immuncompetent patient who presented with acute pancreatitis that was complicated with EP. A 65 year-old male with prior cholecystectomy presented with one day of acute diffuse abdominal pain with mild nausea but no vomiting. He reported no new medication, no alcohol use or recent illness. Exam showed diffusely distended tender abdomen with no rebound. His serum lipase and amylase were 29, 3000 and 4735 U/L in order with normal serum triglycerides. CT abdomen showed diffuse peripancreatic inflammatory stranding and fluid consistent with AP (image 1). Diagnosis of AP of unknown cause was made. The patient was treated with bowel rest, IV fluids, and pain medications. He did not improve clinically and was intubated 4 days after due to altered mental status and respiratory distress. One week after, he was found to have worsening abdominal distention, hypotension, tachycardia, oliguria and rising lactate; picture of septic shock although pancreatic enzymes remained low. Urgent CT abdomen showed severe emphysematous pancreatitis complicated by pneumatosis, portal venous gas and free intraperitoneal air in addition to a large extrapancreatic collection containing air and fluid (image 2). He underwent emergent exploratory laparotomy, pancreatic necrosectomy and GJ tube placement. E coli and numerous Bacteroides fragilis were isolated from the necrotic tissue. He was discharged 5 weeks after surgery. EP is a very rare, potentially fatal variant or complication of severe acute pancreatitis with gas in the pancreatic bed. Mortality and morbidity rates approach about 40% and 100%, respectively. There are isolated case reports describing this condition. EP iscaused by necrotizing infection of the pancreas with gas-forming bacteria as E coli, C perfrigens, Staphylococcus, Streptococcus, Klebsiella and Pseudomonas species. The diagnosis is made clinically and and radiologically. Retroperitoneal gas in a patient who has clinical evidence of pancreatitis warrants early use of antibiotics, percutaneous drainage of the fluid collection, and surgical resection of the infected necrotic tissue if there is no clinical response to those measures.Figure 1Figure 2

Mediastinal Pancreatic Pseudocysts.

Mediastinal pseudocysts are a rare complication of acute pancreatitis. Lack of uniform treatment standards makes the management of this condition a clinical challenge. We report the case of a 43-year-old patient who presented with a left pleural effusion. Pleural fluid revealed a high amylase concentration consistent with a pancreaticopleural fistula. Endoscopic retrograde cholangiopancreatography (ERCP) revealed a disruption of the pancreatic duct with free outflow of contrast medium into the thoracic cavity. A pancreatic stent was placed. The second day after the ERCP, the patient developed septic shock and was admitted to the intensive care unit. Computed tomography (CT) revealed mediastinal pseudocysts and bilateral pleural effusions. After bilateral drainage of the pleural cavities, the patient improved clinically, and a follow-up CT scan showed that the fluid collection and pseudocysts had resolved. We discuss the optimal strategies for diagnosing and treating patients with pancreatic thoracic pseudocysts and fistulas, as well as review the management of these conditions.

The clinical diagnostic aspects of acute pancreatic encephalopathy

The pancreatic encephalopathy is characterized by various focal neurological symptomatic and sporadic fast development of dementia is considered as a rare complication of acute pancreatitis developing in 9-35% of patients with diseases of pancreas. Factually every patient with acute pancreatitis has a risk of development of pancreatic encephalopathy that significantly makes severer course of disease and increases lethality. The review article considers particular aspects of clinical manifestations and probable diagnostic algorithm of neurological disorders observed in patients with acute pancreatitis. The actuality of development of diagnostic algorithm of pancreatic encephalopathy is emphasized. This algorithm will permit ultimately early, probably at pre-clinical stage, discover the mentioned complication of acute pancreatitis with the purpose of not only ultimate early detection of pancreatic encephalopathy but also development of pathogenically conditioned therapeutic algorithm considering all chains of pathogenesis.

The epidemiological and pathogenic aspects of acute pancreatic encephalopathy

The article considers particular aspects of epidemiology and pathogenesis of neurological disorders detected in patients with acute pancreatitis. The pancreatic encephalopathy characterizing by various focal neurological symptomatic and sometimes rapid development of dementia is considered as a rare complication of acute pancreatitis developing in 9-35% of patients with diseases of pancreas. Factually, every patient with acute pancreatitis has a risk of development of pancreatic encephalopathy which significantly increases graveness of course and lethality of disease. Therefore, the emphasis is made on development of diagnostic algorithm under pancreatic encephalopathy permitting discovering this complication of acute pancreatitis at as much as possible early even possibly at pre-clinical stage. The comprehensive investigation of pathogenesis of pancreatic encephalopathy with the purpose of elaboration of pathogenetically conditioned therapeutic algorithm considering all parts of pathogenesis.

Intrascrotal Collection in an Acute Pancreatitis: A Case Report and Review of the Literature.

Context. An inguinoscrotal swelling occurring during an acute pancreatitis is very rare. Case Report. We report a case of right inguinoscrotal swelling appearing in connection with an interstitial edematous acute pancreatitis. We have noticed a spontaneous complete reduction of the right inguinoscrotal swelling after 10 days. Conclusion. The management of a scrotal swelling should be the least invasive possible method but also the most complete possible method to avoid unnecessary interventions. The exclusion of a pathology that could affect the vital prognosis of the testis remains the absolute priority. An acute scrotum swelling must be carried out by the clinical management by a professional and must be completed with an ultrasonography of the scrotum. Despite all that, if the original etiology of the acute scrotum remains unknown, an abdominopelvic CT scan could provide more details and so could offer a different diagnosis of exclusion, different from the diagnosis of acute idiopathic scrotal edema (AISE). This rare complication of acute pancreatitis reported could be mistaken for a more common pathology. If that complication is identified, it will not require a surgical intervention if there is a correct management of the acute pancreatitis which could justify a broader CT scan.

Pancreaticopleural Fistula Causing Massive Right Hydrothorax and Respiratory Failure.

Hydrothorax secondary to a pancreaticopleural fistula (PPF) is a rare complication of acute pancreatitis. In patients with a history of pancreatitis, diagnosis is made by detection of amylase in the pleural exudate. Imaging, particularly magnetic resonance cholangiopancreatography, aids in the detection of pancreatic ductal disruption. Management includes thoracocentesis and pancreatic duct drainage or pancreatic resection procedures. We present a case of massive right hydrothorax secondary to a PPF due to recurrent acute pancreatitis. Due to respiratory failure, urgent thoracocentesis was done. Distal pancreatectomy with splenectomy and cholecystectomy was performed. The patient remains well at one-year follow-up.

Acute pancreatitis complicated by jejunal hematoma in a patient on anti-coagulants and anti-platelets.

Pancreatitis can be associated with significant complications. Bowel hematoma is a rare complication and the second part of the duodenum is the most commonly affected site. Hematomas affecting other parts of the bowel are extremely rare. A 53-year-old female with a history of atrial fibrillation and ischemic heart disease on anticoagulants and aspirin presented with abdominal pain of a few days duration which had worsened prior to presentation. This was associated with abdominal distension, vomiting and melena. Laboratory investigations showed elevated serum amylase, coagulopathy and severe anemia. Computed tomography imaging showed a jejunal hematoma and pancreatitis with peripancreatic inflammation. She responded to conservative treatment in addition to correction of the coagulopathy and a blood transfusion. Her symptoms were resolved within a few days and a repeat computed tomography scan two months later showed complete resolution of the hematoma and the pancreatitis. Our case demonstrates a rare complication of acute pancreatitis in a patient with risk factors.

Scrotal Swelling as a Complication of Hydrochlorothiazide Induced Acute Pancreatitis.

Background. Scrotal swelling is a rare complication of acute pancreatitis with few reported cases in the literature. In this case report, we present a 59-year-old male with hydrochlorothiazide induced pancreatitis who developed scrotal swelling. Case Presentation. A 59-year-old male presented to the emergency department with sharp epigastric abdominal pain that radiated to the back and chest. On physical examination, he had abdominal tenderness and distention with hypoactive bowel sounds. Computed tomography (CT) scan of the abdomen showed acute pancreatitis. The patient's condition deteriorated and he was admitted to the intensive care unit (ICU). After he improved and was transferred out of the ICU, the patient developed swelling of the scrotum and penis. Ultrasound (US) of the scrotum showed large hydrocele bilaterally with no varicoceles or testicular masses. Good blood flow was observed for both testicles. The swelling diminished over the next eight days with the addition of Lasix and the patient was discharged home in stable condition. Conclusion. Scrotal swelling is a rare complication of acute pancreatitis. It usually resolves spontaneously with conservative medical management such as diuretics and elevation of the legs.

Suprahepatic Inferior Vena Cava and Internal Jugular Vein Thrombosis: A Rare Complication Of Pancreatitis: Case Report

Vascular thrombosis of portal veins and splenic vein due to pancreatitis has been described. Involvement of suprahepatic inferior vena and internal jugular vein is a rare complication of acute pancreatitis. Here we report a case of suprahepatic inferior vena cava thrombosis and internal jugular vein thrombosis in an alcoholic patient presented with acute pancreatitis.

Intrasplenic Pancreatic Pseudocyst: A Rare Complication of Acute Pancreatitis

Introduction: Although rare (1-2%), splenic involvement secondary to acute pancreatitis can include hemorrhage, splenic rupture, or vascular injury1. We present a case of intrasplenic pseudocyst, a rare complication of acute pancreatitis. Case: A 46-year-old male presented with LUQ pain, nausea, and emesis 3 months after being diagnosed with acute pancreatitis secondary to alcohol ingestion. He was afebrile and on examination had LUQ tenderness without rebound. Labs included an amylase of 74, lipase of 41, and normal liver function tests; RUQ ultrasound and KUB were unremarkable. Contrast-enhanced CT scan of abdomen and pelvis revealed residual changes consistent with prior pancreatitis and an ill-defined 1-cm focal hypodensity in the tail of the pancreas, consistent with localized pancreatic necrosis vs. pseudocyst. He was treated conservatively and his symptoms subsequently resolved. Five months later (8 months after initial pancreatitis), the patient presented with similar complaints and a repeat CT scan demonstrated an interval progression of the pancreatic tail lesion with extension into the spleen. Endoscopic ultrasound (EUS) revealed changes suggestive of chronic pancreatitis, with a 2.7 x 2.8-cm thin-walled cystic lesion in pancreatic tail with extension into the spleen, highly suspicious for pseudocyst. EUS-guided fine needle aspiration (EUS-FNA) was then performed and 5 cc of turbid, viscous fluid was aspirated. Gram stain and culture were both negative, and cytology revealed rare WBCs and inflammatory cells without evidence of malignancy, consistent with a pancreatic pseudocyst. Patient remained asymptomatic and follow-up imaging after 3 months revealed complete resolution of the pseudocyst. Discussion: Splenic complications from acute pancreatitis can be severe and should be closely followed with imaging studies1. As with our patient, most patients can be managed conservatively, although interventions such as endoscopic drainage, splenectomy, or distal pancreatectomy can be indicated in some cases1. We present a patient with a conservatively managed intrasplenic pseudocyst, a rare complication of acute pancreatitis.Figure: Contrast enhanced CT scan of abdomen showing a cystic lesion in the pancreatic tail extending into the spleen (arrowhead).

Not Your Everyday Case of Acute Pancreatitis: A Rare Complication of a Common Diagnosis

Purpose: Pancreaticopericardial fistula is an extremely rare complication of chronic pancreatitis, and is virtually unheard of in the setting of acute pancreatitis. A 67-year-old male presented with acute necrotizing pancreatitis complicated by pancreatic pseudocyst with a cystoduodenal fistula and pancreaticopericardial fistula. On presentation, the patient had signs of tachypnea, tachycardia, hypotension and cyanosis. Initially, an emergent percardiocentesis was performed for cardiac tamponade with eventual placement of a pericardial window as a result of persistent reaccumulation of fluid. Computed tomography (CT) demonstrated a gas containing pericardial fluid collection extending into the anterior upper abdomen and ill-defined fluid collections within the pancreatic head and neck, representing pancreatic necrosis with probable superimposed infection. Analysis of pericardial fluid showed elevated levels of lipase at 24,000 u/L. Surgical exploration of the subxiphoid window revealed a pancreatic pericardial cutaneous fistula and an infected pericardial window. The patient ultimately passed away from septic shock. We present this rare complication of acute pancreatitis and review the relevant literature.FigureFigureFigure

Spontaneous regression of splenic artery pseudoaneurysm: a rare complication of acute pancreatitis

Spontaneous pseudoaneurysm regression is a rare event. In particular, the spontaneous regression of a splenic artery pseudoaneurysm has, to our knowledge, been previously documented in only two case reports. Furthermore, the pathophysiological mechanism of this event remains unclear. However, it is fully known that this vascular complication is potentially life-threatening and presents a high mortality rate if untreated. We report the case of a 49-year-old man affected by acute pancreatitis. Computed tomography was performed, and showed a pseudoaneurysm of the splenic artery. This patient underwent endoscopic retrograde cholangiopancreatography to treat the pancreatitis, while the vascular complication was managed with a careful and conservative treatment. On day 6 of hospitalization, a second computed tomography scan was performed and revealed complete regression of the pseudoaneurysm. This case describes the diagnosis and management of splenic artery pseudoaneurysm following acute pancreatitis and its spontaneous regression.