Rare Complication Of Chronic Pancreatitis Research Articles

A Case of Pancreatic Pseudoaneurysm

Pancreatic pseudoaneurysm (PSA) is a rare complication of chronic pancreatitis. Diagnosis requires high index of suspicion and urgent intervention is required once diagnosed as delayed treatment leads to poor outcomes and mortality. In this report, we discuss the case of a 30 year old male with a history of chronic pancreatitis who presented with upper gastrointestinal bleed (UGIB). Physical exam was elevated blood pressure, tachycardia and epigastric tenderness. A CT angiogram of abdomen done revealed pseudoaneurysm of pancreas. Patient emergently underwent endovascular embolization and coiling with resolution of GI bleed post procedure.

The detours of pancreatic ducts, internal pancreatic fistulas: a rare complication of chronic pancreatitis

Internal pancreatic fistula occurs due to the disruption of the pancreatic duct, resulting in communication with it and another epithelial surface. A rare variant is the pancreaticopleural and pancreaticogastric fistula, typically associated with chronic necrotising pancreatitis, resulting from posterior disruption of the pancreatic duct. It is a complex disease with different aetiologies, varied clinical presentations and multiple management options. Unlike postoperative pancreatic fistula, internal pancreatic fistula lacks guidelines for classification and management. Once an internal fistula is suspected, further imaging work-up and biochemical analysis needs to be performed. Here, we present an unprecedented case of pancreaticopleural fistula on a background of chronic necrotising pancreatitis, and an asymptomatic pancreatico-gastric fistula. To our knowledge, no such case has been previously reported.

Difficulties in Diagnosis and Surgical Treatment of Bilateral Pancreaticopleural Fistula

The study presented clinical observation of a patient with a rare complication of chronic pancreatitis - a formed bilateral pancreaticopleural fistula. The clinical picture of the disease was similar to that of recurrent bilateral hydrothorax. To specify the diagnosis, it was necessary to perform a pleural puncture with a biochemical analysis of the removed pleural fluid. A high level of pancreatic amylase in the pleural fluid, results of targeted multislice computed tomography of the pancreas with contrast and magnetic resonance cholangiopancreatography revealed a bilateral pancreaticopleural fistula. Distal resection of the pancreas proved to be an effective and sufficient radical surgical intervention, which provided reliable elimination of the pancreaticopleural fistula and bilateral enzymatic pleurisy.

Ruptured mediastinal pseudocyst with pancreaticopleural fistula formation in a 15-year-old boy presenting with white-out hemithorax: A case report

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis described more commonly in adults with alcoholic and necrotizing pancreatitis. We report a rare case of ruptured mediastinal pseudocyst with the formation of PPF in a 15-year-old boy who presented with progressive dyspnea and large left-sided pleural effusion that recurred despite repeated drainage. On the basis of imaging findings and pleural fluid analysis, the diagnosis of PPF with ruptured mediastinal pseudocyst was made. The diagnosis of PPF should be considered in patients with non-resolving large left-sided pleural effusions. The diagnosis can be confirmed either by significantly raised amylase levels in pleural fluid or direct visualization of the fistula on Computed tomography/magnetic resonance cholangiopancreatography.

Abstract 17237: A Pair Of Diaphragm-Crossed Organs: A Pancreatico-Pericardial Fistula

Introduction: Pseudocysts are a known complication of chronic pancreatitis, occurring in 30-40% of patients. They form when disruption of the pancreatic duct system creates fluid-filled pockets with high concentrations of digestive enzymes. Leakage of these enzymes can create pancreatic fistulas. Here, we present a case of an unusual fistula that occurred in an immunocompromised individual. Case Description: A 34-year-old man with a history of Acquired Immunodeficiency Syndrome, alcohol use disorder, and chronic pancreatitis who had recently recovered from acute pancreatitis complicated by pericardial effusion was readmitted with worsening pleuritic chest pain and shortness of breath. He was hemodynamically stable with a normal cardiopulmonary exam without jugular venous distention or pulsus paradoxus. Labs were at his baseline other than an elevated d-dimer level. Computed tomography scan revealed a large, loculated pericardial effusion with a fistula extending through the diaphragm to a large peripancreatic pseudocyst. Gastroenterology performed pancreatic ductal stenting via endoscopic retrograde cholangiopancreatography and Interventional Radiology placed a percutaneous drainage catheter to facilitate resolution of the pseudocyst. Discussion: A pancreatico-pericardial fistula is a very rare complication of chronic pancreatitis. A 2016 review detailed only fifteen cases over a 40-year span with surgical management providing the best outcomes. Given this patient’s immunocompromise and malnutrition surgery was not offered, but endoscopic stenting and percutaneous drainage allowed for successful resolution of his fistula.

Pancreatico-Pleural Fistula: A Rare Complication of Chronic Pancreatitis

Abstract: Pancreatico-pleural Fistula is rare complication of chronic pancreatitis and it occurs in considerably less number of patients. We present a case of left sided pleural effusion that was attributable to pancreatico-pleural fistula. A 30-year old alcoholic patient who had worsening dyspnea, hemoptysis and intractable cough. Diagnosis is difficult due to the prevalance of respiratory symptoms than symptoms due to pancreatitis. Diagnosis is concluded by the detection of high level of amylase and lipase in pleural fluid and by ERCP. It had been managed by placing a stent on main pancreatic duct at the site of leakage by ERCP along with giving octreotide for 7 days. The patient’s symptoms was improved throughout hospitalization. Key words: Pancreatico-pleural fistula, Chronic pancreatitis, Pleural effusion, Amylase, Lipase.

S1549 An Ominous Connection Causing Recurrent Pleural Effusions

Introduction: Fistulation is a rare complication of chronic pancreatitis. Pancreaticopleural fistula (PPF) typically presents with thoracic symptoms. Pathogenesis is related to pancreatic duct obstruction causing leakage of pancreatic fluid, and if persistent can lead to fistula formation. Due to its predominant thoracic over abdominal symptoms, the diagnosis and treatment of PPF are usually delayed. The following case is an example of the potential need for repeat testing to confirm the diagnosis of PPF as well as a multidisciplinary approach to treatment. Case Description/Methods: A 66-year-old white woman presented to the emergency department with 10 days history of worsening dyspnea, orthopnea, and chest tightness. Her medical history was notable for alcohol-induced chronic pancreatitis. On physical examination, she was tachycardic with diminished breath sounds bilaterally. Chest CT angiogram revealed bilateral pleural effusions. Diagnostic right sided thoracentesis revealed exudative fluid pattern, but negative for infection and malignancy. Symptoms initially improved after therapeutic thoracentesis, but pleural effusions shortly recurred requiring repeat thoracenteses. Pleural effusions laboratory findings on thoracenteses are listed in Tables 1 and 2. MRCP showed an irregular tubular tract extending cephalad from the pancreas toward the right diaphragmatic crus and appeared to communicate with the right hydropneumothorax (Figure 1). ERCP was performed which showed diffuse dilatation of the pancreatic duct (Figure 2). Patient underwent therapeutic stenting to the ventral pancreatic duct (Figure 3). She had complete resolution of symptoms and pleural effusions on 2 months follow-up chest CT. Discussion: Pancreatic pleural fistula is a rare complication of chronic pancreatitis and can be a challenging diagnosis as symptoms tend to overlap with other causes of dyspnea, hypoxia and pleural effusions. MRCP is the most sensitive imaging modality, followed by ERCP and CT to visualize pancreatic duct anatomy and guide further therapeutic management. Conservative medical management with bowel rest and somatostatin analog are shown to be effective in patients without pancreatic ductal obstructions. In cases with recurrent pleural effusions despite conservative management, ERCP with therapeutic stenting to alleviate pancreatic ductal obstructions is strongly indicated with high success rate. Owing to its rarity and complexity, a multidisciplinary approach to PPF is warranted to provide the best care possible.Figure 1.: Tables and Figures.

Pancreaticopleural fistula in a child with chronic pancreatitis harboring compound SPINK1 variants

BackgroundPancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis (CP) that requires a high index of clinical suspicion in the patient who presents with a pleural effusion. Visualizing the fistula tract from the pancreatic duct to the pleural space by radiological imaging provides confirmation of this complication.Case presentationA 9-year-old boy who presented with massive right pleural effusion secondary to PPF, a complication of CP from a genetic mutation involving two mutations of SPINK1. We successfully managed the case with by endoscopic pancreatic duct stent placement after failure of conservative treatment approaches.ConclusionsPPF is a rare but serious complication of CP in all ages. The diagnosis of PPF in children requires a high index of clinical suspicion and should be considered in the differential diagnosis of massive pleural effusion where pancreatic pathology is present. A high level of pleural fluid amylase and the results from radiological imaging when the patients have symptoms play essential roles in the diagnosis of PPF. Currently, Magnetic resonance cholangiopancreatigraphy (MRCP) is the imaging modality of choice. Endoscopic therapy and surgery are treatment options for patients who do not respond to conservative therapy.

Pancreaticopleural Fistula: A Cause of Recurrent Pleural Effusions in Chronic Pancreatitis

AbstractPancreaticopleural fistula is a rare complication of chronic pancreatitis caused by disruption of the pancreatic duct and fistulous communication with the pleural cavity. It usually presents with respiratory symptoms from recurrent large volume pleural effusions. Paucity of abdominal symptoms makes it a diagnostic challenge, leading often to delayed diagnosis. Marked elevation of pleural fluid amylase, which is not a commonly performed test, is a sensitive marker in its detection. Imaging with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography can help delineate the fistula. In this report, we present the clinical features, imaging, and management of a 59-year-old male patient with pancreaticopleural fistula, wherein the diagnosis was suspected only after repeated pleural fluid drainages were performed for re-accumulating pleural effusions and it was eventually successfully treated with pancreatic duct stenting. We review the literature with regards to the incidence, presentation, diagnosis, and management of this rare entity.

Staged Interventional and Surgical Treatment of Patient with Chronic Pancreatitis Complicated by Pancreaticopleural Fistula with Lung Abscesses

Patient: Male, 37-year-oldFinal Diagnosis: Chronic alcoholic pancreatitis • pancreaticopleural fistula • left lung abscessesSymptoms: Fever with a body temperature of 39.1°C • left thoracic pain • severe cough with purulent sputum • shortness of breath • upper abdominal painMedication: —Clinical Procedure: Repeated thoracenteses • chest tube • drainage of lung abscesses • ultrasound-guided drainage of pancreatic pseudocyst • ultrasound-guided transparietal external-internal pancreatic duct stenting • Bern modification of Beger procedureSpecialty: SurgeryObjective:Unusual clinical courseBackground:Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Its formation is associated with local disruption of the pancreatic duct or pseudocyst communicating with the ductal system. Rarely, other intrathoracic complications may develop such as mediastinitis, pericarditis, hemothorax, and pleural empyema. The combination of pancreaticopleural fistula with lung abscesses is extremely rare.Case Report:A 37-year-old male patient, a long-term alcohol abuser, was admitted with complaints on left thoracic and upper abdominal pain, fever with a body temperature of 39.1°C, and a severe cough with purulent sputum. Left-sided pneumonia with pleural effusion was diagnosed. Thoracentesis and then a pleural drainage were performed. However, the symptoms persisted. Pleural effusion amylase was very high – more than 60 000 IU/L. Computed tomography and magnetic resonance imaging revealed cystic changes in the pancreatic head, pseudo-cyst in the pancreatic body, dilation of the Wirsung duct, and pancreaticopleural fistula with several left lung abscesses. Step by step, the patient underwent drainage of lung abscesses, external drainage of the pancreatic pseudocyst, and external-internal stenting of the pancreatic duct under ultrasound guidance. After fistula resolution, the patient was readmitted and successfully underwent the Bern variant of the Beger procedure. Six months later, he had no complaints and returned to work. In a follow-up examination, there was no fistula, no ductal hypertension, and only small pulmonary residual changes.Conclusions:A very rare case of chronic pancreatitis complicated by pancreaticopleural fistula with lung abscesses is presented. The clinical outcome was good due to the staged character of treatment and participation of a multi-disciplinary specialist team.

A Rare Complication of Chronic Pancreatitis

A Rare Complication of Chronic Pancreatitis

Bridging the Divisum: A Rare Case of Pancreaticopleural Fistula in the Setting of Complete Pancreatic Divisum Treated Endoscopically

A pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis that occurs either due to a pancreatic duct disruption or a pseudocyst extension. A pancreatic divisum, on the other hand, is a common anatomic variant of the pancreas that is rarely symptomatic. We describe a case of recurrent pleural effusion in a patient with a history of chronic pancreatitis. Investigations revealed the presence of a PPF and a concomitant complete pancreatic divisum. There was resolution of the pleural effusion on endoscopic therapy. This is the fourth reported case of a PPF in the setting of complete pancreatic divisum and the first reported case in a middle-aged female.

1301 Bleeding Pancreaticoduodenal Fistula: An Unusual Case of Melena

INTRODUCTION: Pancreatic fistulas have been described in the setting of pancreatic resection, trauma, and less commonly in acute or chronic pancreatitis (CP). Spontaneous pancreatic fistulas resulting in gastrointestinal (GI) bleeding are rare. CASE DESCRIPTION/METHODS: An 80 year-old woman presented to the emergency room with shortness of breath and melena. She was afebrile, normotensive, and had a heart rate of 93. Labs showed hemoglobin (Hgb) of 5.2 g/dL. EGD showed a 2 mm clean-based duodenal ulcer. As this did not account for melena, she had a colonoscopy and video capsule endoscopy which did not show a clear source of bleeding. As she continued to have melena with drop in Hgb, she had an abdominal CT scan showing a retroperitoneal fluid collection medial to the 2nd and 3rd portions of the duodenum, hyperattenuating material in the 2nd portion of the duodenum concerning for bleeding, and signs of CP with a pancreatic duct (PD) diameter of 14 mm. A second look EGD showed a duodenal mucosal defect suspicious for a fistulous opening into the PD with evidence of active bleeding (Figures 1 and 2). Repeat CT scan revealed extraluminal contrast extravasation into the retroperitoneum medial to the 2nd part of the duodenum and close in proximity to the superior mesenteric vein (SMV) (Figure 3). Abdominal MRI showed signs of CP and multiple small pseudocysts in the body and tail. Patient's melena resolved and Hgb stabilized prior to discharge. DISCUSSION: Bleeding is a rare complication of CP and occurs in 10-15% of CP patients. Pancreatic structures can be destroyed by enzyme digestion and necrosis. This may create pseudoaneurysms which may create cavities, fistulas, or rupture if they involve arterial or venous structures. The splenic and gastroduodenal artery are most commonly involved. Clinical presentation varies depending on location and severity of bleeding. Diagnosis involves abdominal CT and EGD, however laparotomy may sometimes be needed. Management involves embolization or surgery. Our patient's pancreaticoduodenal fistula was the result of previously undiagnosed CP. Bleeding may have resulted from spontaneous hemorrhage into the cystic cavity or as a result of erosion into the SMV given proximity on imaging. This case highlights the need to maintain a high clinical suspicion for pancreaticoduodenal fistulas in patients with a history of pancreatic disease presenting with GI bleeding.

1431 A Bad Connection: Chronic Pancreatitis Leading to a Pancreticopleural Fistula

INTRODUCTION: Pancreatic-pleural/mediastinal fistulas are a rare complication of chronic pancreatitis. Fistulous connections occur through fenestrations in the diaphragm. Pancreatic ductal stenting can be valuable, though medical and surgical options may still be required. We describe a case of pancreatic-pleural fistula with mediastinal tracking successfully treated with combined endoscopic and medical management. CASE DESCRIPTION/METHODS: The patient is a 53-year-old male with a history of chronic pancreatitis secondary to alcohol abuse, a pancreatic pseudocyst, and compensated heart failure. The patient was admitted with new onset shortness of breath and epigastric abdominal pain. CT showed acute on chronic pancreatitis with a pseudocyst in the uncinate process, lower mediastinal inflammatory changes, and bilateral pleural effusions. Thoracentesis was performed, demonstrating an amylase of >7500. Though MRCP did not show a discrete connection, the clinical presentation was consistent with pancreatic-pleural fistula. ERCP was performed, but the endoscopist was unable to cannulate the pancreatic duct. Patient was placed on octreotide and continued to undergo therapeutic thoracenteses as needed. Patient returned 1 month later with complaints of neck fullness, continued shortness of breath, and abdominal pain. CT was significant for a fluid collection extending from pancreatic head to the mediastinum tracking along the anterior aspect of the esophagus and persistent pleural effusions. MRCP was performed and revealed a fistulous connection between the pseudocyst, pleural space, and mediastinum. Repeat ERCP was done with successful pancreatic stent placement. Patient subsequently had resolution of both mediastinal and pleural fluid collections. The pancreatic stent was removed with durable resolution of fluid collections. DISCUSSION: Pancreatic fistulas are reported to resolve with supportive care alone in 80% of external and 50-65% of internal fistulas. In our case, supportive care including octreotide use was insufficient for fistula resolution. The patient was ultimately treated successfully with pancreatic stenting. Had this failed, alternative approaches could have included nasojejunal feeding, endoscopic sealants, or surgical correction. This case highlights a rare, but serious complication of chronic pancreatitis and management options to be considered.

3015 Pancreatic Ascites: A Rare Complication of Chronic Pancreatitis

INTRODUCTION: Pancreatic ascites is a rare complication of chronic pancreatitis. We present a case of recurrent pancreatic ascites refractory to medical management. CASE DESCRIPTION/METHODS: A 62-year-old man with alcohol related chronic pancreatitis thrombosis initially presented with abdominal pain which was treated as a chronic pancreatitis flare which was managed conservatively. CT showed a pseudocyst and a portal vein thrombus, for which he was started on therapeutic enoxaparin (Figure 1). EUS later showed the pseudocyst, along with calcifications and hypoechoic strands in pancreatic parenchyma (Figure 2). Subsequently, the patient had two more hospitalizations for chronic pancreatitis flares, but with new development of abdominal distention. CT confirmed the presence of a large intraabdominal and pelvic ascites. He underwent a diagnostic paracentesis revealing a SAAG less than 1.1, amylase level of 5954 U/L and a total protein of 3.1 mg/dl. Hence a diagnosis of pancreatic ascites was confirmed and portal hypertension was ruled out. The patient suffered rapid reaccumulation of ascites and required weekly paracentesis. He was treated with subcutaneous Octreotide, without improvement. Because of this, he underwent ERCP which showed leakage of contrast from the pancreatic duct (PD) (Figure 3). A PD stent was placed. After this he still developed ascites, but at a slower rate. Repeat paracentesis showed an amylase level of 291 U/L and subsequently 21 U/L. DISCUSSION: Minor PD injuries are common in acute pancreatitis resulting in peripancreatic fluid collections. The fluid collection is often contained and results in pseudocyst formation. Pancreatic fluid collections can also leak into the peritoneum leading to pancreatic ascites. The majority of cases occur in males in the 5th decade of life. Pancreatic ascites is primarily exudative with markedly raised ascitic amylase and protein content greater than 2.5 g/dl. Medical management includes diuretics and somatostatin analogs. If this fails, ERCP with PD stent placement is performed. This decreases intraductal pressure and diverts pancreatic secretion to the small bowel, thereby enhancing healing of the disrupted PD. Surgical therapy is recommended for patients with a lack of response to conservative therapy for 3-4 weeks or failure of endoscopic intervention. Our case report demonstrates the utility of endoscopic PD stent placement in patients with recurrent pancreatic ascites.

Pancreatico-Pleural Fistula Presenting as Recurrent Bilateral Pleural Effusion: A Rare Complication of Chronic Pancreatitis

Pancreatico-Pleural Fistula (PPF) is a rare complication of chronic pancreatitis associated with significant morbidity and mortality. Diagnosis requires a high level of suspicion and management can be very challenging. We present an unusual presentation of recurrent bilateral pleural effusion secondary to PPF. 62 year old female presented to the hospital with worsening shortness of breath. History of multiple admissions in the last 6 months for recurrent left sided pleural effusions. Thoracentesis done at each visit revealed exudative nature of fluid but failed to identify the underlying etiology. Past history significant for an episode of pancreatitis in 2014 secondary to gall stones for which she underwent cholecystectomy. Chest X-ray revealed bilateral pleural effusions and patient eventually underwent bilateral chest tube placement. CT scan of the chest and abdomen revealed massive bilateral pleural effusion along with calcification of the pancreatic head and dilated pancreatic duct. Also noted were a 4 cm pseudocyst in the body and 7 cm pseudocyst in the tail of the pancreas with connection to the pleural space (Image 1,2). Pleural fluid amylase was elevated at 6915 U/L & lipase >3000 U/L. Patient subsequently underwent ERCP and a pancreatogram revealed a high grade stricture in the neck of the pancreas with extravasation of dye at the tail consistent with an internal pancreatic fistula. A 10 cm 7 fr plastic stent was successfully placed and patient was started on octreotide. Patient was subsequently discharged with bilateral pleurex catheters and daily octreotide injections. Day 60 follow up noted the pleural fluids secretions to be minimal with continued use of octreotide. Pancreatico-Pleural Fistula presenting as recurrent bilateral pleural effusions is an extremely rare complication of chronic pancreatitis. Pleural effusion due to PPF accounts for less than 1% of cases, while pleural effusion can be seen in 3—7% of patients with pancreatitis .Diagnosis requires a high degree of suspicion with supporting laboratory and radiological studies. Conservative treatment with pancreatic duct stenting and/or octreotide has been successful in 31—45% of cases, while surgery is curative in 80—90% of cases but with a high rate of mortality upto 10%. Combination of medical management and interventional endoscopy successfully reduced the pleural drainage in our patient.1400_A.tif Figure 1: CT scan of the chest and abdomen showing massive bilateral pleural effusion along with calcification of the pancreatic head with dilated pancreatic duct.1400_B.tif Figure 2: CT scan chest and abdomen showing a 4 cm pseudocyst in the body and 7 cm pseudocyst in the tail of the pancreas with connection to the pleural space

Pancreatic Ascites: A Rare Complication of Chronic Pancreatitis

Pancreatic Ascites: A Rare Complication of Chronic Pancreatitis

A RARE CASE OF CHRONIC PANCREATITIS COMPLICATED BY INTERNAL PANCREATIC FISTULA AND PANCREATOGENIC ASCITES

Objective: pancreatogenic ascites is rare complication of the chronic pancreatitis associated with a rupture in the ductal system and caused by internal pancreatic fistula. It can become as a result of the chronic pancreatitis, injury of the pancreas and stricture of the pancreatic duct. Case presentation: 40 years old male was admitted to our hospital suffered of surrounded epigastric pain, nausea, vomiting, enlargement of the abdomen, dyspnoea. Anamnesis showed that patient suffers of chronic calculous pancreatitis for 4 years, was hospitalized 8-9 times per year for conservative treatment. Patient was admitted to our clinic in medium severity condition. Laparocentesis with the fluid examination revealed amylase level 6007 U/L, protein 3.8 g/L. CT scan showed multiple calcifications in the pancreatic parenchyma, pancreatic duct dilation to 5 - 7 mm, large concrements (5-6 mm) in the pancreatic duct, postnecrotic cyst 34 mm diameter in the pancreatic head, smaller cyst 23 mm diameter in the pancreatic body from which, most likely, proceed pancreatic fistula. Patient was operated. The cystopancreatojejunostomy with dissection of the fistula was performed. Patient returned three months later with recurrent complaints of pain and increasing of the abdomen due to the fluid component. According to preoperative examinations (CT) it was seemed like the recurrence of internal pancreatic fistula. Amylase level of the fluid was 22 U/L, protein level 41 g/L. Nevertheless, considering the chronic calculous pancreatitis surgical treatment was performed: subtotal pancreatic head resection with reconstruction of the pancreatojejunoanastomosis. Conclusion: internal pancreatic fistula with the pancreatogenic ascites is a rare complication of chronic pancreatitis. In cases without any other significant changes (pseudocysts, pancreatic duct dilation, calculous) it can be treated by endoscopic stent placement. Surgical treatment is prior in complicated cases. Surgical approach not always has a positive result because of inflammatory infiltration.

Interesting series of extra abdominal complications in two patients with chronic pancreatitis secondary to chronic alcoholism and pancreatic divisum

Pancreaticopleural fistula is an extremely rare complication of chronic pancreatitis. Interestingly it may present without any symptoms of pancreatitis per se. The diagnosis requires a high index of suspicion due to the predominant thoracic symptoms. Cases with massive, rapidly refilling, refractory pleural effusion in the setting of pancreatitis (symptomatic or asymptomatic) should be suspected of having a pancreaticopleural fistula. We report two cases of pancreaticopleural fistula. One of the patient also had pancreatic divisum and to the best of our knowledge this is the first case report of pancreatic divisum with pancreaticopleural fistula in the literature.

Single Cause, Dual Presentation: Inferior Pancreatico-duodenal Artery Pseudoaneurysm as a Cause of Hemorrhagic Shock and Obstructive Jaundice

Pseudoaneurysm of the inferior pancreaticoduodenal artery (IPDA) is very rare. We report the case of a patient with hemorrhagic shock secondary to a bleeding pseudoaneurysm of the IPDA, also causing obstructive jaundice by virtue of its size and location. To our knowledge, this is the first such reported case in the United States. A 45-year-old male with history of iron deficiency anemia, chronic pancreatitis and alcohol abuse presented with severe right upper quadrant (RUQ) abdominal pain for 1 week. On presentation, vitals were stable and physical examination revealed RUQ abdominal tenderness and scleral icterus. Laboratory study showed hemoglobin 6.1 g/dl, alkaline phosphatase 416U/L, GGT 230 U/L, AST 76 U/L, ALT 132 U/L, total bilirubin 4.4 mg/dl, and direct bilirubin 3.4 mg/dL. Computed tomography (CT) of the abdomen with intravenous contrast showed a pseudoaneurysm arising from the IPDA (6.5x4.1x4.3 cm), acute on chronic pancreatitis and obstruction of biliary tree due to mass effect from pseudoaneurysm, marked intra and extrahepatic biliary dilation with the common bile duct measuring 17 mm and distended gallbladder. Mesenteric angiography also revealed the aneurysm but not amenable to embolization. The patient's abdominal pain worsened and developed hemorrhagic shock requiring additional resuscitation. Stat CT angiography showed increased size of the pseudoaneurysm, and a new hyperdense material within the small bowel loops. Exploratory laparotomy revealed large amount of intraluminal blood in second part of duodenum and a large pseudo aneurysm entering second part of duodenum that was ligated. Distal gastrectomy with duodenotomy with lysis of adhesions was done. LFTs trended down and jaundice resolved after procedure. Pseudoaneursym of IPDA is a rare complication of chronic pancreatitis. The mortality is 90-100% with acute hemorrhage in untreated patients and 12-50% even with aggressive treatment. Even though, most common presentation of pseuodaneusym is acute GI bleed, other presentations should not be overlooked. As shown in this case, our patient presented with obstructive jaundice. Direct pressure over the pancreaticobiliary ducts can cause recurrent pancreatitis and jaundice. Mesenteric angiography is the gold standard diagnostic test. Treatment options include angiographic embolization and surgical treatment. Early multidisciplinary approach with diagnostic and therapeutic interventions is needed to improve the outcome and decrease mortality.Figure: CT abdomen with contrast: Pseudoaneursym of inferior pancreaticoduodenal artery (arrow).Figure: Mesenteric Angiography:Pseudoaneursym of inferior pancreaticoduodenal artery(arrow).