Rare Complication Of Chronic Pancreatitis Research Articles

MANAGEMENT OF PANCREATICOPLEURAL FISTULAS SECONDARY TO CHRONIC PANCREATITIS.

ABSTRACT Introduction:Pancreaticopleural fistula is a rare complication of chronic pancreatitis. Objective:To describe pancreaticopleural fistula due to chronic pancreatitis and perform an extensive review of literature on this topic. Methods:Comprehensive narrative review through online research on the databases Medline and Lilacs for articles published over the last 20 years. There were 22 case reports and four case series selected. Results:The main indication for surgical treatment is the failure of clinical and/or endoscopic treatments. Surgery is based on internal pancreatic drainage, especially by means of pancreaticojejunostomy, and/or pancreatic resections. Conclusion:Pancreaticopleural fistula is a rare complication of chronic pancreatitis and the Frey procedure may be an appropriate therapeutic option in selected cases when clinical and endoscopic treatments are unsuccessful.

Endovascular treatment of splenic artery pseudoaneurysm

Splenic artery pseudoaneurysms are rare complication of chronic pancreatitis or, somewhat less often, acute pancreatitis. We present a case of 34 year old male of acute on chronic pancreatitis admitted with history of severe abdominal pain, radiating toward back. CT revealed a large pseuoaneurysm involving the splenic artery. Endovascular approach was taken to occlude the neck of pseuoaneurysm with a graft stent.

A Case of Pancreaticopleural Fistula Successfully Treated with a Pancreatic Duct Stent

Pancreaticopleural fistula (PPF) is a rare complication of chronic pancreatitis. We present the case of a 34 yearsold male who presented with a massive left side pleural effusion. The MRCP showed the PPF and the patient was rapidly treated with a pancreatic duct stent. There was no recurrence of pleural effusion after twenty-two months of follow-up. This case highlights the prompt recognition of PPF by medical team and the right identification of a fistula amenable to an endoscopic treatment.

Gastric Intramural Pseudocyst: A Rare Complication of Chronic Pancreatitis

Gastric Intramural Pseudocyst: A Rare Complication of Chronic Pancreatitis

Pancreaticopleural Fistula as a Complication of Chronic Pancreatitis

Chronic pancreatitis and pleural effusions are common conditions encountered by clinicians. We present a case of pancreaticopleural fistula that reminds the clinician to consider a pancreatic source of a new pleural effusion in a patient with known chronic pancreatitis. A 64 year old male with a history of chronic alcoholic pancreatitis presented to the emergency department for shortness of breath and left sided chest pain of a few days duration. Chest x-ray showed a new left side pleural effusion. His dyspnea improved after removal of 2L of fluid, but his pleural effusion rapidly re-accumulated. Pleural fluid was exudative with lipase of 10539 U/L and amylase of 16674 U/L. Magnetic resonance cholangiopancreatography (MRCP) revealed a mid-pancreatic duct stricture and possible fistulous tract to the left pleural space. The patient was started on octreotide and placed on total parental nutrition (TPN). He subsequently underwent endoscopic retrograde cholangiopancreatography (ERCP) which confirmed a mid-pancreatic duct stricture with a fistula arising in the body of the pancreas. A pancreatic sphincterotomy was performed and a pancreatic duct stent was placed. He also underwent video assisted thoracoscopic surgery (VATS) with decortication of the organized left pleural effusion. In spite of this, patient developed a Vancomycin resistant enterococcus (VRE) empyema on the decorticated side, which was treated with chest tube drainage and antibiotics. He recovered completely over a course of 6 weeks. After serial pancreatic duct stenting for 6 months the pancreatic stent was removed and a pancreatogram showed persistent mid-pancreatic duct stricture without evidence of pancreatic duct leak. Pancreaticopleural fistula is a rare complication of chronic pancreatitis most commonly presenting with dyspnea and chest pain. Abdominal symptoms are often not present. Pleural fluid usually tends to be exudative and amylase or lipase analysis is necessary to make the diagnosis. Imaging such as MRCP or ERCP is required to identify a pancreatic duct disruption and or stricture. Treatment can include Octreotide, parental nutrition, and supportive care. ERCP with subsequent endotherapy for stricture is often required. Surgery is usually reserved for those cases not responsive to medical or endoscopic therapies. A multi-disciplinary approach is required in caring for these complicated patients.Figure 1Figure 2Figure 3

Acute Obstructive Suppurative Pancreatic Ductitis in an Asymptomatic Patient

Acute obstructive suppurative pancreatic ductitis (AOSPD), defined as suppuration from the pancreatic duct without associated pseudocyst, abscess, or necrosis, is a rare complication of chronic pancreatitis. We present the first case of AOSPD in an asymptomatic patient with a polymicrobial infection and review the literature on this rare clinical entity.

Superior Mesenteric Vein Pseudoaneurysm Presenting as a Pancreatic Mass

Introduction: A 67-year-old man with a past history of hypertension and long-standing alcohol abuse was admitted for shortness of breath secondary to new-onset heart failure. His hospital course was complicated by hypertensive emergency and delirium tremens requiring intubation and midazolam drip. An ultrasound of the abdomen was performed to evaluate for cirrhosis and revealed a questionable mass in the uncinate process of the pancreas and a dilated pancreatic duct to 6 mm in the head. At this time GI was consulted for further evaluation. A palpable epigastric mass was noted on physical exam and labs revealed a low albumin, 2.5 g/dL. Liver function tests, amylase, lipase, and coagulation studies were otherwise normal. CT scan of the abdomen demonstrated a 2.8 x 3.2 x 2.8 cm enhancing lesion concerning for a tumor in the area of the pancreatic head and superior mesenteric vein (SMV). Endoscopic ultrasound (EUS) was performed and revealed a dilated SMV to 25 x 21 mm with pseudoaneurysm formation. The EUS also revealed multiple criteria to establish a diagnosis of chronic pancreatitis. Arteriogram was performed and did not show an arteriovenous malformation. The patient was diagnosed with a SMV pseudoaneurysm and discharged in stable condition, remaining asymptomatic upon outpatient follow-up. Pseudoaneurysms are a rare complication of chronic pancreatitis. It is theorized that pancreatic enzymes may erode the peripancreatic vessels and result in the formation of a pseudoaneurysm. Vessels commonly affected include the splenic, hepatic, gastroduodenal, and cystic arteries. Eighty-nine percent of patients with a pseudoaneurysm complain of abdominal pain and complications include thrombosis and bleeding. When bleeding occurs, surgery is complicated and is associated with a high morbidity and mortality. Conservative management with serial abdominal imaging, usually ultrasound, is generally recommended, as 94% of pseudoaneurysms remain stable and a much smaller percentage regress. We found no published cases of SMV pseudoaneurysms mimicking pancreatic cancer. We present a unique case of an asymptomatic patient with SMV pseudoaneurysm from chronic alcoholic pancreatitis masquerading as pancreatic cancer. Vascular pseudoaneurysms must be considered in the setting of chronic pancreatitis, especially when a mass-like lesion is discovered.Figure 1

Pancreatico-pericardial fistula as a complication of chronic pancreatitis

Pancreatico-pericardial fistula is an extremely rare complication of chronic pancreatitis. We present a case of a 58-year-old man who presented with syncope. Transthoracic echocardiogram revealed a pericardial effusion with tamponade physiology. Pericardiocentesis and pericardial fluid analysis demonstrated a lipase level of 2321 U/L. Subsequently, an endoscopic retrograde cholangiopancreatography (ERCP) was performed, confirming the presence of a pancreatico-pericardial fistula (PPF) from the distal body of the pancreas. A pancreatic duct stent was placed across the duct disruption on two separate occasions; however, despite stent placement, the patient continued to re-accumulate pericardial fluid and deteriorated. While rare, PPFs may complicate chronic pancreatitis, may not respond to pancreatic duct stenting and may portend a poor prognosis.

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

Hepatic Artery Pseudoaneurysm with Extrahepatic Biliary Obstruction

Hepaticartery pseudoaneurysms are a rare complication of chronic pancreatitis. However, giant pseudoaneurysms (80 mm) and complicated biliary obstructions are extremely rare. This article reports a 75 year-old man with chronic pancreatitis that presented as upper abdominal pain and obstructive jaundice. Computed tomography revealed a hepatic artery pseudoaneurysm measuring 80 × 72 × 70 mm. We performed aneurysm resection and common hepatic artery bypass, using a great saphenous vein graft in the patient. The postoperative course was uneventful, and he was discharged on the 10th postoperative day. However, on the 135th postoperative day, he died of massive hemorrhage into the peritoneal cavity.

Upper gastrointestinal bleeding in chronic pancreatitis

Pseudoaneurysm of peripancreatic vessels is a rare complication of chronic pancreatitis. Being close to the pancreas, splenic artery is the most frequently affected vessel whereas right gastroepiploic artery pseudoaneurysm is very rare. Rupture of such pseudoaneurysm is a rare cause of upper gastrointestinal (GI) bleeding. We report a patient of chronic pancreatitis with past history of pancreatic duct stenting who presented with massive upper GI bleeding and stent migration. Bleeding from pseudoaneurysm of right gastroepiploic artery was detected in angiography. Coil embolization was done but later rebleeding occurred and was managed with laparotomy and ligation of the pseudoaneurysm. Patient improved during postoperative period. Keywords: chronic pancreatitis; embolization; pseudoaneurysm DOI: http://dx.doi.org/10.3126/joim.v32i2.4946 Journal of Institute of Medicine, August, 2010; 32: 47-50

Pseudoaneurysm of the Gastroduodenal Artery Secondary to Chronic Pancreatitis

Although pseudoaneurysms are a rare complication of chronic pancreatitis, they are potentially serious both because of the events they can lead to and the diagnostic challenges they may pose. Historically, they used to be treated surgically, through ligation and/or resection; it was not until the last decade that scarcely invasive percutaneous endovascular procedures were introduced. This article reports the case of a patient with chronic pancreatitis presenting with severe upper digestive hemorrhage caused by the rupture of a pseudoaneurysm of the gastroduodenal artery. The patient was successfully treated using selective embolization.

Mediastinal pancreatic pseudocyst with isolated thoracic symptoms: a case report

IntroductionMediastinal pancreatic pseudocysts represent a rare complication of acute or chronic pancreatitis.Case presentationA 55-year-old man with a history of chronic pancreatitis was admitted with intermittent dyspnea, dysphagia and weight loss. Chest X-ray, computed tomography and magnetic resonance imaging revealed a large paracardial pancreatic pseudocyst causing cardiac and esophageal compression.ConclusionMediastinal pancreatic pseudocysts are a rare complication of chronic pancreatitis. These pseudocysts may lead to isolated thoracic symptoms. For accurate diagnostic and therapy planning, a multimodal imaging approach is necessary.

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.

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.

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.

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.

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.

Percutaneous drainage of spontaneous subcapsular haematoma of the spleen complicating chronic pancreatitis

Subcapsular haematoma of the spleen is a rare complication of chronic pancreatitis. In the literature only a handful of cases have been documented. The exact aetiology and natural history of this complication remains speculative and its management controversial. A case of spontaneous subacute haematoma of the spleen in a patient with chronic relapsing alcohol-related pancreatitis was reported. A percutaneous drainage was performed with good outcome. A review of the literature has demonstrated only one previous similar report.

Endoscopic Ultrasonographic Diagnosis of Pancreatic Cancer Complicating Chronic Pancreatitis

Pancreatic cancer is a rare complication of chronic pancreatitis (CP), and its diagnosis remains difficult. The present study attempted to evaluate the ability of endoscopic ultrasonography (EUS) to diagnose pancreatic masses associated with CP and provide evidence of malignancy in patients with a pancreatic mass on EUS. Between 1991 and 1994, EUS examinations yielded a diagnosis of CP in 85 patients at our institution. Forty patients had early CP, 18 had pancreatic pseudocysts complicating CP, and 27 had advanced chronic pancreatitis - five of whom were considered as presenting pancreatic cancer associated with CP. The five patients studied had jaundice, weight loss, and calcifications visible on plain abdominal films. Three of them had histological confirmation of pancreatic carcinoma. The pancreatic carcinomas were hypoechoic masses of 20-35 mm, with an irregular, rounded shape. Calcifications were limited to the periphery of the hypoechoic masses. Two patients had negative EUS-guided cytological punctures, and are still alive two years later. They were considered as false-positive cases. EUS showed a hypoechoic mass with peripheral calcifications in one of these false-positive patients, with a large central calcification in the other case. The overall sensitivity of EUS for the diagnosis of pancreatic carcinoma was 100%, but the positive predictive value was 60%. EUS is highly sensitive in detecting abnormal masses in cases of CP, but the positive predictive value of the diagnosis of pancreatic cancer seems to be weak.