Penn State University Milton S. Hershey Medical Center Hershey, PA
Gloria Hwang, MD1, Roland Y. Lee, MD2, Rachel V. White, DO1, Benjamin J. Shin, MD2, Kathryn McGillen, MD1; 1Penn State University Milton S. Hershey Medical Center, Hershey, PA; 2Penn State Health Milton S. Hershey Medical Center, Hershey, PA
Introduction: Emphysematous pancreatitis (EP) is a rare form of necrotizing pancreatitis associated with gas-forming bacteria and a high mortality rate. Extra-pancreatic complications include pleural effusion, ascites, vascular and gastrointestinal involvement. Disruption of the pancreatic duct can cause pancreatic ascites and pleural effusion. Gastroduodenal artery (GDA) pseudoaneurysms are rare complications of EP caused by release of proteolytic enzymes leading to weakening and ballooning of the vessel wall.
Methods: We present a case of an 82-year-old male ex-smoker with a history of hyperlipidemia, peptic ulcer disease, and noninsulin-dependent diabetes mellitus, who presented with postprandial epigastric pain. During the first 24 hours of onset, he met three out of the five Ranson criteria: age greater than 55, LDH above 350, glucose of 393 mg/dl, with additional findings of AST 46 IU/L, WBC 14.64, amylase 2,378, and lipase greater than 600. CT revealed pancreatic gas, bilateral pleural effusions, and cholelithiasis, the latter of which was determined to be the cause of acute EP (Figure 1). The patient required surgical debridement and ERCP with stenting of biliary and pancreatic ducts (Figure 2). Intraoperative cultures were negative for enteric, fungal, or anaerobic organisms. One month later, the patient presented with septic shock and leukocytosis. Abdominal CT revealed sequelae of necrotizing pancreatitis with increased extent of fluid collection. Upper endoscopic ultrasound identified a 35 mm fluid-filled lesion in the pancreatic head positive for gram-negative rods and Streptococcus anginosus. The following week, the patient presented with melena and painless bleeding from his Davol drain. Abdominal CT angiography showed a pseudoaneurysm arising from the distal GDA and endovascular coil embolization was performed (Figure 3). One year later, the patient presented with weight loss. Abdominal CT identified a 7.0 cm pancreatic pseudocyst causing extrinsic compression in the gastric body and antrum leading to LA Grade C stasis esophagitis. A 15 mm cystgastrostomy metal stent was placed across the posterior gastric wall to relieve gastric outlet obstruction. Discussion: Our case offers a unique sequela of EP causing GDA pseudoaneurysm with delayed formation of a pancreatic pseudocyst leading to severe esophagitis and gastric outlet obstruction. Effective diagnostic and therapeutic management helped this patient survive his multiple, life-threatening complications associated with EP.
Figure 1. Abdominal CTs in coronal view performed 6 hours apart. (A) Initial abdominal CT without contrast showed extensive inflammatory and air (white arrow) around the pancreatic head concerning for emphysematous pancreatitis versus duodenal perforation. (B) Subsequent same-day CT examination with oral contrast only demonstrated marked increase in pancreatic gas and inflammatory changes (white arrow) concerning for rapid progression. There was no extravasation of oral contrast (dashed white arrows) thereby ruling out perforated viscus as a cause for the air.
Figure 2. ERCP and sphincterotomy were performed given the known pancreatic head necrosis. The main pancreatic duct (A) and common bile duct (B) were cannulated, and temporary pancreatic and biliary stents were placed.
Figure 3. (A) Abdominal CT angiography showed pseudoaneurysm (white arrow) arising from a branch of the gastroduodenal artery in the region of peripancreatic inflammatory changes. (B) The gastroduodenal artery was embolized with multiple coils (dashed white arrow) endovascularly to treat the pseudoaneurysm.
Disclosures: Gloria Hwang indicated no relevant financial relationships. Roland Lee indicated no relevant financial relationships. Rachel White indicated no relevant financial relationships. Benjamin Shin indicated no relevant financial relationships. Kathryn McGillen indicated no relevant financial relationships.