Reid Malcolm, DO1, Pooja D. Patel, DO1, Ruchit N. Shah, DO2, Harshit S. Khara, MD, FACG1; 1Geisinger Medical Center, Danville, PA; 2Geisinger Commonwealth School of Medicine, Danville, PA
Introduction: Acute pancreatitis is one of the most common gastrointestinal diagnoses seen in inpatients, accounting for almost 280,000 hospital admissions annually. Cholelithiasis is the most common cause, followed by prolonged alcohol abuse. Hypertriglyceridemia, drugs, autoimmune disease, and infection each account for less than 5% of cases. Here we present a rare case of acute pancreatitis secondary to Type B aortic dissection.
Methods: A 61-year-old male presented with sudden onset right-sided and periumbilical abdominal pain with radiation to the epigastrium and mild chest pain. He had no pertinent medical history and no significant alcohol use history. On presentation, he was hypertensive and tachypneic. Physical examination revealed a diaphoretic male with diffuse abdominal tenderness. Laboratory work up showed a leukocytosis of 17.24 K/uL, lactate 4mmol/L, LDH 374 U/L, and lipase 383 U/L. CT angiography showed a prominent Stanford Type B aortic dissection with an intramural hematoma extending along the descending thoracic aorta through the upper abdominal aorta leading to occlusion of the celiac artery. His dissection was treated with esmolol drip with rapid correction of blood pressure to goal systolic blood pressure 100-120. Due to persistent leukocytosis, on hospital day 3 repeat CT imaging was performed revealing increasing irregular fluid scattered throughout the upper abdomen consistent with acute pancreatitis. Alternative etiologies were ruled out and this pancreatitis was presumed to be caused by vascular compromise in the setting of a type B aortic dissection and celiac artery hematoma. He showed gradual clinical improvement with medical management and was discharged home. Discussion: Blood supply to the pancreas is provided by pancreatic branches of the splenic artery (from the celiac artery), and the superior and inferior pancreaticoduodenal arteries (from the superior mesenteric artery). The mechanism of pancreatitis caused by type B aortic dissection is organ ischemia, through occlusion of either the celiac artery or the superior mesenteric artery SMA. Most type B aortic dissections are managed conservatively with antihypertensives, but end organ ischemia can be an indication for surgical management. This presentation is exceedingly rare; we note only 6 similar cases in the literature. As our case demonstrates, acute pancreatitis as a complication of aortic dissection can be managed with standard conservative measures and does not necessitate surgical intervention.
Computed tomography angiogram shows a Stanford Type B Aortic Dissection (2 views).
Chest computed tomography imaging shows irregular fluid scattered throughout the upper abdomen representative of acute pancreatitis.