급성 췌장염 합병증으로 인한 십이지장 폐쇄: 증례 보고
A Rare Cause of Duodenal Obstruction due to Complications of Acute Pancreatitis: A Case Series
Article information
Abstract
급성 췌장염의 드문 합병증인 가성동맥류는 파열 시 생명을 위협할 수 있으나 본 증례와 같이 위장관 폐쇄로 나타나는 경우는 매우 드물다. 본 증례에서는 가성동맥류 파열로 인한 십이지장 폐쇄를 보인 두 명의 환자를 보고하였다. 한 명은 경동맥색전술로, 다른 한 명은 보존적 감압 치료로 증상이 호전되었다. 구역이나 구토 등 위장관 폐쇄 증상이 있는 급성 췌장염 환자에서 출혈 없이도 가성동맥류 파열을 감별 진단에 포함시키는 것이 필요할 것으로 보인다.
Trans Abstract
Pancreatic pseudoaneurysm is a rare but life-threatening complication of pancreatitis, with varied clinical presentations. We report two cases in which patients presented with duodenal obstruction caused by pseudoaneurysmal rupture. One patient was successfully treated with transarterial embolization, while the other recovered with conservative decompression. These cases suggest the importance of considering pseudoaneurysm as a differential diagnosis in patients with pancreatitis who present with obstructive gastrointestinal symptoms, even in the absence of hemorrhage. Prompt recognition and appropriate intervention are essential to prevent serious outcomes.
INTRODUCTION
Pancreatitis is a inflammatory condition of the pancreas that disrupts its normal function and can lead to a cascade of serious complications, profoundly impacting overall health [1]. Depending on the extent and severity of inflammation, a range of complications may occur, including paralytic ileus, pseudocyst formation, splenic vein thrombosis, and vascular abnormalities such as pseudoaneurysm [2]. Among these, pancreatic pseudoaneurysm is one of the most fatal complications. If ruptured, it can cause life-threatening hemorrhage and carries a high mortality rate, with symptoms ranging from abdominal pain to gastrointestinal bleeding or shock [3]. Early clinical suspicion and prompt diagnosis are essential for improving outcomes.
Although rare, duodenal obstruction caused by pseudoaneurysmal rupture has been reported in a limited number of case studies [4-6]. Herein, we describe two such cases of patients who presented with obstructive gastrointestinal symptoms and were ultimately diagnosed with pseudoaneurysmal rupture secondary to pancreatitis.
CASE
1. Case 1
A 53-year-old male presented to the emergency department with obstructive gastrointestinal symptoms, including nausea and vomiting that had begun 3 days earlier. His medical history was notable for chronic alcohol use disorder and dyslipidemia. On physical examination, he appeared dehydrated, with a dry tongue and decreased skin turgor. Initial laboratory investigations revealed acute kidney injury, with a serum creatinine level of 2.18 mg/dL. Pancreatic enzyme levels were unremarkable, with an amylase level of 62 U/L (reference range, 28-100 U/L) and a mildly elevated lipase level of 73 U/L (reference range, 13-60 U/L).
To investigate the underlying cause of his symptoms, contrast-enhanced abdominopelvic computed tomography (CT) was performed. The scan revealed a markedly distended gastric lumen and narrowing of the second portion of the duodenum with surrounding periduodenal fat stranding (Fig. 1A), suggestive of duodenal stenosis possibly secondary to acute pancreatitis with associated duodenitis. Esophagogastroduodenoscopy (EGD) showed extrinsic compression between the second and third portions of the duodenum, along with multiple hyperemic lesions (Fig. 1B). The patient received conservative management with intravenous fluid resuscitation, which led to an improvement in his obstructive symptoms. He was able to resume oral intake and was discharged in stable condition.
Clinical course and outcome of case 1. (A) Transverse CT image of distended gastric lumen due to the luminal narrowing at 2nd portion of duodenum. (B) Endoscopy showed luminal obstruction between 2nd and 3rd duodenum. (C) Transarterial angiography showed pseudoaneurysmal rupture causing a large hematoma (red arrow). (D) Coil embolization was performed using a microcatheter and microcoils (red circle). (E) Transverse image of coiling state of pancreatic pseudoaneurysm at just below uncinate process of pancreas. (F) Endoscopy showed interval improvement of luminal obstruction between 2nd and 3rd duodenum. CT, computed tomography.
However, he returned within a week with recurrent symptoms of gastrointestinal obstruction. A follow-up CT scan demonstrated a large periduodenal hematoma and a 9-mm pancreatic pseudoaneurysm arising from the pancreaticoduodenal artery, just inferior to the uncinate process of the pancreas. Angiographic embolization was subsequently planned. Selective angiography of the superior mesenteric artery (SMA) revealed a sizable pseudoaneurysm originating from a pancreaticoduodenal branch (Fig. 1C), with arterial supply from both the SMA and the celiac axis. Embolization was successfully performed using a microcatheter and interlock microcoils to occlude both the afferent and efferent branches of the pancreaticoduodenal arcade (Fig. 1D).
A few days later, follow-up CT imaging showed resolution of the duodenal obstruction (Fig. 1E), and repeat EGD demonstrated improvement in the luminal narrowing between the second and third portions of the duodenum (Fig. 1F). The patient was discharged shortly thereafter without any complications.
2. Case 2
A 69-year-old male presented with progressive lower limb weakness and was diagnosed in our neurosurgical department with spinal stenosis, grade I degenerative spondylolisthesis, and a bulging disc at the levels between the second and third thoracic vertebrae and the fourth and fifth lumbar vertebrae. He previously had a medical history of dyslipidemia. Ten days after successfully undergoing posterior lumbar interbody fusion and decompressive laminectomy, he suddenly developed vomiting immediately after food intake and was referred to the gastroenterology department for further evaluation. Laboratory studies revealed elevated pancreatic enzyme levels (amylase, 105 U/L; lipase, 136 U/L). To investigate the cause of his symptoms, a contrast-enhanced CT scan was performed, and revealed a 13.6 cm sized thick-walled cystic mass, consistent with an intraperitoneal hematoma and pancreatic pseudoaneurysm without extravasation. The mass was compressing the second portion of the duodenum, resulting in upstream gastric and duodenal dilatation (Fig. 2A).
Clinical course and outcome of case 2. (A) Transverse CT image of duodenal 2nd portion obstruction caused by extrinsic compression. (B) Endoscopy showed duodenal obstruction, which interrupted scope entering the 3rd portion. (C) Contrast showed hematoma formation around the pancreas. (D) A pigtail insertion was successfully performed. (E) Transverse image of disappearance of hematoma at anterior pararenal space. (F) Endoscopy showed completely improving state of 3rd portion of duodenal obstruction. CT, computed tomography.
EGD was performed to evaluate another cause of obstruction and showed extrinsic compression of the second portion of the duodenum, corroborating the CT findings (Fig. 2B). A consultation with the interventional radiology team concluded that angiographic embolization was not necessary, as there was no evidence of active bleeding. The patient was managed conservatively with a L-tube drainage for gastric decompression and hydration for 7 days. However, despite the initial improvement, the patient experienced recurrence of symptoms. Plain abdominal radiography revealed gastric distension, and trans-abdominal ultrasonography confirmed a hematoma anterior to the second portion of the duodenum, with no significant changes observed on follow-up ultrasound. Since the patient’s vital signs remained stable, a conservative, non-surgical approach was chosen. A pigtail catheter was inserted into intraperitoneal hematoma to facilitate drainage (Fig. 2C, D). Several days later, follow-up CT imaging showed significant reduction in the size of the liquefied hematoma (Fig. 2F). Subsequent EGD confirmed luminal patency of the duodenum (Fig. 2E), and the patient started the diet. Although surgical intervention was recommended as a definitive treatment for the pseudoaneuysm, the patient declined the surgery. He was fortunately discharged without further complications, and to date, there has been no recurrence of his symptoms.
DISCUSSION
Pancreatitis is often associated with a number of conditions, including gallstones, long-term alcohol use, hypertriglyceridemia and autoimmunity [7]. Among these factors, the cause of the first patient’s pancreatitis was chronic alcohol use and while the second patient’s condition may have been related to acute iatrogenic pancreatitis following spinal surgery. While most cases of acute pancreatitis are mild and self-limiting, certain complications such as pseudocyst formation, peripancreatic fluid collections, and vascular events including pseudoaneurysm can arise, occasionally leading to mechanical obstruction of adjacent gastrointestinal structures [8,9]. In both presented cases, obstructive symptoms were primarily due to mass effect from peripancreatic hematomas or inflammation, rather than intrinsic duodenal pathology.
When pancreatic enzymes leak from an inflamed pancreas, they can cause extensive local tissue damage, resulting in complications such as widespread hemorrhage, severe necrosis, or the formation of a pseudoaneurysm [10]. In some cases, a visceral artery may become incorporated into the wall of a pseudocyst, subsequently developing into a pseudoaneurysm [11]. The clinical presentation of a pancreatic pseudoaneurysm can range from asymptomatic to severe, including abdominal pain, melena, hematochezia, or even hemorrhagic shock [2,4]. In our cases, however, the patients presented with obstructive gastrointestinal symptoms-an uncommon manifestation. This suggests that pseudoaneurysmal rupture and the subsequent mass effect of the hematoma should be considered in the differential diagnosis of pancreatitis patients presenting with persistent nausea or vomiting.
Pseudoaneurysms pose a high risk of rupture and rebleeding, with mortality rates ranging from 20% to 50% if left untreated, underscoring the need for prompt intervention. Treatment options for pseudoaneurysmal rupture secondary to pancreatitis include conservative management, transarterial embolization (TAE), and surgical intervention. Previous studies have reported that conservative management in cases of active bleeding from a pseudoaneurysm is associated with high mortality rates, emphasizing the need for more aggressive and interventional approaches [12]. Historically, surgery was considered the standard treatment for pseudoaneurysmal rupture related to pancreatitis, with reported mortality rates ranging from 10% to 50% [13]. However, TAE has emerged as a less invasive and highly effective alternative. Recent evidence suggests that TAE is now regarded as the preferred first-line treatment for patients with pancreaticoduodenal artery aneurysms [14]. In the first case, the patient was successfully treated with embolization without any complications. In the second case, embolization was initially considered; however, it was ultimately not performed as the patient declined the procedure, and the interventional radiology team deemed it unnecessary due to the absence of active bleeding. Instead, conservative decompression was carried out. Fortunately, the patient has remained well without any complications since then.
In summary, we presented two cases of pancreatitis complicated by pseudoaneurysmal rupture. Although pancreatic pseudoaneurysm is an uncommon cause of duodenal obstruction, it was the underlying mechanism in both patients described. Hematoma formation secondary to rupture may lead to life-threatening complications, with variable clinical presentations. Therefore, pseudoaneurysm should be considered in the differential diagnosis of patients with duodenal obstruction, particularly those with a history of pancreatitis.
Notes
Conflict of Interest
No conflict of interest in this study.