Kuo-Chang Sung et al. Acute Pancreatitis With Pulmonary Embolism: A Case Report Kuo-Chang Sung 1, Chien-Chin Hsu 1 Abstract Acute pancreatic inflammation is associated with systemic hypercoagulability, which increase the risk of peripancreatic vascular thrombosis. Pulmonary thrombosis is a rare complication of acute pancreatitis, and few cases have been reported. In this study, we report a case of acute pancreatitis with pulmonary embolism. A 76-year-old woman presented at the emergency department with acute upper abdominal pain and syncope. Computed tomographic scans of her chest and abdomen revealed pulmonary embolism and pancreatitis. We discuss the pathogenesis and management of pulmonary thrombosis complicating acute pancreatitis. Familiarity with this complication can aid its early diagnosis and treatment, and prevent pulmonary embolism. Key Words: acute pancreatitis, pulmonary embolism, vascular thrombosis, epigastric pain Introduction A Pulmonary embolism (PE) is a blockage of a main artery of a lung or one of its branches by a substance that has traveled from elsewhere in the body through the bloodstream. 3,4 It most commonly results from a blood clot in the deep veins of the legs or pelvis that breaks off and migrates to the lung, through a process termed venous thromboembolism. 3 A small proportion of cases are caused by the embolization of air, fat, talc (in the drugs of intravenous drug abusers), or amniotic fluid. The reported mortality rate of untreated PE is 26%. 3 Acute pancreatitis is a sudden inflammation of the pancreas, which is associated with severe complications and a high mortality rate. The complication of acute pancreatitis can be systemic or locoregional. 1,2 Systemic complications include acute respiratory distress syndrome, multiple organ dysfunction syndrome, disseminated intravascular coagulation, hypocalcemia, hyperglycemia, and insulin dependent diabetes mellitus. 1 Locoregional complications include pancreatic pseudocyst, phlegmon, or abscess formation; splenic artery pseudoaneurysms; hemorrhage from erosions into the splenic artery and vein; and thrombosis of the splenic vein, superior mesenteric vein, and portal veins. 1 Pulmonary thrombosis is a rare complication of acute pancreatitis, and few cases have been reported. 1-4 In this study, we report a rare case of pulmonary thrombosis complicating pancreatitis, and discuss its pathogenesis and management. Awareness of this rare complication can facilitate its early diagnosis and treatment. Correspondence: Dr. Kuo-Chang Sung Emergency Department, Chi Mei Medical Center; 901, Chunghua Road, Yungkang District, Tainan City 710, Taiwan (R.O.C.) Tel: 886-6-2812811 ext. 57196; Fax: 886-6-2816161; E-mail: guojhang@gmail.com Emergency Department, Chi Mei Medical Center, Tainan City, Taiwan 1 90
Acute pancreatitis with pulmonary embolism Case report A 76 -year-old woman with a history of hypertension and rheumatoid arthritis was admitted to an emergency department because of syncope. She recalled experiencing epigastric pain before falling and losing consciousness. A family member stated that she had experienced shortness of breath and palpitations but had no history of syncope. She did not complain of chest pain, cold sweats, or radiating pain in the shoulder. She was a non-smoker, did not consume alcohol, and had no history of gallstone or peptic ulcer disease. Her vital signs were stable on arrival, with a Glasgow Coma Scale score of 15/15. Her temperature was 36 C, breathing rate 16 breaths per minute, heart rate 75 beats per minute, and blood pressure 141/82 mmhg. Physical examination revealed tenderness in the epigastrium, but no rebound tenderness. Cardiac examination revealed a regular heart beat without pathological murmur. There was no clinical evidence of deep venous thrombosis. The results from laboratory evaluations were as follows: white blood cells 17.3 109/L, red blood cells 3.21 1012/L, hemoglobin 101 g/ L, platelets 275 109/L, blood lipase 439 U/L, alanine aminotransferase 12 U/L, total bilirubin 11.7 μmol/l, lactate dehydrogenase 417 U/L, serum creatinine 104.3 mmol/l, random blood glucose 10.8 mmol/l, and serum lactate 0.27 mmol/l. The result from a plasma dimerized plasmin fragment D (D-dimer) assay was 7636 μg/l. A contrast enhanced computed tomographic (CT) scan of the patient s chest was arranged because of progressive dyspnea and suspicion of pulmonary embolism. A CT scan of her abdomen was simultaneously arranged to exclude intraabdominal infection. The CT scan of the abdomen revealed high density fluid collection and fat stranding over the right hepato-renal space, indicating pancreatitis (Figure 1). The CT scan of the chest revealed a bilateral pulmonary embolism (Figure 2). The patient was subsequently admitted to an intensive care unit (ICU). After admission to the ICU, intravenous Figure 1. CT scan of the abdomen revealing pancreatitis. High-density fluid collection and fat stranding over the right hepatorenal space (white arrows) Figure 2. CT scan of the chest revealing pulmonary embolism. Filling defects in the bilateral pulmonary arteries (white arrows). 91
Kuo-Chang Sung et al. antibiotics were administered to treat for intraabdominal infection. An anticoagulant agent was used to treat the pulmonary embolism: initially delteparin (low- molecular weight heparin) and subsequently oral warfarin. After 7 days of intravenous hydration and bowel rest, the patient began to tolerate enteral nutrition and was discharged after 10 days of hospitalization. Discussion Acute pancreatitis is an inflammatory disease characterized by a local tissue injury that can trigger a systemic inflammatory response. The vascular complications of pancreatitis are a major cause of morbidity and mortality, and are related to hemorrhage resulting from arterial erosion or pseudoaneurysms, ischemic complications, and venous complications, specifically splanchnic venous thrombosis and associated varices. 2 Previous studies have shown that pulmonary thrombosis is a rare complication of pancreatitis. 4 A case of pulmonary thrombosis resulting from thrombosis of the inferior vena cava in a patient with acute pancreatitis has also been reported. 9 The proposed mechanisms underlying systemic hypercoagulability and vascular thrombosis complicating pancreatitis include inflammatory cytokine activity, direct vasculitis, and release of pancreatic enzymes into the systemic circulation, resulting in endothelial injury and dysfunction. 5,6 Previous studies have proposed that the mechanism underlying the formation of a pulmonary thrombus is cyst communication with the pancreatic duct penetrating into the vessel, allowing pancreatic juice to enter the vessel and trigger the formation of a thrombus. 7-9 A pulmonary thromboembolism is a severe complication of vascular thrombosis in acute pancreatitis. Our patient exhibited the clinical features of pulmonary thrombosis, such as difficulty breathing and palpitations. In addition, she had an episode of syncope, which resulted from the pulmonary embolism. We based our diagnosis on the clinical observations, combined with the results from laboratory tests and imaging studies. Contrast venography, ultrasonography, contrast-enhanced CT scan, and magnetic resonance imaging (MRI) are all modalities with defined roles in the diagnosis of vascular thrombosis. 3 No clear guidelines exist on the appropriate therapy for patients with pulmonary thrombosis secondary to pancreatitis. 10-12 A strategy including a complete CT scan with contrast to evaluate the visceral vessels for signs of occlusion, and anticoagulation treatment, initially with heparin and subsequently with oral warfarin, is recommended. 10 In conclusion, a pulmonary thrombosis is a rare but potentially lethal complication of pancreatitis. If pancreatitis patients develop shortness of breath, chest pain, syncope, or palpitations, and vascular thrombosis is suspected, image evaluation by using CT and MRI is required. The early recognition and investigation of thromboembolism is imperative because accurate diagnosis and timely radiological intervention can reduce mortality. Early treatment with unfractionated heparin or low-molecular-weight heparin followed by oral warfarin is most commonly used in clinical practice. References 1. Mendelson RM, Anderson J, Marshall M, Ramsay D. Vascular complications of pancreatitis. ANZ J Surg 2005;75:1073-1079. 2. Mallick IH, Winslet MC. Vascular complications of pancreatitis. Jop 2004;5:328-337. 3. Zhang Q, Zhang QX, Tan XP, et al. Pulmonary embolism with acute pancreatitis: A case report and literature review. World J Gastroenterol 2012;18:583-586. 4. Deiss R, Young P, Yeh J, Reicher S. Pulmonary embolism and acute pancreatitis: Case series and review. Turk J Gastroenterol 2014;25:575-577. 5. Vollmar B, Menger M. Microcirculatory dysfunction in acute pancreatitis. Pancreatology 2003;3:181-190. 6. Balthazar EJ. Complications of acute pancreatitis: clinical and CT evaluation. Radiol. Clin. North Am 2002;40:1211-1227. 7. Ohta H, Hachiya T. A case of inferior vena cava thrombosis and pulmonary embolism secondary to 92
Acute pancreatitis with pulmonary embolism acute exacerbation of chronic pancreatitis: A rare finding in radionuclide venography. Ann Nucl Med 2002;16:147-149. 8. Hanterdsith B. Fatal pulmonary thromboembolism due to inferior vena cava thrombosis. Ann Vasc Dis 2011;4:121-123. 9. Vinod KV, Arun K, Nisar KK, Dutta TK. Inferior vena cava thrombosis: a rare complication of acute pancreatitis. JAPI 2014;62:430-432. 10. Krummen DM, Cannova J, Schreiber H. Conservative management strategy for pancreatitis-associated mesenteric venous thrombosis. The American Surgeon 1996;62:432-434. 11. Boley S, Kaleya R, Brandt L. Mesenteric venous thrombosis. Surg Clin N Am 1992;72:183-201. 12. Gertsch P, Matthews J, Lerut J, et al. Acute thrombosis of the splanchnic veins. Arch Surg 1993;128:341-345. 93
宋國漳等 急性胰臟炎併發肺栓塞 : 病例報告 宋國漳 1 1, 許建清 摘要 急性胰臟炎與全身的高凝固性相關, 這會增加胰臟周圍血管內栓塞形成 然而, 肺栓塞是胰臟炎極少見的併發症, 到目前僅有少數病例被報導 我們提出一個急性胰臟炎併發肺栓塞的病例 一位七十六歲的女性來急診由於急性上腹痛, 後來發生短暫暈厥 胸部和腹部電腦斷層掃瞄發現肺栓塞和胰臟炎 我們簡短地討論胰臟炎引發肺栓塞的病理機轉及治療 熟稔這種併發症將有助於早期診斷 治療以及預防肺栓塞 關鍵詞 : 急性胰臟炎, 肺栓塞, 血管內栓塞, 上腹痛 通訊作者 : 宋國漳醫師 710 台南市永康區中華路 901 號 ; 奇美醫療財團法人奇美醫院急診醫學部電話 :06-2812811 轉 57196; 傳真 :06-2816161;E-mail:guojhang@gmail.com 1 奇美醫療財團法人奇美醫院急診醫學部 94