Acute Pancreatitis due to Extracorporeal Shock Wave Lithotripsy: A Rare Complication Onder Limon MD, Funda Ugur KANTAR MD, Erkan S¸AH ˙IN MD, Murat Arslan MD, Aslı Aydınoglu UGURHAN MD PII: DOI: Reference:

S0735-6757(14)00270-8 doi: 10.1016/j.ajem.2014.04.026 YAJEM 54256

To appear in:

American Journal of Emergency Medicine

Received date: Revised date: Accepted date:

14 March 2014 31 March 2014 1 April 2014

˙ Erkan, Arslan Please cite this article as: Limon Onder, KANTAR Funda Ugur, S ¸ AHIN Murat, UGURHAN Aslı Aydınoglu, Acute Pancreatitis due to Extracorporeal Shock Wave Lithotripsy: A Rare Complication, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.04.026

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ACCEPTED MANUSCRIPT Title: Acute Pancreatitis due to Extracorporeal Shock Wave Lithotripsy: A Rare Complication

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Onder Limon, MD, Assist Prof. Corresponding Author

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Izmir University, Faculty of Medicine, Department of Emergency Medicine

Turkey Tel: +90 505 525 26 52

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E-mail: [email protected]

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Medical Park Izmir Hastanesi, Yeni Girne Blv. 1825 Sk. No: 12 Karşıyaka, 35530 İzmir,

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Funda Ugur KANTAR, MD, Assist Prof. Izmir University, Faculty of Medicine, Department of Gastroenterology

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Turkey

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Medical Park Izmir Hastanesi, Yeni Girne Blv. 1825 Sk. No: 12 Karşıyaka, 35530 İzmir,

Tel: +90 532 760 70 28 E-mail: [email protected] Erkan ŞAHİN, MD, Assist Prof. Izmir University, Faculty of Medicine, Department of Radiology Medical Park Izmir Hastanesi, Yeni Girne Blv. 1825 Sk. No: 12 Karşıyaka, 35530 İzmir, Turkey Tel: +90 554 871 10 18

Acute pancreatitis due to ESWL

ACCEPTED MANUSCRIPT E-mail: [email protected]

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Izmir University, Faculty of Medicine, Department of Urology

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Murat Arslan, MD, Assist Prof.

Medical Park Izmir Hastanesi, Yeni Girne Blv. 1825 Sk. No: 12 Karşıyaka, 35530 İzmir,

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Turkey

E-mail: [email protected]

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Tel: +90 554 871 10 77

Aslı Aydınoglu UGURHAN, MD, Assist Prof.

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Izmir University, Faculty of Medicine, Department of Emergency Medicine

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Medical Park Izmir Hastanesi, Yeni Girne Blv. 1825 Sk. No: 12 Karşıyaka, 35530 İzmir,

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Turkey Tel: +90 505 525 21 81

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E-mail: [email protected]

Keywords: Acute Pancreatitis, ESWL, urinary stone

Acute pancreatitis due to ESWL

ACCEPTED MANUSCRIPT Acute Pancreatitis due to Extracorporeal Shock Wave Lithotripsy: a Rare Complication Abstract

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Extracorporeal shock wave lithotripsy (ESWL) is considered the treatment of choice for most renal and upper ureteral stones. Although extensive data have documented its safety, serious

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complications have been reported in 1% of patients, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury

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and rupture of aortic aneurysms. Here, we report a 41-year-old woman who underwent ESWL for a calculus at the right renal pelvis and immediately developed acute pancreatitis after the procedure. Although the possibility of post-ESWL acute pancreatitis is extremely low,

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physicians must be aware of this complication in emergency departments.

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Introduction

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The ease of use, effectiveness and non-invasive nature of extracorporeal shock wave lithotripsy (ESWL) have made it the procedure of choice for small renal and upper urinary

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tract stones. Although extensive data have documented its safety, serious complications have been reported in 1% of patients, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury and rupture of aortic aneurysms. Here, we report a 41-year-old woman who underwent ESWL and immediately developed acute pancreatitis following ESWL for a calculus at the right renal pelvis. [1,2,3]

Acute pancreatitis due to ESWL

ACCEPTED MANUSCRIPT Case A 41-year-old woman presented to the emergency department (ED) with epigastric and right

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flank pain. Her vital signs were within normal ranges. On physical examination, there was

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guarding at the epigastric region and tenderness at the right upper quadrant and right costovertebral angle. Bowel sounds were normal. On further medical examination, she had a

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history of right renal calculus but no previous history of biliary lithiasis, gastritis, chronic alcohol consumption or abdominal surgery. One week previously, a urinary computed

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tomography (CT) had revealed an 8.7 mm calculus at her right ureteropelvic junction, with grade II hydronephrosis. The urology department had decided to treat it with outpatient ESWL. ESWL (ELMED Lithotripsy Systems, Orlando, USA) was performed using 3002 shocks at 15 kV. At the third session, epigastric and right flank pain occurred during the

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procedure. Laboratory data demonstrated a white blood cell count of 10, 3 × 103mm3, a serum

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amylase level of 5178 U/L (normal range, 25–125 U/L), an alanine aminotransferase (ALT) level of 74 U/L and an aspartate transaminase (AST) level of 132 U/L. The bilirubin levels

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were within normal ranges. An abdominal ultrasound showed that the edematous pancreas

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contained a small amount of free fluid. An intravenous contrast-enhanced abdominal CT was performed, visualizing the parenchymal edema of the pancreas, peripancreatic fat stranding and free fluid. The gallbladder, intra-hepatic and extra-hepatic biliary systems were all completely normal (Figure 1a, 1b.). A residual 7-millimeter stone in the right ureter was also detected, suggesting that the lithotripter was correctly focused on the target stone. The considered diagnosis was acute pancreatitis as a complication of ESWL. Oral intake was prohibited. The patient was admitted to the gastroenterology department. Her lipid panels were in a normal range, and magnetic resonance cholangiopancreatography (MRCP) revealed no pathologies (Figure 1c). Her lipase level was 1013 U/L. On the third day of hospitalization,

Acute pancreatitis due to ESWL

ACCEPTED MANUSCRIPT her symptoms and laboratory values improved; further, she was able to tolerate oral intake. She was discharged from the hospital in good condition on the fourth day of admission.

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Discussion

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Extracorporeal shock wave lithotripsy (ESWL) is one of the most common urologic procedures performed today. The recent literature has shown the procedure to be a safe and

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effective treatment modality; however, it has also been associated with serious complications,

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as in our case, which are becoming increasingly recognized due to the procedure’s widespread availability and use.[2] The kidney is the most commonly injured organ as a result of ESWL. However, injuries to the adjacent organs have been reported in less than 1% of patients. The major complications of ESWL for urinary tract stones include the following: pulmonary

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contusions, psoas abscess, sub-renal hematoma, urosepsis, aortic aneurysm rupture, portal and iliac vein thrombosis, erosion in gastrointestinal tract, retroperitoneal hemorrhage, colonic and

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splenic injury, small bowel perforation, hepatic hematoma, pancreatitis, cardiac arrhythmias

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and brain hemorrhage due to transient hypertension caused by autonomic nerve hyperreflexia in patients with spinal cord injuries.[1,5] The mechanisms leading to acute pancreatitis after

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ESWL remain unclear. One hypothesis involves the inadvertent fragmentation of gallstones or common bile duct stones by the accidental shock waves causing the obstruction of the pancreatic duct, resulting in pancreatitis.[2,4,5] Another hypothesis suggests that the postoperative adhesions between the pancreas and surrounding tissues are a cause of mechanical injury, resulting in pancreatitis after ESWL, as Abe et al. reported.[5] Other mechanisms, including vasoconstriction and infected urine leaks from the renal collecting system, have also been discussed [2]. The most probable cause of pancreatic injury is likely to be cell damage caused by the cavitation and shear forces produced by the shock waves.[2,4,5]

Acute pancreatitis due to ESWL

ACCEPTED MANUSCRIPT In our case, no biliary stone was detected on radiologic studies. Additionally, except for the ESWL procedure, no other predisposing factors for pancreatitis (e.g., recent alcohol use,

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hyperlipidemia, abdominal surgery or hypercalcemia) were present in our patient.

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In conclusion, physicians caring for patients who present to the ED following ESWL sessions

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should be aware of these complications. References

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1. Karakayali F, Sevmiş S, Ayvaz I, Tekin I, Boyvat F, Moray G. Acute necrotizing pancreatitis as a rare complication of extracorporeal shock wave lithotripsy. Int J Urol. 2006;13(5):613-5.

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2. Gülüm M, Yeni E, Savaş M, Çelik H, Çiftçi H. Do the applied shock wave numbers and the application side effect pancreatic exocrine functions in patients who have undergone

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extracorporeal shock wave lithotripsy for upper urinary tract calculi? Turk J Med Sci 2012; 42 (4): 591-596

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3. Skolarikos A, Alivizatos G, de la Rosette J. Extracorporeal shock wave lithotripsy 25 years

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later: complications and their prevention. Eur Urol. 2006; 50(5):981-90; 4. Hassan I, Zietlow SP. Acute pancreatitis after extracorporeal shock wave lithotripsy for a renal calculus. Urology. 2002; 60(6):1111. 5. Abe H, Nisimura T, Osawa S, Miura T, Oka F. Acute pancreatitis caused by extracorporeal shock wave lithotripsy for bilateral renal pelvic calculi. Int J Urol. 2000; 7(2):65-8.

Acute pancreatitis due to ESWL

ACCEPTED MANUSCRIPT Figure Legends Figure 1a. An abdominal ultrasound was used to visualize the edematous pancreas with a

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small amount of free fluid. 1b. An intravenous contrast-enhanced abdominal CT was able to

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indicate the parenchymal edema of the pancreas, peripancreatic fat stranding and free fluid

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1c. Magnetic resonance cholangiopancreatography revealed no pathologies.

Acute pancreatitis due to ESWL

Acute pancreatitis due to extracorporeal shock wave lithotripsy: a rare complication.

Extracorporeal shock wave lithotripsy (ESWL) is considered the treatment of choice for most renal and upper ureteral stones. Although extensive data h...
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