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Comjwterized yCdical Ima&ng and Grqphics, Vol. 15, No. 6, pp. 407-409, 1991 Primed in the USA. AU rights merved.
AORTIC DISSECTION PRESENTING AS ACUTE PANCREATITIS: CT DIAGNOSIS F. Pombo*, M. Marini, A. Berazaand E. Rodriguez Department of Radiology, Hospital “Juan Canalejo,” Xubias de Arriba, 84, 15006 La Coruiia, Spain (Received
21 August
1990)
Abstract-A 42-year-old male developed epigastric pain and elevation of serum amylase of 2045 U/L. A contrast-enhanced abdominal CT dischsed inflammatory changes involving tbe pancreas and peripancreatic tissues and findings indicative of aortic dksection. The possibility of aortic dissection should be considered in the management of patients with acute pancreatitis. Key Words: Aortic dissection, Acute pancreatitis
INTRODUCTION
In the abdominal aorta, the celiac artery arose from the false aortic lumen (Fig. 2). Medical treatment was ineffective and the patient underwent surgery. A thoracic aneurysm distal to the left subclavian artery was resected and replaced with a 25 cm tubular Dacron graft. The patient’s condition was good 6 months after surgery.
Elevations in the serum amylase, occasionally reaching levels indicative of acute pancreatitis, have been reported in aortic dissection (AD) (1). However, severe acute pancreatitis as a form of presentation of AD is unusual and, to our knowledge, no such presentation has been reported in the radiologic literature.
DISCUSSION The diagnosis of AD is easily established in presence of chest pain, pulse deficits and murmur of aortic insufficiency (2). However, as a consequence of the involvement of the peripheral visceral arteries by the dissection process, patients with AD frequently present with findings of primary intraabdominal disease. Abdominal pain, localized in epigastrium or diffuse, occurs at the onset of dissection in one-third of affected patients (1). Nausea and vomiting are also frequent (1, 2). Gastrointestinal hemorrhage and findings related to the urinary tract are very rare (l-4). Moderate elevations in the serum amylase have been reported in AD (1). However, severe acute complicated pancreatitis as a form of presentation of acute AD is very unusual, and we have not found a similar case cited in the radiologic literature. The ischemic necrosis is the mechanism implicated in the etiology of acute pancreatitis in AD (5). We believe that in our patient an ischemic pancreatitis took place. In fact, pancreatic blood perfusion was markedly diminished because the celiac artery arose from the false aortic lumen. In summary, acute pancreatitis must be taken into
CASE REPORT A 42-year-old male with long standing hypertension was admitted to our hospital complaining of continuous epigastric pain for 12 hours. On physical examination, the abdomen was tender and distended and bowel sounds were diminished. Radial and femoral pulses were equal and full symmetrically. Blood pressure was 170/120 mmHg; pulse 120 beats/min. The main laboratory findings were: serum amylase, 2045 U/L (normal, 110-330 U/L), WBC count, 20,400 cells/ml; total bilirubin, 2.19 mg/dL (normal, 0.20-1.0 mg/dL); serum calcium, 5.8 mg/dL (normal, 8.1-10.5 mg/dL). Chest X-ray showed a prominent aortic shadow. Plain abdominal film was normal. Abdominal CT performed after a 100~mL bolus of contrast medium revealed edema of the pancreas and inflammatory changes involving the peripancreatic soft tissues. Findings indicative of abdominal aortic dissection were also evident (Fig. 1). Thoracic and abdominal aortography showed a dissecting aneurysm beginning caudal to the origin of the left subclavian artery (DeBakey type III).
*To whom all correspondence should be addressed. 407
408
Computerized Medical
Imaging
and Graphics
November--December/l99 1, Volume 15, Number 6
Fig. 1. Postcontrast abdominal CT showing moderate pancreatic enlargement and bhtrring of the anterior margin of the gland. Findings of peripancreatic inflammation with small fluid collections (*) can be seen in the anterior pararenal space. An intimal flap (arrows) indicative of dissection is evident within a dilated abdominal aorta.
account as a possible presentation of AD. Special emphasis must be made on the use of contrast-enhanced CT in the management of acute pancreatitis. In this
G-4 Fig. 2. (a) Abdominal aortic lumen. Left renal true aortic lumen. Note later film, the filling
case, contrast-enhanced CT allowed us to suggest that an AD was the posible cause of the pancreatitis and enabled prompt treatment.
(b)
aortogram shows filling of superior mesenteric and right renal arteries from the true (T) artery appears to opacify from the false (F) lumen. Celiac artery does not opacify from the the intimal flap (arrowheads) and marked narrowing of the true aortic lumen. (b) In this of the celiac artery and its common hepatic (CH) and splenic (SP) branches is evident.
Aortic dissection presenting as acute pancreafifis l
SUMMARY
An unusual case of acute ischemic pancreatitis representing the first clinical manifestation of an aortic dissection diagnosed by CT is presented here. This case demonstrates the importance of contrast-enhanced CT in the evaluation of patients with acute pancreatitis. REFERENCES 1. Hirst, A.E., Jr.; Johns, V.J., Jr.; Kime, SW. Dissecting aneurysm of the aorta: A review of 505 cases. Medicine 37:217-279; 1958. 2. Slater, E.E.; DeSanctis, R.W. The clinical recognition of dissecting aortic aneurysm. Am. J. Med. 60:625433; 1976. 3. Nath, H.P.; Jaques, P.F.; Soto, B.; Keller, F.S.; Ceballos, R. Aortic dissection masquerading as gastrointestinal disease. Cardiovasc. Intervent. Radial. 9:3741; 1986. 4. Demos. T.C.: Gadwood. K: Games. M.A.: Moncada. R.: Marson, R. Aortic dissection: presentation as a renal problem in three patients. Am. J. Radiol. 137:1268-1270; 1981. 5. Becker-, V.; Jannke, H.A. Isch%nische NeKrosen in der Bauchspeicheldrttse. Patologe. 10:272-277; 1989.
F. POMBO
et al.
409
About the Author-Fwasco POMBOgraduated from the Medical Faculty of Santiago de Compostela in 1976 and finalized his residency in Diagnostic Radiology in the Department of Radiology at the Juan Canalejo Hospital, La Coruiia, in 1981. He is presently Chief of the Section of Body-CT at Juan Canalejo Hospital, La Coruiia, Spain. About the Author-Mru\cRos MARINI graduated from the Medical Faculty of Santiago de Compostela in 1977. She completed her residency in ‘Diagnostic Radiology in the Department of Radiology at Juan Canalejo Hospital, La Coruiia. She is now Adjoint of the Section of Vascular and Interventional Radiology at Juan Canalejo Hospital, La Coruila, Spain. About the Author-Ammm BWAZA graduated from the Medical Faculty of Bilbao in 1970. He completed his Residency in Diagnostic Radiology at the San Carlos Hospital in Madrid. He is now Adjoint of the Section of Vascular and Interventional Radiology at Juan Canalejo Hospital, La Cormia, Spain. About the Author-ESTHER RODRIGUEZ graduated from Medical Faculty of Santiago de Compostela in 1985. She is currently in her fourth year of a Diagnostic Radiology Residency at Juan Canalejo Hospital. La Corufia, Spain.
Comjwterized yCdical Ima&ng and Grqphics, Vol. 15, No. 6, pp. 407-409, 1991 Primed in the USA. AU rights merved.
AORTIC DISSECTION PRESENTING AS ACUTE PANCREATITIS: CT DIAGNOSIS F. Pombo*, M. Marini, A. Berazaand E. Rodriguez Department of Radiology, Hospital “Juan Canalejo,” Xubias de Arriba, 84, 15006 La Coruiia, Spain (Received
21 August
1990)
Abstract-A 42-year-old male developed epigastric pain and elevation of serum amylase of 2045 U/L. A contrast-enhanced abdominal CT dischsed inflammatory changes involving tbe pancreas and peripancreatic tissues and findings indicative of aortic dksection. The possibility of aortic dissection should be considered in the management of patients with acute pancreatitis. Key Words: Aortic dissection, Acute pancreatitis
INTRODUCTION
In the abdominal aorta, the celiac artery arose from the false aortic lumen (Fig. 2). Medical treatment was ineffective and the patient underwent surgery. A thoracic aneurysm distal to the left subclavian artery was resected and replaced with a 25 cm tubular Dacron graft. The patient’s condition was good 6 months after surgery.
Elevations in the serum amylase, occasionally reaching levels indicative of acute pancreatitis, have been reported in aortic dissection (AD) (1). However, severe acute pancreatitis as a form of presentation of AD is unusual and, to our knowledge, no such presentation has been reported in the radiologic literature.
DISCUSSION The diagnosis of AD is easily established in presence of chest pain, pulse deficits and murmur of aortic insufficiency (2). However, as a consequence of the involvement of the peripheral visceral arteries by the dissection process, patients with AD frequently present with findings of primary intraabdominal disease. Abdominal pain, localized in epigastrium or diffuse, occurs at the onset of dissection in one-third of affected patients (1). Nausea and vomiting are also frequent (1, 2). Gastrointestinal hemorrhage and findings related to the urinary tract are very rare (l-4). Moderate elevations in the serum amylase have been reported in AD (1). However, severe acute complicated pancreatitis as a form of presentation of acute AD is very unusual, and we have not found a similar case cited in the radiologic literature. The ischemic necrosis is the mechanism implicated in the etiology of acute pancreatitis in AD (5). We believe that in our patient an ischemic pancreatitis took place. In fact, pancreatic blood perfusion was markedly diminished because the celiac artery arose from the false aortic lumen. In summary, acute pancreatitis must be taken into
CASE REPORT A 42-year-old male with long standing hypertension was admitted to our hospital complaining of continuous epigastric pain for 12 hours. On physical examination, the abdomen was tender and distended and bowel sounds were diminished. Radial and femoral pulses were equal and full symmetrically. Blood pressure was 170/120 mmHg; pulse 120 beats/min. The main laboratory findings were: serum amylase, 2045 U/L (normal, 110-330 U/L), WBC count, 20,400 cells/ml; total bilirubin, 2.19 mg/dL (normal, 0.20-1.0 mg/dL); serum calcium, 5.8 mg/dL (normal, 8.1-10.5 mg/dL). Chest X-ray showed a prominent aortic shadow. Plain abdominal film was normal. Abdominal CT performed after a 100~mL bolus of contrast medium revealed edema of the pancreas and inflammatory changes involving the peripancreatic soft tissues. Findings indicative of abdominal aortic dissection were also evident (Fig. 1). Thoracic and abdominal aortography showed a dissecting aneurysm beginning caudal to the origin of the left subclavian artery (DeBakey type III).
*To whom all correspondence should be addressed. 407
408
Computerized Medical
Imaging
and Graphics
November--December/l99 1, Volume 15, Number 6
Fig. 1. Postcontrast abdominal CT showing moderate pancreatic enlargement and bhtrring of the anterior margin of the gland. Findings of peripancreatic inflammation with small fluid collections (*) can be seen in the anterior pararenal space. An intimal flap (arrows) indicative of dissection is evident within a dilated abdominal aorta.
account as a possible presentation of AD. Special emphasis must be made on the use of contrast-enhanced CT in the management of acute pancreatitis. In this
G-4 Fig. 2. (a) Abdominal aortic lumen. Left renal true aortic lumen. Note later film, the filling
case, contrast-enhanced CT allowed us to suggest that an AD was the posible cause of the pancreatitis and enabled prompt treatment.
(b)
aortogram shows filling of superior mesenteric and right renal arteries from the true (T) artery appears to opacify from the false (F) lumen. Celiac artery does not opacify from the the intimal flap (arrowheads) and marked narrowing of the true aortic lumen. (b) In this of the celiac artery and its common hepatic (CH) and splenic (SP) branches is evident.
Aortic dissection presenting as acute pancreafifis l
SUMMARY
An unusual case of acute ischemic pancreatitis representing the first clinical manifestation of an aortic dissection diagnosed by CT is presented here. This case demonstrates the importance of contrast-enhanced CT in the evaluation of patients with acute pancreatitis. REFERENCES 1. Hirst, A.E., Jr.; Johns, V.J., Jr.; Kime, SW. Dissecting aneurysm of the aorta: A review of 505 cases. Medicine 37:217-279; 1958. 2. Slater, E.E.; DeSanctis, R.W. The clinical recognition of dissecting aortic aneurysm. Am. J. Med. 60:625433; 1976. 3. Nath, H.P.; Jaques, P.F.; Soto, B.; Keller, F.S.; Ceballos, R. Aortic dissection masquerading as gastrointestinal disease. Cardiovasc. Intervent. Radial. 9:3741; 1986. 4. Demos. T.C.: Gadwood. K: Games. M.A.: Moncada. R.: Marson, R. Aortic dissection: presentation as a renal problem in three patients. Am. J. Radiol. 137:1268-1270; 1981. 5. Becker-, V.; Jannke, H.A. Isch%nische NeKrosen in der Bauchspeicheldrttse. Patologe. 10:272-277; 1989.
F. POMBO
et al.
409
About the Author-Fwasco POMBOgraduated from the Medical Faculty of Santiago de Compostela in 1976 and finalized his residency in Diagnostic Radiology in the Department of Radiology at the Juan Canalejo Hospital, La Coruiia, in 1981. He is presently Chief of the Section of Body-CT at Juan Canalejo Hospital, La Coruiia, Spain. About the Author-Mru\cRos MARINI graduated from the Medical Faculty of Santiago de Compostela in 1977. She completed her residency in ‘Diagnostic Radiology in the Department of Radiology at Juan Canalejo Hospital, La Coruiia. She is now Adjoint of the Section of Vascular and Interventional Radiology at Juan Canalejo Hospital, La Coruila, Spain. About the Author-Ammm BWAZA graduated from the Medical Faculty of Bilbao in 1970. He completed his Residency in Diagnostic Radiology at the San Carlos Hospital in Madrid. He is now Adjoint of the Section of Vascular and Interventional Radiology at Juan Canalejo Hospital, La Cormia, Spain. About the Author-ESTHER RODRIGUEZ graduated from Medical Faculty of Santiago de Compostela in 1985. She is currently in her fourth year of a Diagnostic Radiology Residency at Juan Canalejo Hospital. La Corufia, Spain.
