Inflammation Colon

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WILLIAM

and Necrosis of the Transverse Secondary to Pancreatitis

M. THOMPSON.’

FREDERICK

A variety of radiographically demonstrable colon abnormalities associated with pancreatitis are illustrated. Extensive changes of either localized or diffuse inflammation are more common than has generally been appreciated. Localized changes may mimic carcinoma. Transverse colon inflammation secondary to pancreatitis may be appreciated on plain abdominal radiographs and to better advantage with a contrast enema. This pattern is distinctive and suggests a severe underlying pancreatitis. A water soluble contrast enema is recommended if there is any evidence of colon necrosis or fistula. Recognition of all of the changes of pancreatitis may lead to earlier management of the severe complications.

M. KELVIN.

AND

REED

P. RICE

Findings Clinical

The 1 2 patients acute pancreatitis strong

history

with colon abnormalities secondary ranged in age from 23 to 65 years.

of alcholism

was

obtained

in 10.

One

developed acute pancreatitis the day after section. The other patient had no recognizable the

pancreatitis.

(120

Serum

Somogyi

correlation

units)

was

amylase

to 2,000

noted

between

levels

ranged

from

units.

the

of serum

level

The radiographic manifestations of pancreatitis involving the upper gastrointestinal system have been discussed in depth by Eaton and Ferrucci [1]. Meyers and Evans [2] have emphasized the colon complications secondary to acute pancreatitis. Earlier, Meyers [3] stressed the high proportion of colon changes that take place at the attachment of the phrenicocolic ligament. The radiographic features of pancreatitis producing widespread inflammation and necrosis of the transverse colon have received little attention [4-91. These changes are important since they are not usually suspected on clinical grounds and indicate severe underlying pancreatic disease. This paper discusses the spectrum of colon abnormalities produced by pancreatitis. In particular, the findings of inflammation of the transverse colon and colon necrosis are discussed.

sign)

developed

the acute ful

phase

recovery.

malities

colon

of pancreatitis.

All four

The

eight

1 week

of the underlying

indicated

a more

matory

process.

surgery:

three

flexure masses

pancreatitis. and

these

of one

patient

with

the only

inflam-

for of

drainage

the

Radiographic The

colon

changes

were

classified

into

six

types

Material

Records and radiographs of 220 patients with acute pancreatitis treated at Duke University Medical Center and Durham Veterans Administration Hospital from 1973 to 1976 were reviewed. Colon abnormalities were detected in 12 patients. Plain abdominal radiographs demonstrated abnormalities in eight. Four of the eight had abnormal contrast enemas; in one of the eight, the enema was normal. Three patients with normal plain abdominal radiographs had a colon abnormality demonstrated by a contrast enema. The remaining patient had a colocutaneous fistula, secondary to a pancreatic abscess, demonstrated by a fistulogram. No other colon abnormalities were detected; however, the majority of the patients did not have contrast enemas.

Received

October

26, 1976;

accepted

after

revision

February

22.

Am

J Roentgenol

128:943-948.

June

1977

TABLE Colon

Abnormalities

1 in Pancreatitis

Abnormality

No

Transverse colon ileus Displacement of transverse colon Transverse colon inflammation Stricture Fistula Necrosis Total Note-Data abnormality.

on

12

patients;

1977

Presented at the annual meeting of the American Roentgen Ray Society. W. M. Thompson is a James Picker Foundation Scholar 1 All authors: Department of Radiology. Duke University Medical Center.

colon

died.

1). Patient

splenic

The pancreatic spontaneously. developed

who

the

findings

underwent

two

abscess

patient

colon

pancreatic

a stricture

a pancreatic

She was

abnor-

during

patients

which was felt to be a neoplasm. in the other two patients resolved

necrosis.

colon

These

eight

during

later

abscesses, for

cut-off

an unevent-

had

extensive

pancreatic and

amylase

(colon

made

patients

severe

normal

No definite

abnormality

to 2 months

Six for

pseudocysts,

One

other

diagnosed

course

of

a radiographic

patient

a cesarean cause of

Somogyi

and the severity of the colon abnormalities. The four patients with only a colon ileus

to A

Washington. Durham.

943

D.C., North

September

Carolina

27710

1976

three

4 3 5 1 1

_____ 15 had

more

than

one

(table

THOMPSON

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944

ET AL.

I ..

Fig. 3.-23-year’old creatitis. Transverse haustratons, and Pancreatic pseudocyst

Transverse localized

colon

black male with severe acute colon has some irregularity of is displaced cephalad by large was drained 4 months later.

colon to

the

ileus.

Four

transverse

abnormalities

patients

patients

colon

(fig.

hemorrhagic bowel wall, pancreatic

pan absent mass.

showed

dilatation

1 ) with

no

other

encountered.

Displacement of transverse pancreatic masses displaced in two

p.

‘

(figs.

colon. Large inflammatory transverse colon inferiorly

the

2 and

5)

and

superiorly

in a third

(fig. 3). The inflammatory areas of spiculation of displacement in one patient Inflammation findings

of

of narrowed

and/or

a grossly

indicate

inflammation

than

masses produced localized the mucosa at the site of (fig. 2). transverse colon. The radiographic

merely

(figs.

of these necrosis

patients involving

ileus.

3-5

and

The

This

matory

Two

.,.1L

ass’s

23

yPar old cliplic’colon -

.-

,#{231}jqF’stS,,Iflflam,rnatr,y

present

demonstrated

Abdominal large

,

fem’ile

4 da,’s nfer,orl .m . process,Residual

ultrasonography pancreatic

postpartum irrows .

.

.,

.

with

-

contrast

and mass

Mild ,

upper

severe spicilatiori .

pa creat t s of mucosa

. ..

om

gastrointestinal

-

..

-:

is

urogram

series

mass

the

splenic Fistula.

into

the

r

tail

bed which skin. Direct Necrosis. of transverse

and

findings

of the

produced

communicated

colon

rather

present

to

in five

performed

in two gross and

fat the

inflammation

patient

sug-

in the tail of the 6). A large inflam-

pancreas

extending

around

at surgery. pancreatic abscess a fistula

with

in one

from

the splenic

the

subsequently

eroded

pancreatic

flexure

injection of the sinus demonstrated One patient with initial radiographic colon

wall,

felt

demonstrated mesocolon

or carcinoma colon (fig.

flexure demonstrated In one patient a large colon

was

colon

were

colon.

radiographic

in the

transverse

pattern

(figs. 5 and 7) the transverse

gested a colon carcinoma pancreas eroding into the

-

the

of the

pattern

7). Laparatomy

of the transverse

Stricture.

irregularity

haustral

involving

a colon

patients

serosa

lumen,

abnormal

and the the

fistula. findings

developed

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TRANSVERSE

COLON

IN PANCREATITIS

945

.‘

Fig. Barium in better

4-25-year-old study demonstrating detail

male

with 3 year history edematous mucosal

of severe pancreatitis pattern in transverse

colon

Abdominal B. Right

ultrasound posterior

demonstrated oblique view

13 X of splenic

15cm flexure

pancreatic showing

pseudocyst A. mucosal edema

946

THOMPSON

ET AL.

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-.1

,,1

.-

.

t

-

.o _________________ Fig. 6-65-year-old but intact mucosa. spleen.

. male Laparotomy

(Courtesy

of

Holy

with 3 month and pancriatic

Cross

Hospital.

.-

history of abdominal biopsy revealed Fort

Lauderdale.

pain extensive

suggesting

large

pancreatic

the

presence

abscess

of

colon

was also present

with

pancreatitis

tensive patients creatic a result

are

colon important

abnormalities since

they

in

A

patients

indicate

underlying inflammatory process. with colon findings other than ileus masses. Six of these patients required of the underlying pancreatic disorder.

an ex-

The eight all had pansurgery as

Pathophysiology

The anatomic relationship of the pancreas to the transverse colon provides the pathway for the dissemination of pancreatic inflammatory products [2, 9-111. Minor inflammation of the transverse mesocolon leads to spasm and, if more severe, dilatation of the transverse colon [1]. Extensive spread of the pancreatic enzymes produces widespread fat necrosis and large inflammatory masses. Most investigators consider these large inflammatory masses responsible for localized colon strictures [12-17]. However, Hunt and Mildenhall [6] postulate that an ischemic

process

and

not

an encircling

pericolic

constricting lesion in splenic flexure component extending into colon

-

.

-

with irregular and hilum of

be responsible. Venous and arterial occlusion have been suggested as a mechanism producing colon necrosis in patients with severe pancreatitis [4, 18]. Large pancreatic masses may lead to fistula formation by eroding into the colon, usually in the region of the splenic flexure. Clinical

uncommon,

demonstrates with inflammatory

-

7C).

Discussion Although

..-

Fla.)

necrosis.

(fig.

.

:.

Barium study pancreatitis

necrosis of the transverse colon (fig. 7). This severe cornplication was not suspected initially, but a retrospective review of abdominal radiographs revealed an unchanged position of a dilated ahaustral splenic flexure over a 6 day period,

,.

mass

may

Presentation

None of our patients described any specific colon symptoms. This is not surprising since the clinical features of even the more severe colon abnormalities will usually be masked by the underlying pancreatitis. Patients with colon strictures secondary to pancreatitis may have clinical findings of a change in bowel habits, guaiac positive stool [12, 17], or abdominal pain [12-16]. Hematochezia [7, 19-23] has been the most prominent finding in patients with a colon fistula secondary to pancreatitis; some patients have exsanguinated [22]. Even in patients with colon necrosis, the clinical picture can be confusing [9, 23, 24] since there are no specific symptoms or laboratory findings which will differentiate colon necrosis from underlying pancreatitis. Radiology

The radiographic appearance of transverse colon inflammation is distinctive, suggesting a more severe underlying pancreatitis than the colon cut-off sign. Thus we feel it should be considered a separate abnormality. This radio-

-

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TRANSVERSE

COLON

graphic picture on plain abdominal films (figs. 3, 5A, and 7A) may mimic the more recognized causes of colitis such as Crohn’s disease, ischemic colitis, or ulcerative colitis. A contrast enema (figs. 4, 58, and 78), which demonstrates that the abnormality is localized to the transverse colon and, in addition, is not an ulcerative process, should help differentiate the transverse colon inflammation of pancreatitis from other entities. These radiographic findings suggested the correct diagnosis in two of the 12 patients before

a clinical

diagnosis

Of the 17 reported cases to pancreatitis, 15 occurred

was

suspected.

of colon strictures secondary in the splenic flexure and two

IN PANCREATITIS

947

at the hepatic flexure [6, 12-17]. Twelve of the patients underwent surgery because the appearance of the lesion was so suggestive of neoplasm [6, 151. A contrast enema will usually suggest intact mucosa and thus strongly militate against a colon carcinoma (fig. 6). Regression of a stricture secondary to pancreatitis has been documented [13, 15]. A follow-up barium enema in these patients may obviate surgical intervention. Establishing a radiologic diagnosis of colon necrosis or gangrene is usually difficult. The findings of marked loss of haustra, mucosal irregularity, dilatation of the bowel lumen, and, in particular, fixation of the loop of

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948

THOMPSON

bowel are highly suggestive of necrotic intestine [24]. Contrast enemas in patients with colon necrosis following ischemic colitis have revealed a spectrum of findings including localized perforation, distention with irregular destroyed mucosa, large penetrating ulcers, and pseudopolyp formation [25]. While our patient with colon necrosis did not have a contrast enema, the plain film findings suggested the possibility of necrosis in the region of the splenic flexure (fig. 7C). A contrast enema is not indicated in all patients with acute pancreatitis. a consideration

However, it is an important study when of a colon abnormality arises in patients with known or suspected pancreatitis. It is useful in confirming the transverse colon inflammation of pancreatitis suggested by plain films, in evaluating strictures of the colon secondary to pancreatitis, and in studying patients suspected of harboring a fistula or colon necrosis. Whenever there is a question of perforation or colon necrosis, water soluble contrast is recommended. The aggressive use of contrast enemas in patients with pancreatitis suspected of having a severe colon abnormality should speed the recognition of these complications.

El AL.

8. Siler VE, Wulsin JH : Consideration of the lethal factors in acute pancreatitis. Arch Surg 63:496-504, 1951 9. Price CWR: “Colon cut-off” sign in acute pancreatitis. Med JAust 1:313-314, 1956 10. Brascho

cut-off

DJ.

Reynolds,

sign”

in acute

1. Eaton

SB Jr. Ferrucci JT: Radiology of the Pancreas and Philadelphia. Saunders, 1973 2. Meyers MA, Evans JA: Effects of pancreatitis on the small bowel and colon: spread along mesenteric planes. Am J Duodenum.

119:151-165, 1973 MA: Roentgen significance of Radiology 95:539-545, 1970

ligament. 4. Case records

C:

pancreatitis: preliminary investigation of sign. J Fac Radiol8:50-58, 1956 1 2. Schwartz SI, Nadelhaft J : Simulation of colon obstruction at the splenic flexure by pancreatitis. Am J Roentgenol 78: 607-616. 1957 1 3. Aronson AR, Davis DA: Obstruction near hepatic flexure in pancreatitis: a rarely reported sign. JAMA 176:133-134, 1961 Stuart

Acute

new radiodiagnostic

14. Mohiuddin lesions

5, Sakiyalak

of the

102:229-231,

1 5. Lindahl

of the

Massachusetts

P. Gullick secondary

HD, Webb to

WR: Stenosing

pancreatitis.

Arch

Surg

1971

F. Vejlsted H, Backer OG: Lesions of the actue pancreatitis. Scand J Gastroenterol

lowing

378,

colon

colon fol7:375-

1972

1 6. Lukash W. Bishop RP: Acute pancreatitis affecting the transverse colon. Am J Dig Dis 12:734-736, 1967 17. Remington JH, Mayo CW, Dockerty MD: Stenosis of the colon secondary to chronic pancreatitis. Mayo Clin Proc 1947

Hopkins

Hosp

58:212-259,

1 9. Howard JM, Philadelphia,

20. Berne

TV,

studies on Bull Johns

1936

Jordan GL: Surgical Lippincott, 1960

Edmondson

HA:

Diseases

Colonic

of the Pancreas.

fistulization

due

Am J Surg 1 1 1 :359-363, 1966 21. Corlette MB Jr. Lynch JA: Pancreatitis presenting colonic fistula. Arch Surg 104:708-711, 1972 22. Mason HDW, Forgash A. Balch HH: Intestinal fistula plicating pancreatic abscess. Surg Gynecol Obstet 39-43, 1975

to

pancreatitis.

the

General

phrenicocolic Hospital.

case

N EngI J Med 233:433-436, 1945 5. Coffey RJ: Unusual features of acute pancreatic disease. Ann Surg 135:715-720, 1952 6. Hunt DR. Mildenhall P: Etiology of strictures of the colon associated with pancreatitis. Am J Dig Dis 20:941-946. 1975 7. Katz P. Dorman MJ, Aufses AH Jr: Colonic necrosis complicating postoperative pancreatitis. Ann Surg 170:403-405, 1974 31411.

P: Radiographic “colon Radiology 79:763-768.

18. Rich AR, Duff G: Experimental and pathologic pathogenesis of acute hemorrhagic pancreatitis.

REFERENCES

3. Meyers

Zanca

1962 11.

22:260-264,

Roentgenol

TN,

pancreatitis.

23. Sabehjami

H,

Gillespie

L,

Ferris

PJ,

Danovitch

SH:

as a com140: Rectal

bleeding as presenting symptoms of acute pancreatitis. Am J Gastroenterol 54:388-394, 1970 24. Miller WT, Scott J, Rosato EF, Crow H: lschemic colitis with gangrene. Radiology 94:291-297, 1970 25. Moss AA, Margulis AR: lschemic colitis with perforation. Am J Roentgenol 113:338-342, 1971