Pancreatology 14 (2014) 146e147
Contents lists available at ScienceDirect
Pancreatology journal homepage: www.elsevier.com/locate/pan
Case report
Necrotizing pancreatitis complicated by oesophageal haemorrhage Georgia Malamut a, b, c, *, Charles Foulkes a, d, Laure Fournier a, e, Clémence Hollande a, b, Anne Berger a, d, Christophe Cellier a, b, c a
Université Paris Descartes, Paris, France Gastroenterology Department, Hôpital Européen Georges Pompidou APHP, Paris, France c Inserm U989, Paris, France d Digestive Surgery Department, Hôpital Européen Georges Pompidou APHP, Paris, France e Radiology Department, Hôpital Européen Georges Pompidou APHP, Paris, France b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 April 2013 Received in revised form 17 November 2013 Accepted 12 December 2013
Bleeding is a rare complication of pancreatic pseudocyst. We describe an exceptional case of necrotizing pseudocyst with mediastinal extension providing cataclysmic oesophageal haemorrhage. The patient was successfully treated by adequate endoscopic, radiological and surgical management. Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
Keywords: Chronic pancreatitis Pseudocyst Oesophageal haemorrhage Arteriography Embolization
1. Case report Pancreatic pseudocyst is common in patients with previous acute or chronic pancreatitis, developing respectively in up to 15% and 40% of them [1]. Bleeding is a rare complication, involving less than 5% of patients [2]. Haemorrhage may occur following spontaneous gastrointestinal fistula mainly gastric fistula [3]. Duodenal and colonic fistulae were previously described but oesophageal fistula remains exceptional [4,5]. A 62 years old man with insulin dependent diabetes presented to our hospital with severe abdominal pain in a context of chronic alcoholic pancreatitis. Computed tomography (CT) scan revealed hemorrhagic pancreatitis collected between pancreas and suprarenal gland (arrow) (Fig. 1A). In the following days, the patient developed dysphagy, fever with increase of C reactive protein (CRP). Nineteen days after admission sudden haemodynamic failure occurs with massive gastrointestinal bleeding. Upper endoscopy showed oesophageal fistula extruding active bleeding 5 cm above the cardia. After haemostasis with clips during endoscopy and blood transfusions, control CT-scans showed
* Corresponding author. Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France. Tel.: þ33 1 56 09 35 52; fax: þ33 1 56 09 35 29. E-mail address: [email protected] (G. Malamut).
mediastinal extension of a pseudocyst contiguous with oesophagus (arrows) (Fig. 1BeC). CT-guided percutaneous drainage induced collapse of the pseudocyst (Fig. 1C) but haemorrhage recurred leading to emergency arteriography and embolization of the phrenic and splenic arteries. Surgical treatment consisted in splenopancreatectomy. Treatment of pseudocyst was total except its superior part contiguous to oesophagus. Fistula was drained and patient was treated by antibiotherapy and parenteral nutrition for 20 days. Control CT-scan showed a small residual collection (arrow) (Fig. 1D). Feeding was taken over gradually and patient discharged one month after surgery. 2. Discussion Oesophageal fistulization of pancreatic pseudocyst is very rare and represents an exceptional cause of haemorrhage in alcoholic chronic pancreatitis [5]. Complications of portal hypertension such as bleeding of oesophageal varices need to be first considered because of possibility of alcoholic cirrhosis or portal venous thrombosis associated to chronic pancreatitis [5]. In our case, dysphagia, uncommon in oesophageal varices, developed progressively after entrance and should be considered as a warning sign of mediastinal extension of pseudocyst. Bleeding of pancreatic pseudocyst has a very poor prognosis with high mortality rate (15%e43%) [6]. Indeed, the present case
1424-3903/$ e see front matter Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pan.2013.12.002
G. Malamut et al. / Pancreatology 14 (2014) 146e147
147
Fig. 1. Oesophageal fistulization of pancreatic pseudocyst before and after treatment.
raises two therapeutic challenges to treat in emergency, haemorrhage and infection of pseudocyst. Arteriography with embolization should be preferred first to stop haemorrhage [7]. Moreover, it prevents the risk of relapsing haemorrhage favoured by depression induced by percutaneous drainage set to treat infection [8]. Indeed a significantly greater mortality rate was described in patients undergoing surgery as first intervention compared with those undergoing angiography with embolization before surgical procedure [9]. Left splenopancreatectomy was the surgical procedure performed in our patient after stabilization to cure necrotizing pseudocyst and clear off peritoneal cavity from residual necrotic debris. Controlled drainage led to progressively dry up fistula without adverse effects [10]. Endoscopic stent represents an alternative possibility to treat oesophageal fistula [11]. In conclusion, oesophageal fistula of chronic pseudocyst is rare and threaten the life being. It requires adequate endoscopic, radiological and surgical management. Authors contribution Georgia Malamut performed the retrospective analysis of the medical file and wrote the paper. Charles Foulkes performed surgery and performed review of literature. Laure Fournier performed the centralized radiological review of CT-Scan. Clémence Hollande collected clinical data. Anne Berger and Christophe Cellier discussed the case and participate to therapeutic strategy. All the authors reviewed the paper.
Conflict of interest The authors declare no conflict of interest.
References [1] Baillie J. Pancreatic pseudocyst (part I). Gastrointest Endosc 2004;59:873e9. [2] Urakami A, Tsunoda T, Kubozoe T, Takeo T, Yamashita K, Imai H. Rupture of a bleeding pancreatic pseudocyst into the stomach. J Hepatobiliary Pancreat Surg 2002;9:383e5. [3] Sondenaa K, Soreide A. Pancreatic pseudocyst causing spontaneous gastric haemorrhage. Eur J Surg 1992;158:257e60. [4] Sahakian AB, Krishnamoorthy S, Taddei TH. Necrotizing pancreatitis complicated by fistula and upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2011;9:e66e7. [5] Castelli MF, Hamilton JD, Wynn-Williams A. Letter: esophageal hemorrhage due to pancreatitis. Can Med Assoc J 1975;113:605e6. [6] Carr JA, Cho JS, Shepard AD, Nypaver TJ, Reddy DJ. Visceral pseudoaneurysms due to pancreatic pseudocysts: rare but lethal complications of pancreatitis. J Vasc Surg 2000 Oct;32(4):722e30. [7] Boudghene F, L’Hermine C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol 1993;4: 551e8. [8] Pitchumoni CS. Gastroenterol Clin North Am 1999;28:615e35. [9] Srinivasan Balachandra MS, Ajith K, Siriwardena MD. Systematic appraisal of the management of the major vascular complications of pancreatitis. Am J Surg 2005;190:489e95. [10] Rosière A, Michel L, Scavée V, Mulier S, Khoury A. Abdominal esophageal perforation. Ann chir 2005;130:495e7. [11] Dai Y, Chopra SS, Kneif S, Hünerbein M. Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents. J Thorac Cardiovasc Surg 2011;141:1213e7.
Contents lists available at ScienceDirect
Pancreatology journal homepage: www.elsevier.com/locate/pan
Case report
Necrotizing pancreatitis complicated by oesophageal haemorrhage Georgia Malamut a, b, c, *, Charles Foulkes a, d, Laure Fournier a, e, Clémence Hollande a, b, Anne Berger a, d, Christophe Cellier a, b, c a
Université Paris Descartes, Paris, France Gastroenterology Department, Hôpital Européen Georges Pompidou APHP, Paris, France c Inserm U989, Paris, France d Digestive Surgery Department, Hôpital Européen Georges Pompidou APHP, Paris, France e Radiology Department, Hôpital Européen Georges Pompidou APHP, Paris, France b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 9 April 2013 Received in revised form 17 November 2013 Accepted 12 December 2013
Bleeding is a rare complication of pancreatic pseudocyst. We describe an exceptional case of necrotizing pseudocyst with mediastinal extension providing cataclysmic oesophageal haemorrhage. The patient was successfully treated by adequate endoscopic, radiological and surgical management. Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved.
Keywords: Chronic pancreatitis Pseudocyst Oesophageal haemorrhage Arteriography Embolization
1. Case report Pancreatic pseudocyst is common in patients with previous acute or chronic pancreatitis, developing respectively in up to 15% and 40% of them [1]. Bleeding is a rare complication, involving less than 5% of patients [2]. Haemorrhage may occur following spontaneous gastrointestinal fistula mainly gastric fistula [3]. Duodenal and colonic fistulae were previously described but oesophageal fistula remains exceptional [4,5]. A 62 years old man with insulin dependent diabetes presented to our hospital with severe abdominal pain in a context of chronic alcoholic pancreatitis. Computed tomography (CT) scan revealed hemorrhagic pancreatitis collected between pancreas and suprarenal gland (arrow) (Fig. 1A). In the following days, the patient developed dysphagy, fever with increase of C reactive protein (CRP). Nineteen days after admission sudden haemodynamic failure occurs with massive gastrointestinal bleeding. Upper endoscopy showed oesophageal fistula extruding active bleeding 5 cm above the cardia. After haemostasis with clips during endoscopy and blood transfusions, control CT-scans showed
* Corresponding author. Hôpital Européen Georges Pompidou, 20 rue Leblanc, 75015 Paris, France. Tel.: þ33 1 56 09 35 52; fax: þ33 1 56 09 35 29. E-mail address: [email protected] (G. Malamut).
mediastinal extension of a pseudocyst contiguous with oesophagus (arrows) (Fig. 1BeC). CT-guided percutaneous drainage induced collapse of the pseudocyst (Fig. 1C) but haemorrhage recurred leading to emergency arteriography and embolization of the phrenic and splenic arteries. Surgical treatment consisted in splenopancreatectomy. Treatment of pseudocyst was total except its superior part contiguous to oesophagus. Fistula was drained and patient was treated by antibiotherapy and parenteral nutrition for 20 days. Control CT-scan showed a small residual collection (arrow) (Fig. 1D). Feeding was taken over gradually and patient discharged one month after surgery. 2. Discussion Oesophageal fistulization of pancreatic pseudocyst is very rare and represents an exceptional cause of haemorrhage in alcoholic chronic pancreatitis [5]. Complications of portal hypertension such as bleeding of oesophageal varices need to be first considered because of possibility of alcoholic cirrhosis or portal venous thrombosis associated to chronic pancreatitis [5]. In our case, dysphagia, uncommon in oesophageal varices, developed progressively after entrance and should be considered as a warning sign of mediastinal extension of pseudocyst. Bleeding of pancreatic pseudocyst has a very poor prognosis with high mortality rate (15%e43%) [6]. Indeed, the present case
1424-3903/$ e see front matter Copyright Ó 2013, IAP and EPC. Published by Elsevier India, a division of Reed Elsevier India Pvt. Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pan.2013.12.002
G. Malamut et al. / Pancreatology 14 (2014) 146e147
147
Fig. 1. Oesophageal fistulization of pancreatic pseudocyst before and after treatment.
raises two therapeutic challenges to treat in emergency, haemorrhage and infection of pseudocyst. Arteriography with embolization should be preferred first to stop haemorrhage [7]. Moreover, it prevents the risk of relapsing haemorrhage favoured by depression induced by percutaneous drainage set to treat infection [8]. Indeed a significantly greater mortality rate was described in patients undergoing surgery as first intervention compared with those undergoing angiography with embolization before surgical procedure [9]. Left splenopancreatectomy was the surgical procedure performed in our patient after stabilization to cure necrotizing pseudocyst and clear off peritoneal cavity from residual necrotic debris. Controlled drainage led to progressively dry up fistula without adverse effects [10]. Endoscopic stent represents an alternative possibility to treat oesophageal fistula [11]. In conclusion, oesophageal fistula of chronic pseudocyst is rare and threaten the life being. It requires adequate endoscopic, radiological and surgical management. Authors contribution Georgia Malamut performed the retrospective analysis of the medical file and wrote the paper. Charles Foulkes performed surgery and performed review of literature. Laure Fournier performed the centralized radiological review of CT-Scan. Clémence Hollande collected clinical data. Anne Berger and Christophe Cellier discussed the case and participate to therapeutic strategy. All the authors reviewed the paper.
Conflict of interest The authors declare no conflict of interest.
References [1] Baillie J. Pancreatic pseudocyst (part I). Gastrointest Endosc 2004;59:873e9. [2] Urakami A, Tsunoda T, Kubozoe T, Takeo T, Yamashita K, Imai H. Rupture of a bleeding pancreatic pseudocyst into the stomach. J Hepatobiliary Pancreat Surg 2002;9:383e5. [3] Sondenaa K, Soreide A. Pancreatic pseudocyst causing spontaneous gastric haemorrhage. Eur J Surg 1992;158:257e60. [4] Sahakian AB, Krishnamoorthy S, Taddei TH. Necrotizing pancreatitis complicated by fistula and upper gastrointestinal hemorrhage. Clin Gastroenterol Hepatol 2011;9:e66e7. [5] Castelli MF, Hamilton JD, Wynn-Williams A. Letter: esophageal hemorrhage due to pancreatitis. Can Med Assoc J 1975;113:605e6. [6] Carr JA, Cho JS, Shepard AD, Nypaver TJ, Reddy DJ. Visceral pseudoaneurysms due to pancreatic pseudocysts: rare but lethal complications of pancreatitis. J Vasc Surg 2000 Oct;32(4):722e30. [7] Boudghene F, L’Hermine C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol 1993;4: 551e8. [8] Pitchumoni CS. Gastroenterol Clin North Am 1999;28:615e35. [9] Srinivasan Balachandra MS, Ajith K, Siriwardena MD. Systematic appraisal of the management of the major vascular complications of pancreatitis. Am J Surg 2005;190:489e95. [10] Rosière A, Michel L, Scavée V, Mulier S, Khoury A. Abdominal esophageal perforation. Ann chir 2005;130:495e7. [11] Dai Y, Chopra SS, Kneif S, Hünerbein M. Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents. J Thorac Cardiovasc Surg 2011;141:1213e7.
