The spleen in inflammatory pancreatic disease

Development and validation of a nomogram based on Lasso-Logistic regression for predicting splenomegaly secondary to acute pancreatitis

PURPOSE

Investigate the clinical characteristics of splenomegaly secondary to acute pancreatitis (SSAP) and construct a nomogram prediction model based on Lasso-Logistic regression.

METHODS

A retrospective case-control study was conducted to analyze the laboratory parameters and computed tomography (CT) imaging of acute pancreatitis (AP) patients recruited at Xuanwu Hospital from December 2014 to December 2021. Lasso regression was used to identify risk factors, and a novel nomogram was developed. The performance of the nomogram in discrimination, calibration, and clinical usefulness was evaluated through internal validation.

RESULTS

The prevalence of SSAP was 9.2% (88/950), with the first detection occurring 65(30, 125) days after AP onset. Compared with the control group, the SSAP group exhibited a higher frequency of persistent respiratory failure, persistent renal failure, infected pancreatic necrosis, and severe AP, along with an increased need for surgery and longer hospital stay (P < 0.05 for all). There were 185 and 79 patients in the training and internal validation cohorts, respectively. Variables screened by Lasso regression, including platelet count, white blood cell (WBC) count, local complications, and modified CT severity index (mCTSI), were incorporated into the Logistic model. Multivariate analysis showed that WBC count ≦9.71 × 109/L, platelet count ≦140 × 109/L, mCTSI ≧8, and the presence of local complications were independently associated with the occurrence of SSAP. The area under the receiver operating characteristic curve was 0.790. The Hosmer-Lemeshow test showed that the model had good fitness (P = 0.954). Additionally, the nomogram performed well in the internal validation cohorts.

CONCLUSIONS

SSAP is relatively common, and patients with this condition often have a worse clinical prognosis. Patients with low WBC and platelet counts, high mCTSI, and local complications in the early stages of the illness are at a higher risk for SSAP. A simple nomogram tool can be helpful for early prediction of SSAP.

Two Cases of Gastric Varices with Left-sided Portal Hypertension Due to Essential Thrombocythemia Treated with Gastric Devascularization or Partial Splenic Embolization

Left-sided portal hypertension (LSPH) is a condition of extrahepatic portal hypertension that often results in bleeding from isolated gastric varices (GVs). LSPH is sometimes caused by myeloproliferative diseases, such as essential thrombocythemia (ET). We herein report two cases of GVs with LSPH due to ET that were successfully controlled by gastric devascularization (GDS) or partial splenic embolization (PSE). Since each patient with LSPH due to ET has a different pathology, optimal treatment should be performed depending on the patient's condition, such as platelet counts, hemodynamics, or the prognosis. We believe that these cases will serve as a reference for future cases.

Splenic hematoma following acute pancreatitis, and the role of conservative management: A case report

Key clinical message

We reported a unique case in which the patient developed splenic hematoma following acute pancreatitis, the condition responded well to conservative management without any surgical intervention.

Abstract

Splenic hematoma following acute pancreatitis is a rare complication that is thought to be due to the distribution of pancreatic exudates to the spleen. We presented a case of a 44-year-old patient with acute pancreatitis who developed a splenic hematoma. He responded well to conservative management and the hematoma was resolved.

Emphysematous pancreatitis with pulmonary embolism: A case report

Background

Emphysematous pancreatitis is a severe systemic inflammatory process with reports of pulmonary embolism in the setting of acute pancreatitis rarely described.

Case presentation

A 61-year-old woman presented with severe abdominal pain of 1 day duration. She was found to have acute interstitial pancreatitis. During her hospitalization, the patient developed worsening abdominal pain associated with increasing oxygen demands, requiring supplemental oxygen through nasal cannula. Workup showed pulmonary embolism in the posterior segmental branch of the left lower lobar artery and development of emphysematous pancreatitis was noted on imaging. The patient was started on intravenous antibiotics and therapeutic anticoagulation; her condition improved and was discharged home.

Conclusion

Patients with severe acute pancreatitis may be at risk for pulmonary embolism due to immobilization and other inflammatory mechanisms. Mitigating individualized risk factors and anticoagulation use as prophylaxis should be considered in patients with pancreatitis to prevent embolism. Early detection by clinicians is critical to reduce misdiagnosis and mortality rates.

Differential Diagnosis of Cystic Lesions of the Spleen: A Review of Clinical, Imaging and Pathological Findings

Cystic lesions of the spleen are being noticed with increased frequency as "incidentalomas" during imaging work-up for unrelated causes. As a group, these lesions encompass pure cystic and mixed cystic and solid, benign and malignant processes that in general require a tissue sample for definitive diagnosis. In this review, we will describe the differential diagnosis of cystic lesions of the spleen, highlighting key imaging, clinical and pathologic findings.

Activation of TLR4 induces severe acute pancreatitis-associated spleen injury via ROS-disrupted mitophagy pathway

Severe acute pancreatitis (SAP) is complicated by systemic inflammatory response syndrome and multiple organ dysfunction, the disease will eventually result in death in almost half of the case. The spleen, as the largest immune organ adjacent to the pancreas, is prone to damage in SAP, thereby aggravating the damage of other organs and increasing mortality. However, to date, the research on the mechanism and treatment of spleen injury caused by SAP is still in its infancy. Herein, we investigated the mechanism of spleen injury, and explored the application potential of tuftsin for relieving spleen damage in SAP mice. Firstly, SAP mice model was constructed via the retrograde infusion of 3.5 % sodium taurocholate into the biliopancreatic duct. Then, we proved that the up-regulation of Toll-like receptor 4 (TLR4) in spleen would lead to the accumulation of reactive oxygen species (ROS) and mitochondrial dysfunction under SAP conditions. The splenic ROS and mitochondrial dysfunction could be improved by N-acetylcysteine (NAC) treatment or knocking out TLR4 in SAP mice. Meanwhile, we found that NAC treatment could also improve the autophagy of spleen tissue, suggesting that splenic ROS may affect impaired autophagy, causing the accumulation of damaged mitochondria, aggravating spleen damage. Furthermore, we verified the mechanism of spleen injury is caused by splenic ROS affecting PI3K/p-AKT/mTOR pathway-mediated autophagy. In addition, we detected the spleen injury caused by SAP could decrease the concentration of tuftsin in the serum of mice. Whereas, exogenous supplementation of tuftsin ameliorated the pathological damage, ROS accumulation, impaired autophagy, inflammation expression and apoptosis in damaged spleen. In summary, we verified the new mechanism of SAP-caused spleen damage that TLR4-induced ROS provoked mitophagy impairment and mitochondrial dysfunction in spleen via PI3K/p-AKT mTOR signaling, and the application potential of tuftsin in treating spleen injury, which might expand novel ideas and methods for the treatment of pancreatitis.

Splenic Artery Embolisation for the Emergency Treatment of Sinistral Portal Hypertension: A Systematic Review

Objectives Sinistral portal hypertension (SPH) is caused by increased pressure on the left portal system secondary to splenic vein stenosis or occlusion and may lead to gastric varices. The definitive management of SPH is splenectomy, but this is associated with significant mortality and morbidity in the acute setting. In this systematic review, we investigated the efficacy and safety of splenic artery embolisation (SAE) in managing refractory variceal bleeding in patients with SPH.

Methods A comprehensive literature search was conducted using MEDLINE and Embase databases. A qualitative analysis was chosen due to heterogeneity of the studies.

Results Our search yielded 339 articles, 278 of which were unique. After initial screening, 16 articles relevant to our search remained for full text review. Of these, 7 were included in the systematic review. All 7 papers were observational, 6 were retrospective. Between them they described 29 SAE procedures to control variceal bleeding. The technical success rate was 100% and there were no cases of rebleeding during follow up. The most common complication was post-embolisation syndrome. Four major complications occurred, two resulting in death. These deaths were the only 30-day mortalities recorded and were in patients with extensive comorbidities.

Conclusions Although there is a distinct lack of randomized controlled studies comparing SAE to other treatment modalities, it appears to be safe and effective in treating hemorrhage secondary to SPH.

Acute abdomen due to pancreatic pseudocyst with splenic extension and rupture

Pancreatic pseudocyst is a common complication of acute and chronic pancreatitis. However, spleen involvement in pancreatitis is rare. We present a patient with a pancreatic tail pseudocyst with splenic extension and rupture. Due to initial stability, conservative management was decided. However, he developed tachycardia with severe abdominal pain associated with signs of peritoneal irritation, requiring an emergency laparotomy. A large pancreatic tail pseudocyst was identified in addition to a ruptured spleen. Splenectomy and double layer hand-sewn gastrocystic anastomosis were performed. The patient had a satisfactory recovery and was discharged on the 11th postoperative day. Conservative management is an option in stable patients but with a high rate of failure. Surgery remains the standard choice in these cases.

Spontaneous Subcapsular Splenic Hematoma: A Rare Complication of Pancreatitis

Subcapsular hematoma of the spleen is a rare complication of pancreatitis despite its close proximity to the pancreas. Pancreatic pseudocyst involving the tail of the pancreas may erode into the splenic hilum causing hilar vessel bleeding with subcapsular dissection and hematoma formation. The management of such complication is still controversial. It has been suggested that most of these complications spontaneously regress and therefore can be managed conservatively. A case of spontaneous splenic subcapsular hematoma resulting from pancreatitis was managed conservatively with a good outcome.

A New Role for the Spleen: Aggravation of the Systemic Inflammatory Response in Rats with Severe Acute Pancreatitis

Little is known about the role of the spleen in mediating systemic inflammatory responses in severe acute pancreatitis (SAP). We investigated the role played by the spleen in rats after SAP induction. Splenectomy was performed at designated time points after SAP induction. Pancreatic tissue and serum samples were collected and subjected to histologic, immunohistochemical, and immunologic analyses. After SAP induction, the splenic immune response was enhanced during SAP progression, as shown by the increased diameter of the splenic periarterial lymphatic sheath and the thickness of the splenic marginal zone. Rats with splenectomy developed acute pancreatitis more slowly than rats without splenectomy. In addition, pancreatic tissues of rats with splenectomy contained lower levels of serum amylase, tumor necrosis factor-α, and IL-6 and exhibited less acinar cell death, leukocyte infiltration, and interstitial edema than those of rats without splenectomy. Compared with splenectomy alone, cotreatment with splenectomy and the administration of splenic cells originating from a rat with SAP 12 hours after induction increased systemic inflammation in SAP rats. Splenic factors exacerbated SAP-associated liver and lung injury and accentuated intestinal mucosal barrier dysfunction. Splenectomy altered the serum cytokine profile in rats with SAP. In a rat model of SAP, the spleen exacerbated the systematic inflammatory responses and injury to multiple organs, indicating a new role for the spleen in SAP.

[Abdominal pain and signs of acute pancreatitis in a 60-year-old man]

Spontaneous splenic rupture is an uncommon complication of acute pancreatitis. This report describes the case of a 60-year-old man with acute pancreatitis complicated by splenic rupture. The patient was admitted to the emergency department with pain in the upper abdomen that had been present for 2 days. He was diagnosed with acute pancreatitis of alcoholic etiology. The patient was admitted to the hospital for two recurrent episodes in the last 4 months of acute pancreatitis of alcoholic etiology. Magnetic resonance imaging of the abdomen revealed a suspicious area of necrosis. Seventy-two hours after admission, the patient had significant improvement in symptoms and the inflammation markers rapidly decreased. However, he showed clinical worsening on the seventh day of hospitalization, with increasing abdominal distension and reduced hemoglobin levels. A CT angiography showed a large amount of free fluid in the abdominal cavity, along with a large splenic hematoma. The patient subsequently underwent laparotomy, which showed hemoperitoneum due to rupture of the splenic parenchyma. A splenectomy was performed with resection of the pancreatic tail.

Spleen and splenic vascular involvement in acute pancreatitis: an MRI study

Background

To investigate the spleen and splenic vascular involvement in acute pancreatitis (AP) and their correlations with the severity of AP using magnetic resonance imaging (MRI).

Methods

MRI of 239 patients with AP was retrospectively reviewed to assess splenic and splenic vascular complications, and the severity of AP. The severity of AP was graded by the MRI severity index (MRSI) and the New Revised Classification of AP 2012. The intravoxel incoherent motion (IVIM) parameters (D, D*, and f) of spleen were measured. Thirty-five subjects without pancreatic and splenic disorders were enrolled as controls for IVIM parameters.

Results

Among the 239 patients with AP, splenomegaly (16.7%), splenic infarction (0.4%), splenic vein thrombosis (4.2%), phlebitis (7.5%) and arteritis (4.2%) were observed. Splenic vascular involvement was positively correlated with the severity of AP based on both the MRSI and the New Revised Classification of AP 2012 (P<0.05). In the control and AP groups, the splenic f values were (0.164±0.074) vs. (0.210±0.095) (P=0.023) respectively. In AP patients with and without splenomegaly, f = (0.240±0.091) vs. (0.203±0.095) (P<0.001).

Conclusions

Splenic vascular involvement and splenomegaly were common in AP. The vascular involvement was associated with the severity of AP. This complication should be considered when severity and prognosis of AP are assessed. Quantitative analysis of the spleen with IVIM might be a useful imaging biomarker for splenic perfusion changes in AP, especially in those with splenomegaly.

Renal Vein and Inferior Vena Cava Thrombosis: A Rare Extrasplanchnic Complication of Acute Pancreatitis

Acute pancreatitis is an inflammatory disorder often associated with various complications. Approximately one fourth of patients with acute pancreatitis develop vascular complications, of which venous thrombosis forms a major group. Extrasplanchnic venous thrombosis is less common, and simultaneous renal vein and inferior vena cava thrombosis is reported only twice. We report a case of alcohol-related acute pancreatitis complicated by simultaneous renal vein and inferior vena cava thrombosis.

A Case of a Chronic Pancreatic Pseudocyst Causing Atraumatic Splenic Rupture without Evidence of Acute Pancreatitis

Atraumatic splenic rupture is a rare complication of a pancreatic pseudocyst (PP), described in the setting of chronic pancreatitis. There is common understanding, within the literature, that an inflammatory process at the tail of the pancreas may disrupt the spleen and result in such splenic complications. The authors present a case report of a 29-year-old male with a PP, associated with chronic pancreatitis. The patient had a history of excessive alcohol intake and presented to the emergency department with a short history of abdominal pain and vomiting. He denied any significant history of trauma and serum amylase levels were normal. An admission computed tomography (CT) scan of the abdomen confirmed the presence of a PP in direct contact with the spleen. The CT also demonstrated a heterogenous hypodense area of the splenic hilum, along with perisplenic fluid. The patient was admitted for observation. His abdominal pain progressed, and he became haemodynamically unstable. An emergency ultrasound scan (USS) at this time revealed intra-abdominal haemorrhage. A subsequent CT confirmed splenic rupture, which was managed surgically with a full recovery. Few such cases are documented within the literature and more understanding of preempting such events is needed.

Endoscopic management of splenic pseudocysts associated with acute and chronic pancreatitis

Background

Splenic pseudocysts (SP) are a rare consequence of both acute and chronic pancreatitis. Surgery has been conventional treatment for SP and literature on role of endoscopic treatment is scant. In this study, we retrospectively evaluated SP clinical and radiological characteristics as well as the outcome following endoscopic drainage.

Methods

Retrospective analysis of SP patients seen at our unit from January 2002 to June 2015. All patients were treated with attempted endoscopic transpapillary drainage with a nasopancreatic drain or stent. Patients not responding underwent endoscopic ultrasound-guided transmural or percutaneous radiological drainage.

Results

Eleven patients with SP (all male; mean age: 40.5±8.8 years) were studied. Seven patients had chronic pancreatitis and 4 patients had SP following acute pancreatitis. The majority (10/11; 91%) had alcohol-related acute or chronic pancreatitis with one patient having coexistent pancreas divisum. Seven (64%) patients were treated successfully with transpapillary drainage only; one (9%) patient needed combined transpapillary and transmural drainage; and 3 (27%) patients needed surgery.

Conclusion

Endoscopic transpapillary drainage is an effective treatment for SP especially when it is not infected and with clear contents, and is associated with partial ductal disruption that can be bridged by an endoprosthesis.

Occult splenic rupture in a case of chronic calcific pancreatitis with a brief review of literature

INTRODUCTION

Splenic rupture in chronic pancreatitis is a life threatening rare complication. The anatomical proximity of the pancreas with the spleen and the pathophysiological process in acute and chronic pancreatitis form the basis of this dreaded complication.

PRESENTATION OF CASE

We cite the case of a young male previously undiagnosed with chronic pancreatitis presenting with atraumatic splenic rupture. Definitive diagnosis was made by contrast enhanced computed tomography of the abdomen, intra operative findings, and histopathological examination of the splenectomy specimen.

DISCUSSION

The splenorenal ligament forms the main anatomic proximity between the pancreas and the spleen. A few pathophysiological mechanisms though suggested are incompletely understood. splenic vein thrombosis, intrasplenic pseudocysts, splenic rupture, infarction, necrosis, splenic hematoma, and severe bleeding from eroded splenic vessels are the complications noted of which splenic rupture is the second most common following splenic vein thrombosis forming 36% of the complications noted. Chronic pancreatitis as an etiology of occult splenic rupture is rare and forms 8.27% of cases; commonest causes being neoplastic and infectious. The diagnosis is based on clinical and radiological findings and the management is predominantly surgical.

CONCLUSION

High clinical suspicion on the part of the treating physician and the emergency team is essential to the management of atraumatic splenic rupture. The increasing understanding of the pathophysiology and presentation of splenic complications in pancreatitis may alert the index physician to these fatal complications.

An interesting cause of collapse in a patient with chronic pancreatitis

A 55-year-old man attended the emergency department following an episode of collapse. He was known to have chronic pancreatitis and a pancreatic pseudocyst. He had recently been recumbent due to chronic abdominal pain. On arrival he was unwell. Baseline observations revealed an oxygen saturation of 87% on room air, pulse 115 bpm and blood pressure 86/57 mm Hg. Physical examination was unremarkable except for mild abdominal tenderness. He was started on high-flow oxygen, intravenous fluid and broad-spectrum antibiotics. A chest x-ray was unremarkable. Massive pulmonary embolus was considered a likely diagnosis. The patient underwent an urgent CT pulmonary angiogram (CTPA). As this was undertaken as an urgent investigation straight from the resuscitation area a d-dimer test was not performed. The CTPA showed no evidence of pulmonary embolism but demonstrated a subdiaphragmatic collection. An arterial phase abdominal CT scan was thus performed, which confirmed a large subcapsular splenic haematoma and splenic vein thrombosis. The patient was resuscitated with blood products and transferred for splenic artery embolisation.

Unusual presentation of spontaneous splenic haematoma due to severe pancreatitis: a cautionary tale

We report the case of a patient with multiple splenic complications from chronic pancreatitis with pseudocyst formation, including splenic vein thrombosis, subcapsular splenic haematoma and splenic artery pseudoaneurysm. The initial presentation was associated with pleuritic chest pain, clinically resembling symptoms of pulmonary embolism. The patient was treated with therapeutic low-molecular-weight heparin, without confirmatory imaging. However, the latter arranged computed tomographic pulmonary angiogram was negative, while the abdominal sequences of the CT revealed the splenic haematoma as causative pathology. The patient was initially treated conservatively, and discharged from inpatient care. On a subsequent CT, a pseudoaneurysm of the splenic artery was found and treated with coil embolisation. The patient is currently awaiting definitive management of the pancreatic pseudocyst.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

Pancreatic tail pseudocyst associated with spontaneous resolution of intrasplenic pancreatic pseudocyst

A 27-year-old man, an alcohol abuser, had alcoholic pancreatitis complicated by a 3.2 cm pancreatic tail speudocyst and intrasplenic pseudocysts presenting with left upper quadrant pain of one-month duration. Surgical resection or percutaneous drainage of the cystic lesions of the pancreas and the spleen was refused. Analgesic agents were given for relief of abdominal pain. Three months later, another episode of alcoholic pancreatitis occurred. A computed axial tomographic scans of the abdomen showed diffuse enlargement of the pancreas with a 3.0-cm pseudocyst in the pancreatic tail, but there was no evidence of previous intrasplenic pseudocysts. The patient was treated conservatively and was discharged on the 7th hospital day. There was no recurrence of abdominal pain after 3 months follow-up.

Imaging assessment of acute pancreatitis: a review

Acute pancreatitis is one of the more commonly encountered etiologies in the emergency setting. While in the majority of cases it is a self-limiting disease which responds rapidly to conservative management, in some cases acute pancreatitis may present with a more pronounced, sometimes dramatic, clinical picture and requires immediate medical care to avoid fatal complication. In this context, imaging plays a significant role because it enables identification of the development of the disease and local/systemic complications. The purpose of this article is to offer an overview of the disease and a spectrum of imaging findings in patients with acute pancreatitis, emphasizing the role of ultrasound, computed tomography, and magnetic resonance imaging according to the appropriate clinical context and advantages and limitations of each imaging modality are examined.

[Atraumatic rupture of the spleen: experience of 10 cases]

The most common cause of splenic rupture is trauma. Less frequently the spleen ruptures due to an ongoing hematologic, infectious or tumoral disease (pathologic rupture). We present a series of 10 patients with atraumatic splenic rupture: in seven patients there was a pathologic rupture. Two of the remaining three patients with spontaneous rupture were morbidly obese; this association has not previously been reported. The present review discusses the etiology, pathogenesis and optimal treatment of this entity.

Percutaneous drainage of large subcapsular hematoma of the spleen complicating acute pancreatitis

The splenic complications associated with acute or chronic pancreatitis are rare, including splenic vein thrombosis, arterial pseudoaneurysm, subcapsular splenic hematoma, and splenic rupture. The management for subcapsular splenic hematoma in pancreatitis remains controversial. We herein report a rare case of large subcapsular splenic hematoma complicating acute pancreatitis, which was successfully treated by ultrasound-guided percutaneous drainage. A 32-year-old male suffered from intermittent epigastric pain radiating to his back. Acute pancreatitis complicated with subcapsular splenic hematoma (15.0 x 13.0 x 9.5 cm) was shown on abdominal computed tomography (CT). He underwent ultrasound-guided percutaneous drainage of the splenic hematoma. The size of the splenic hematoma had reduced to 9.5 x 2.3 cm 10 days later. After 4-week drainage of the hematoma, the abdominal pain improved and the patient was discharged. Follow-up abdominal CT 6 months later showed that the subcapsular splenic hematoma had almost completely resolved. The post-drainage course was smooth, and the patient had no abdominal symptoms at the 1-year follow-up.

Left-sided portal hypertension

Left-sided portal hypertension is a rare clinical syndrome which may lead to bleeding from isolated gastric varices. Pancreatic disease is the most common etiology. Left-sided portal hypertension should be considered in the presence of gastrointestinal bleeding with normal liver function and unexplained splenomegaly. It may be difficult to diagnose this entity both endoscopically and radiologically. While splenectomy is the treatment of choice for cases complicated by variceal bleeding, there is no consensus on the treatment of asymptomatic patients. The prognosis of left-sided portal hypertension mainly depends on the underlying etiology.

Solitary splenic lesions

Solitary splenic lesions are unusual. A differential diagnosis can be organized around their basic imaging appearance as either predominantly cystic or solid. Other imaging characteristics, including vascular enhancement and activity on Tc-99m sulfur colloid scan, as well as clinical history may narrow the diagnostic possibilities. Cystic lesions include post-traumatic, inflammatory and infectious pseudocysts, congenital cysts, lymphangiomas and cystic metastasis. Solid lesions include both nonneoplastic lesions such as splenic hamartoma, benign tumors such as hemangioma and malignant masses including lymphoma and angiosarcoma. Percutaneous biopsy may be used for histologic diagnosis when required.

Endoscopic therapy of a splenic abscess: definitive treatment via EUS-guided transgastric drainage

BACKGROUND

Splenic complications of pancreatitis are exceedingly rare, occurring in only 2.2% of cases. Patients typically present in a dramatic fashion and often need an urgent procedure to prevent overwhelming infection or hemorrhage. Historically, the procedures involve surgery (distal pancreatectomy and splenectomy) or percutaneous drainage.

SETTING

Walter Reed Army Medical Center.

PATIENT

A patient with acute or chronic pancreatitis presented with pleuritic chest pain and fever up to 105 degrees F (40.6 degrees C). A CT of the abdomen and the pelvis demonstrated a splenic abscess.

INTERVENTION

Because of the technical inability to perform transpapillary drainage, EUS-guided transgastric drainage resolved the splenic abscess.

CONCLUSIONS

This is the first reported case of a splenic abscess treated definitively with endoscopic therapy. In the face of a worsening clinical picture and reported morbidities up to 79% with surgical and percutaneous drainage procedures, endoscopic therapies should be considered in the management of splenic complications of pancreatitis.

Report of 24 left-sided portal hypertension cases: a single-center prospective cohort study

Our aim was to analyze patients diagnosed with left-sided portal hypertension prospectively and to document the complications at follow-up. Twenty-four patients with isolated splenic vein thrombosis (diagnosed by ultrasonography or angiography or intraoperatively) and/or isolated fundal varices (diagnosed by endoscopy or endosonography) were involved in this study. Demographics, clinical presentation, diagnostic and therapeutic procedures, and morbidity and mortality were recorded in their follow-up. There were 11 and 13 left-sided portal hypertension cases associated with pancreatic diseases and nonpancreatic disorders, respectively. Chronic abdominal pain and gastrointestinal bleeding were the two most common complaints. All patients except one had isolated esophageal (2 cases) or fundal (21 cases) varices. Thirteen patients had splenomegaly on ultrasonography. On Doppler sonography, the splenic vein could be evaluated in 21 of the 24 patients (9 and 6 had complete and partial occlusion, respectively, and 6 had patent blood flow). Urgent intervention with therapeutic endoscopy and splenectomy was performed for two patients each. Medical therapy was begun for three patients according to the underlying diseases. Three patients underwent elective surgery. Two patients were lost to follow-up after the first visit and the mean follow-up of the remaining 22 patients after diagnosis of left-sided portal hypertension was 20 months. Only one patient (with pancreas cancer) had gastrointestinal bleeding at follow-up. All patients with pancreas and gastric cancer died within 2-12 months. Left-sided portal hypertension has various etiologies. It may be difficult to diagnose this entity both endoscopically and radiologically. Treatment should be directed at the underlying diseases. Recurrent hemorrhage due to left-sided portal hypertension is not usual and the prognosis depends mainly on the underlying etiology.

Splenic abnormalities: a comparative review of ultrasound, microbubble-enhanced ultrasound and computed tomography

The ultrasound appearances of abnormalities of the spleen are reviewed and images compared with computed tomography. Focal lesions, both benign and malignant, trauma, infarction and congenital abnormalities are presented. The use of microbubble ultrasound contrast media as an aid to identifying and characterizing abnormalities is discussed.

Prevalence and treatment of bleeding complications in chronic pancreatitis

OBJECTIVES

As spontaneous major haemorrhage in patients with chronic pancreatitis is rare, limited data have been reported, and no evidence-based guidelines are currently available regarding the optimal treatment modality.

PATIENTS AND METHODS

We report our experience with 36 patients with severe bleeding complications from a series of 541 patients presenting with chronic pancreatitis (representing a prevalence of 6.7% of admitted patients), treated in one surgical department over a period of 9.5 years, with a median follow-up of 4.1 years.

RESULTS

Haemorrhage was indirectly related to chronic pancreatitis in eight patients (22.2%) with ulcer or variceal bleeding. Three patients (8.4%) demonstrated spleen infarction or rupture. The most common causes of major haemorrhage were pseudoaneurysms in 25 patients (69.4%). Nine of them were treated with primary embolization. Sixteen patients with pseudoaneurysms underwent surgery. The only mortalities (8.3%) observed were from bleeding-associated complications of pseudoaneurysms. Two patients died after surgery, and one after primary embolization. We observed a higher re-bleeding rate after surgery (25% vs 11% after embolization). The presence of haemorrhagic shock, and the amount of blood transfused, were significant determinants of hospital mortality. Patient age, pseudoaneurysm location, and treatment modality had no significant influence on mortality.

CONCLUSIONS

Any haemodynamically stable patient with haemorrhage due to arterial pseudoaneurysms should undergo angiography with embolization when technically possible. If there are no other pancreas-related indications for surgery, embolization remains the definitive treatment. If embolization is not available or has failed, surgery is indicated, although perioperative morbidity will be higher.

Major resection for chronic pancreatitis in patients with vascular involvement is associated with increased postoperative mortality

Background

The aim was to evaluate the outcome of major resection for chronic pancreatitis in patients with and without vascular involvement.

Methods

Of 250 patients with severe chronic pancreatitis referred between 1996 and 2003, 112 underwent pancreatic resection. The outcome of 17 patients (15·2 per cent) who had major vascular involvement was compared with that of patients without vascular involvement.

Results

The 95 patients without vascular involvement had resections comprising Beger's operation (39 patients), Kausch–Whipple pancreatoduodenectomy (28), total pancreatectomy (25) and left pancreatectomy (three). Twenty-five major vessels were involved in the remaining 17 patients. One or more major veins were occluded and/or compressed producing generalized or segmental portal hypertension, and three patients also had major arterial involvement. Surgery in these patients comprised Beger's operation (eight), total pancreatectomy (five), Kausch–Whipple pancreatoduodenectomy (two) and left pancreatectomy (two). Perioperative mortality rates were significantly different between the groups (two of 95 versus three of 17 respectively; P = 0·024). There were similar and significant improvements in long-term outcomes in both groups.

Conclusion

Resection for severe chronic pancreatitis in patients with vascular complications is hazardous and is associated with an increased mortality rate. Vascular assessment should be included in the routine follow-up of patients with chronic pancreatitis, to enable early identification of those likely to develop vascular involvement and prompt surgical intervention.

Percutaneous drainage of spontaneous subcapsular haematoma of the spleen complicating chronic pancreatitis

Subcapsular haematoma of the spleen is a rare complication of chronic pancreatitis. In the literature only a handful of cases have been documented. The exact aetiology and natural history of this complication remains speculative and its management controversial. A case of spontaneous subacute haematoma of the spleen in a patient with chronic relapsing alcohol-related pancreatitis was reported. A percutaneous drainage was performed with good outcome. A review of the literature has demonstrated only one previous similar report.

Multislice helical CT of the pancreas and spleen

Multislice helical CT (MSCT) with its multidetector technology and faster rotation times, has led to new dimensions in spatial and temporal resolution in CT imaging. In contrast to single-slice CT, smaller slice collimations can be applied that lead to almost isotropic voxels and allow high quality multiplanar and 3-D image reconstructions. The high speed of multislice CT can be used to reduce the time needed to cover a given volume, to increase the spatial resolution along the z-axis by applying thinner slice collimations, and to cover longer anatomic volumes. The speed of MSCT allows organ imaging in clearly defined perfusion phases, e.g. the arterial, parenchymal, and portal venous perfusion phases. Contrast agents with higher iodine concentrations (400 mg iodine per ml compared with 300 mg iodine per ml) lead to higher contrast enhancement of the pancreas (arterial+portal venous phases), the kidneys (arterial+portal venous phases), the spleen (arterial phase), the wall of the small intestine (arterial+portal venous phases), the larger and smaller arteries (arterial phase), and the portal vein (portal venous phase). All of these advancements lead to improved visualization of small structures and of various pathologies, such as pancreatic tumors, liver metastases, vessel infiltration, and vascular diseases.

Splenic atrophy in experimental severe acute pancreatitis

INTRODUCTION

In severe acute pancreatitis, immunologic impairment is supposed to be linked to the development of subsequent infectious complications.

AIM

To examine alterations of spleen in rat experimental severe acute pancreatitis.

METHODOLOGY

Severe necrotizing pancreatitis was induced by retrograde injection of 3% sodium deoxycholate into the biliopancreatic ducts of male Wistar rats.

RESULTS

In the rats with pancreatitis 12 and 24 hours after the induction, splenic weights were significantly lower than those of sham-operated rats. Numbers of splenocytes were also significantly reduced simultaneously. By in situ nick-end labeling, DNA fragmentation enzyme linked immunosorbent assay (ELISA), and DNA electrophoresis, no apoptosis was detected on the splenocytes from the rats with pancreatitis 6, 12, and 24 hours after the onset. Peripheral lymphocytes in the rats with pancreatitis were significantly decreased 6, 12, and 24 hours after the onset compared with those in sham-operated rats. With antecedent splenectomy, peripheral lymphocyte counts 12 hours after the onset were significantly lower than those in rats who had not undergone splenectomy. Moreover, nuclear fragmentation was noted, and DNA fragments were significantly increased in peripheral lymphocytes at 6 hours in sodium deoxycholate pancreatitis.

CONCLUSION

These results indicate that splenic atrophy resulting from splenocyte reduction occurs in rat experimental severe acute pancreatitis. It is suggested that splenocytes are recruited into systemic circulation in response to peripheral lymphocyte reduction as a result of apoptosis.

The significance of sinistral portal hypertension complicating chronic pancreatitis

BACKGROUND

Sinistral portal hypertension, a localized (left-sided) form of portal hypertension may complicate chronic pancreatitis as a result of splenic vein thrombosis/obstruction.

AIM

To determine appropriate surgical strategy for patients with splenic vein thrombosis/obstruction secondary to chronic pancreatitis.

METHODS

We reviewed our experience with operative management of 484 consecutive patients with histologically documented chronic pancreatitis treated between 1976 and 1997. The diagnosis of sinistral portal hypertension was based on clinical presentation, preoperative endoscopic and radiographic imaging, and operative findings. "Symptomatic," herein defined, denotes those patients with sinistral hypertension and either gastrointestinal bleeding or hypersplenism. "Asymptomatic" patients were those with sinistral hypertension alone.

RESULTS

Sinistral portal hypertension was present in 34 of the 484 patients (7%). Gastric or gastroesophageal varices were confirmed in 12 patients (35%), of whom 6 had variceal bleeding and 4 had hypersplenism (25%). All symptomatic patients were treated by splenectomy alone or in conjunction with distal pancreatectomy. Splenectomy at the time of pancreatectomy for primary pancreatic symptoms was also performed in 15 patients with (asymptomatic) sinistral portal hypertension. None of the 23 patients who had splenectomy rebled in mean follow-up of 4.8 years. In contrast, 1 of the 11 patients with asymptomatic sinistral portal hypertension who underwent pancreatic surgery without splenectomy died of later variceal bleeding 3 years after lateral pancreatojejunostomy.

CONCLUSIONS

Symptomatic sinistral portal hypertension is best treated by splenectomy. Concomitant splenectomy should be strongly considered in patients undergoing operative treatment of symptomatic chronic pancreatitis if sinistral portal hypertension and gastroesophageal varices are also present.

Transient splenomegaly in acute pancreatitis

Serial changes in splenic volume of 25 patients (18 men and seven women; 53.4 +/- 20.8 years old, range 25-83) with acute pancreatitis who underwent CT examinations were retrospectively studied. Abdominal CT was performed within 3 days after the onset and there was at least one follow-up CT examination after this time. The percentage changes of splenic volume in the first (4-30 days) and second (31-100 days) follow-up CT were calculated. Splenic volume increased in the first follow-up CT (mean +/- SD: 197.8 +/- 121.0 cm3) compared with the initial CT (124.8 +/- 70.0; p < 0.0001), and then decreased in the second follow-up CT (179.7 +/- 100.7; p < 0.002). The average splenic volume increased 65.5 +/- 88.7% (range -10.4-377.4%) between the initial and first follow-up CT examinations. Five of 25 cases (20%) in whom size of spleen increased more than twice had severe acute pancreatitis (p < 0.05), complicated pseudocyst requiring surgical drainage (p < 0.05), pleural effusion (p < 0.01), splenic vein thrombosis or compression (p < 0.05) and longer hospital stay (p < 0.02) compared with patients with a smaller increase in splenic volume. In conclusion, transient splenomegaly was commonly seen in acute pancreatitis, especially in severe or complicated cases. Congestive splenomegaly caused by obstruction or stenosis of the splenic vein and non-specified acute splenitis were suspected of contributing to the transient splenomegaly.

Splenic complications in chronic pancreatitis: prevalence and risk factors in a medical-surgical series of 500 patients

BACKGROUND

The prevalence, course, treatment, outcome and risk factors of splenic complications in chronic pancreatitis are poorly documented.

METHODS

Patients with splenic complications in a medical-surgical series of 500 consecutive patients with proven chronic pancreatitis prospectively followed up for a mean of 7.0 years were compared with patients without splenic complications.

RESULTS

Eleven men (2.2 per cent) with alcoholic chronic pancreatitis (median duration 2 (range 0-5) years) had a splenic complication: intrasplenic pseudocyst (n=5), subcapsular haematoma (n=2) or splenic rupture (n=4). All patients except one underwent splenectomy, five of whom also underwent distal pancreatectomy. There were no deaths. Patients with splenic complications had pancreatic tail necrosis (six of 11 versus 17.4 per cent; P=0.007), distal pseudocyst (six of 11 versus 11.7 per cent; P=0.0009) or splenic vein occlusion (seven of 11 versus 10.8 per cent; P< 0.0001) more frequently than those without. In the 22 patients with distal pseudocyst and splenic vein occlusion, the prevalence of splenic complications was 18 per cent (odds ratio 15.0 (95 per cent confidence interval 4.0-55.7).

CONCLUSION

Splenic complications occur early in the course of chronic pancreatitis, are rare and are favoured by splenic vein occlusion and pseudocyst or necrosis of the pancreatic tail. Surgical treatment is usually required.

Splenic abscess in chronic calcifying pancreatitis

Abscess formation in chronic pancreatitis is rare and the pancreas and liver are the most frequent localizations. We present a novel case of splenic abscess in chronic pancreatitis that led to diabetic ketoacidosis in an alcoholic patient. Percutaneous drainage and antibiotic treatment sufficed to resolve completely the abscess.

Splenic parenchymal complications of pancreatitis: CT findings and natural history

PURPOSE

Splenic parenchymal complications of pancreatitis are unusual and potentially life threatening. They usually require splenectomy in patients in poor condition. The present study describes natural history of splenic parenchymal complications and the role of CT scan in diagnosis and follow-up.

METHOD

A retrospective study of 16 consecutive patients with splenic complications diagnosed by CT during staging of pancreatitis was performed. The presence and importance of splenic infarct, abscess, subcapsular collection, and hemoperitoneum were correlated with the patients' symptoms, type of management, and follow-up.

RESULTS

No specific symptomatology was observed except in two cases of acute and massive hemoperitoneum. Fourteen infarcts, 11 subcapsular collections, 1 abscess, and 3 hemoperitoneums were observed. Four patients underwent splenectomy including two as an emergency for hemodynamic instability. Twelve patients were conservatively and successfully managed.

CONCLUSION

Most splenic parenchymal complications of pancreatitis regress spontaneously and may be managed conservatively. Surgical indication is based mainly on clinical findings. CT is useful for detection and follow-up of these complications.

Percutaneous drainage of intrasplenic pancreatic pseudocyst. Case report

The intrasplenic pancreatic pseudocyst is very rare and surgical treatment has been recommended. We report on a patient with this condition who was successfully treated with percutaneous drainage. Special considerations apply when the drainage catheter is inserted intercostally.