Acute pancreatitis preliminary investigation of a new radiodiagnostic sign

Recurrent Large Bowel Obstruction Caused by Necrotizing Pancreatitis: A Rare Manifestation

Mechanical obstruction of the colon is rare with necrotizing pancreatitis but is associated with high morbidity and mortality. However, pancreatic ileus, colonic necrosis, and pancreatic colonic fistulae with necrotizing pancreatitis are well known. The anatomic proximity of the pancreas to the transverse colon becomes clinically relevant when a patient with pancreatitis demonstrates a localized ileus of the transverse colon (an old term “the colon cut-off sign”), even when the disease is mild, or lower gastrointestinal bleeding secondary to necrosis of the segment in severe acute pancreatitis. We present the case of a 25-year-old female with choledocholithiasis who presented with severe abdominal pain and was found to have recurrent large bowel obstruction secondary to walled-off pancreatic necrosis. Bowel obstruction is a rare complication of walled-off necrosis, but clinicians should be aware of it due to significantly increased mortality rates. Recurrent bowel obstructions are rarely known in necrotizing pancreatitis and may warrant a bowel resection either electively or acutely. Walled-off necrosis does not respond to typical treatment of symptomatic pseudocysts, which includes endoscopic cystogastrostomy or percutaneous drainage with small-bore catheters. Endoscopic or surgical necrosectomy is necessary for the resolution of walled-off necrosis to evacuate the non-liquefied components.

[Intestinal occlusion due to pancreatitis mimicking stenosing neoplasm of the splenic angle of the colon]

Colonic involvement in patients with severe acute pancreatitis or chronic pancreatitis is common and complications such as paralytic ileus, segmental necrosis and pancreatic-colonic fistulae have been described. However, mechanical occlusion of the colon due to pancreatitis is infrequent. We present the case of a 45-year-old man with occlusion of the colon secondary to asymptomatic pancreatitis mimicking a locally advanced stenosing neoplasm of the splenic angle. Ten years prior to the present episode the patient had presented acute alcoholic pancreatitis complicated by a pseudocyst requiring surgery. The current reason for admission was abdominal colic pain and constipation with onset 5 days previously. Contrast enema was administered showing colonic occlusion caused by stenosis at the splenic flexure, suggesting the presence of a neoplasm. Urgent laparotomy showed the presence of a tumor originating in the colon that infiltrated the splenic hilum. Subtotal colectomy and en-bloc splenectomy were performed. Histopathological analysis showed pericolonic inflammation and fibrosis secondary to pancreatitis; the colonic mucosa showed no tumoral infiltration. To date, fewer than 30 cases of this infrequent complication have been published.

Colonic complications of severe acute pancreatitis

Colonic complications are rare in acute pancreatitis. Over the last 9 years at St. Mary's Hospital, London, UK, we have managed severe acute pancreatitis by intensive supportive therapy followed by sub-total pancreatic resection and/or debridement in those who fail to improve. Of the 22 patients who have undergone this form of surgery, nine were found to have colonic involvement in the form of either necrosis or perforation. In addition, one patient presenting at West Middlesex University Hospital, Isleworth, UK, had severe acute pancreatitis and almost total colonic necrosis as an unexpected finding at emergency laparotomy. These ten patients comprised seven men and three women of median age 59 years and with a median of four Ranson criteria. In seven patients, colonic involvement was discovered at the time of pancreatic surgery or laparotomy for pancreatitis and in the remainder it presented between 1 and 3 weeks later as either a faecal fistula (n = 2) or persistent abdominal sepsis (n = 1). The ascending colon was involved in one patient, the splenic flexure and descending colon in one, the transverse colon in three, the splenic flexure alone in four, and one patient had almost total colonic involvement. All patients underwent resection of the involved colon and exteriorization with either a proximal colostomy (n = 7) or ileostomy (n = 3) and a distal mucous fistula. Pathological examination of the resected colons revealed a spectrum of changes from pericolitis through to ischaemic necrosis suggesting at least two possible mechanisms. Six patients died from overwhelming sepsis between 1 day and 4 weeks (median 11 days) after colonic resection. Severe acute pancreatitis must be recognized as a cause of colonic ischaemia and necrosis; this complication is associated with a very poor prognosis despite surgical intervention.

The expanded role of the barium enema in the evaluation of patients presenting with acute abdominal pain

The role of the barium enema in the evaluation of patients with acute abdominal pain is well established. It is utilized in the diagnosis and treatment of several suspected clinical entities, including appendicitis, diverticulitis, intussusception, and volvulus. There is another group of patients in whom a vague clinical presentation and an indeterminate bowel gas pattern fail to clarify the diagnosis. The role of the barium enema has been expanded as an early diagnostic aid in the evaluation of these patients. Based on abdominal film findings, three patient categories are presented, in whom the early use of a "judicious" barium enema may safely and quickly contribute to the preoperative definition of the underlying disease process, allowing for the correct mode of therapy to be undertaken.

Colonic complications of acute pancreatitis and pancreatic abscess

Colonic involvement should be suspected in patients with severe acute pancreatitis, especially in the following clinical settings: plain abdominal radiographs suggesting bowel ischemia, colonic obstruction, acute lower gastrointestinal hemorrhage, gram-negative septicemia, enteric bacteria on Gram stain or culture of peritoneal fluid, and feculent abdominal drainage from a previously drained pancreatic abscess. Intraoperatively, the pancreas should be widely drained and the fecal stream diverted. Colonic hemorrhage and nonviable bowel require immediate resection. Broad-spectrum antibiotic administration and vigorous nutritional support also are required in these critically ill patients. Although proximal diversion and pancreatic diversion alone may suffice, colonic resection may be required later for persistent obstruction or fistulization, but in a more elective setting. Colonic anastomoses should be performed only when pancreatic inflammation and associated sepsis have resolved completely.

Do plain films of the chest and abdomen have a role in the diagnosis of acute pancreatitis?

Radiographs taken on the day of admission on 52 patients with acute pancreatitis have been compared with similar radiographs of 30 patients with acute cholecystitis and 22 patients with perforated duodenal ulcer. Two radiologists, who were unaware of the clinical features, looked specifically for the presence of 30 radiological signs. The only abdominal signs seen more frequently in acute pancreatitis were fluid levels in the stomach and duodenum, usually associated with dilatation. Duodenal abnormalities were seen in 42% of patients with acute pancreatitis and 21% of the controls (P less than 0.05) while gastric dilatation with a fluid level was seen in 29% of cases of acute pancreatitis compared with 12% of controls (P less than 0.05). Seventy per cent of the patients with severe acute pancreatitis had an abnormal chest radiograph on admission compared with 18% of those with mild disease. Left pleural effusion was the most common abnormality in severe pancreatitis (43%) and was seen significantly more often than in mild pancreatitis (P less than 0.01) and the control group (P less than 0.05). Therefore, consideration of the admission chest radiograph may help at an early stage to distinguish patients with severe pancreatitis from those with mild disease.

Colonic fistulization in pancreatitis: case report and literature review

A case is reported in which pancreatic abscess with erosion into the colon and the splenic artery was treated successfully. The 35 previously reported cases of colonic fistulization in pancreatitis are reviewed, and the pathophysiology, diagnosis, and management of this complication are discussed.

The plain abdominal radiograph in acute pancreatitis

The radiographs of 100 patients with acute pancreatitis were reviewed and compared with 100 controls by two radiologists and a surgeon. Our aim was to assess the frequency and usefulness of the signs described in the literature. Calcification of the pancreas was seen in one case only. Abnormalities of the biliary tree (visible gallbaldder, biliary gas and gallstones) were seen in 10%. The left psoas shadow was more frequently absent in the pancreatitis series. Paucity of gastrointestinal gas although observed in 12 cases was ascribed to vomiting. A more important sign was the gaseous outline of an adynamic duodenal loop which was seen in half of the patients examined in the left lateral decubitus position. Dilated jejunum was seen in 31 cases, associated with sentinel loops in 10 and multiple fluid levels in 25 patients. Dilatation of thet ransverse colon was the most constant colonic sign (18%), but the colon 'cut-off' sign was not seen. It was concluded that the most prominent signs in order of importance are a gaseous distension of the duodenal loop, gas in the duodenal cap, a dilated transverse colon and the sentinel loop. The gasless abdomen is a striking but rare sign and in our series was always associated with severe pancreatitis.

The spectrum of colonic involvement in pancreatitis

Colonic involvement as a result of pancreatitis is an uncommon but interesting complication of the disease. Among the significant manifestations we have seen are: 1) adynamic ileus of the transverse colon, 2) fibrosing, stenosing pericolitis localized to the splenic flexure area, and 3) colonic hemorrhage secondary to necrosis and fistula formation. Ordinarily, conservative treatment will suffice, but in complicated cases, individualized surgical treatment becomes necessary.

Etiology of strictures of the colon associated with pancreatitis

Colonic strictures are an uncommon complication of pancreatitis. Three new cases are described and in each case the histological features strongly resemble those seen in strictures of ischemic origin. It is postulated that ischemia and not encircling pericolic inflammation, is the cause of strictures associated with pancreatitis.