Pancreatic pseudocyst rupture into the portal vein

Vascular complications of pancreatitis

More than 200000 hospital admissions happen per year for acute pancreatitis and more than 50000 for chronic pancreatitis in the United States of America. Necrotizing pancreatitis accounts for 20%-30% of the cases. One-quarter of the patients with pancreatitis develop vascular complications, which carries a high mortality. This mini-review will address these complications that can help primary care physicians and hospitalists in managing their patients effectively.

Pancreatic-Portal Vein Fistula: a Rare Diagnosis with Wide-Ranging Complications-13-Year Experience of a Pancreas Center of Excellence

PURPOSE

To determine factors affecting mortality, and long-term patency of portal vein, in patients with pancreatic-portal vein fistula (PPVF).

METHODS

Consecutive cases of PPVF at the University of Pittsburgh Medical Center from 2008 to 2020 were retrospectively identified. Clinical history, imaging studies, management strategies, complications, and long-term outcomes were analyzed.

RESULTS

Fourteen patients, representing the largest PPVF cohort reported to date (mean age 58.6 years, 64.3% women, median follow-up 10 months [1-98 months]) were identified. Underlying chronic pancreatitis was seen in 9 (64.3%) patients, while 5 (35.7%) developed PPVF with first attack of acute pancreatitis. PPVF involved proximal main portal vein (MPV) in 10 (78.6%) patients. Of the 5 patients (35.7%) who died, all had occlusive (n=4) or near-occlusive (n=1) PPVF-associated filling defect (FD) in the MPV. Conversely, 7 of 9 survivors (87.5%) had subocclusive FD and patent MPV. In patients with sepsis (n=5), 1 underwent surgical necrosectomy and survived, while 3 of 4 (75%) patients without debridement died.

CONCLUSION

Occlusive/near-occlusive PPVF-associated MPV FD, and sepsis, are associated with high mortality rates, while subocclusive MPV FD is associated with survival and long-term MPV patency. PPVF is a potentially life-threatening, and possibly under-diagnosed, entity that warrants early clinical suspicion for timely diagnosis, to facilitate optimal management.

Pancreatic pseudocyst-portal vein fistula: a case treated with EUS-guided cyst-drainage and a review of the literature

Pancreatic pseudocyst and portal vein thrombosis are common conditions resulting from acute and chronic pancreatitis. However, pancreatic pseudocyst-portal vein fistula (PPVF) is a rare and life-threatening complication. In PPVF patients, drainage or operative therapy is necessary under certain conditions, including communication between the pseudocyst and pancreatic duct, pancreatic duct stricture, pancreatic duct stone, and infection that is difficult to control with antibiotics. We describe the case of a 78-year-old woman who presented with an infected pancreatic pseudocyst invading the portal venous system with obstruction due to thromboembolization. Conservative therapy with antibiotics was insufficient. We, therefore, performed endoscopic ultrasound-guided cyst-drainage (EUS-CD). During EUS-CD, PPVF and pseudocyst-pancreatic duct fistula were confirmed by contrast medium injection. Despite the presence of the pseudocyst-pancreatic duct fistula, the pancreatic duct was not visualized in the pancreatic head, suggesting stricture in the main pancreatic duct. We, therefore, performed endoscopic retrograde pancreatography, which revealed pancreatic stone in the main pancreatic duct. Then, we added a 7-Fr pancreatic stent. She was discharged after 89 days of hospitalization. We reviewed the literature on the management of PPVF formation, and EUS-CD is considered to be a good treatment option for PPVF patients without portal vein patency.

Case 273: Pancreatic Duct-to-Portal Vein Fistula with Secondary Portal Vein Pyophlebitis-A Rare Complication of Chronic Pancreatitis

HistoryA 55-year-old man with a history of chronic pancreatitis secondary to chronic alcohol abuse presented to the hospital with acute abdominal pain, generalized weakness, weight loss, and pyrexia. A clinical examination revealed he was tender to touch in the upper abdomen. Laboratory tests revealed a serum alkaline phosphatase level of 370 U/L (6.1 µkat/L) (normal range, 30-130 U/L [0.5-2.2 µkat/L]), a lipase level of 172 U/L (2.9 µkat/L) (normal range, 0-60 U/L [0-1.0 µkat/L]), a C-reactive protein level of 159 mg/L (1514 nmol/L) (normal value, <8.0 mg/L [76.2 nmol/L]), and a white cell count of 7 × 10⁹/L (normal range, [4-11] × 10⁹/L). During the present admission, the patient underwent urgent CT for his acute symptoms. His relevant medical history included a hospital admission 2 months earlier for abdominal discomfort. Given his history of chronic pancreatitis, baseline abdominal MRI was performed to determine the cause of his symptoms and to assess the pancreas.

Pancreatic Walled-Off Necrosis Eroding into the Inferior Vena Cava

Walled-off necrosis (WON) is a well-known delayed local complication of acute necrotizing pancreatitis. Occasionally, WON may spontaneously rupture into the gastrointestinal tract or peritoneal cavity. However, erosion of a WON to a systemic vein has not been reported in literature so far. We report an unusual case of a 63-year-old male with acute necrotizing pancreatitis in whom WON was eroding into the inferior vena cava resulting in its thrombosis. Our patient also had a bunch of other well-described complications of pancreatitis including splanchnic venous thrombosis.

Pancreaticoportal Fistula Formation as a Consequence of Recurrent Acute Pancreatitis: Clinical and Imaging Considerations

A pancreatic-portal vein fistula (PPVF) is an extremely rare complication of pancreatitis. In this report, we present a patient with a PPVF in the setting of recurrent pancreatitis and portal vein thrombosis diagnosed by cross-sectional imaging and endoscopic retrograde cholangio-pancreatography, who responded to medical management and anticoagulation. A critical review of this disease process is explored to highlight pathology, imaging characteristics, and essential alternative diagnostic considerations. We also discuss potential complications and current treatment strategies. PPVFs pose a unique diagnostic challenge and awareness of its clinical presentation can further improve patient outcomes.

Spontaneous rupture of intrahepatic pseudocyst into the inferior vena cava

We present an extremely rare case of caudate lobe intrahepatic pancreatic pseudocyst with spontaneous rupture into the inferior vena cava (IVC). A 58-year-old male, a chronic alcoholic, presented with features of pancreatitis for which imaging was done. Ultrasound and contrast-enhanced computed tomography were carried out, which revealed intrahepatic pancreatic pseudocyst in the caudate lobe of the liver. There was suggestion of spontaneous rupture of the pseudocyst into the IVC, which was well delineated on imaging.

Massive pancreatic pseudocyst with portal vein fistula: case report and proposed treatment algorithm

Pancreatic pseudocyst is a relatively common occurrence resulting from acute or chronic pancreatitis. However, a rare subset of these patients present with a pseudocyst fistulizing into the portal vein. We present the case of a 58 year-old woman with a rapidly expanding pancreatic pseudocyst with portal venous fistulization causing portal vein thrombosis, in addition to biliary and duodenal obstruction. The patient underwent surgical decompression with a cyst-gastrostomy and was well until one week post-operatively when she experienced massive gastrointestinal hemorrhage leading to her death. A review of the literature is presented and a treatment algorithm to manage patients with pancreatic pseudocyst to portal vein fistula is proposed.

Diagnosis of pancreatic duct-portal vein fistula; a case report and review of the literature

Pseudocysts containing activated enzymes are a common complication of pancreatitis. Pseudocysts can rupture into adjacent structures including the peritoneal cavity, adjacent organs, and rarely vascular structures. While arterial pseudoaneurysms and venous thrombosis or occlusion are well known complications of acute and chronic pancreatitis, only 17 cases of pancreas-portal venous fistula have been encountered in review of the literature. A patient with chronic pancreatitis presented with a history of weight loss, fatigue and was found to have a pancreatic duct-portal vein fistula. The patient was treated surgically with good outcome.

Spontaneous pancreatic pseudocyst-portal vein fistula: a rare and potentially life-threatening complication of pancreatitis

Pseudocyst formation following acute and chronic pancreatitis is a well known complication. A pancreatic pseudocyst fistulating into the portal vein is a rare and potentially fatal complication. We report a case of pancreatic pseudocyst – portal vein fistula, which was managed with a conservative approach.