Ağustos 2011 / (19 - 2)
Akut pankreatiti takiben abondan gastrointestinal sistem kanaması: Olgu sunumu
Yazarlar
İbrahim SAKÇAK1, Barış Doğu YILDIZ1, Sabri ÖZDEN1, Akın BOSTANOĞLU1, Nevzat AKDOĞAN2, Mehmet Fatih AVŞAR1,3
Kurumlar
Department of 16th General Surgery, Ankara Numune Teaching and Research Hospital, Ankara
Department of 2General Surgery, Elazığ Teaching and Research Hospital, Elazığ
Department of 3General Surgery, Kafkas University, School of Medicine, Kars
Özet
61 yaşında kadın olgu alt gastrointestinal sistem kanaması nedeniyle acil servise başvurdu. Şikayetleri iki ay önce sırtta ağrı şeklinde başlamıştı. Sol üst
kadranda ele gelen kitle tespit edildi. Anjiografide splenik arter distalinde
anevrizma olguğu görüldü ve embolizasyon uygulandı. Laparotomi yapıldığında transvers kolona 2 cm çapında ağızlaşmış kistik lezyonla karşılaşıldı.
Kolon segmenti rezeke edilerek uç-uca anastomoz yapıldı. Postoperatif 17.
gün dren bölgesinden pankreatik sıvı gelmeye başladı. Drenaj miktarının
azalmaması üzerine, endoskopik retrograd kolanjiopankreatografi yapılarak
nazo-pankreatik kateter yerleştirildi. Postoperatif 47. gün fistül bölgesinden
akıntı kesildi. Patolojide nekroz içeren non- neoplastik kist, kolon ve kist arasında fibrozis bulguları vardı. Akut pankreatit sonrası gastrointestinal sistem
kanaması olan olgularda, pankreas, vasküler yapılar ve komşu organlar arasında fistül akılda bulundurulmalıdır.
Anahtar Kelimeler
Pankreatit, pankreatik psödokist, gastrointestinal kanama
Giriş
Visceral artery aneurysms are most commonly encountered in
the splenic artery (60%), although the overall rate in the population is quite low (1%). These are usually pseudoaneurysms and are seen after chronic or acute pancreatitis and
pancreas surgery. Splenic pseudoaneurysms can be mortal.
They present with left upper quadrant and back pain. Incidence of rupture is less than 2% in asymptomatic splenic pseudoaneurysms, while this rate is higher in symptomatic counterparts (1,2). To prevent rupture, endovascular coiling or
surgical interventions can be utilized.
After acute pancreatitis, pancreatic pseudocyst can form in four weeks. If the pseudocyst becomes infected, necrosis may
occur and colonic or other neighboring organ fistulizations
might ensue (3,4). Although rare, infection and cyst impingement might cause bleeding of surrounding arteries into the
pseudocyst (5).
Both splenic artery aneurysm and colonic fistula are rare
complications of pancreatitis. In this article, we present a case
with simultaneous occurrence of both complications associated with lower gastrointestinal bleeding, which is even rarer.
Olgu
Colonic complications of acute pancreatitis are rare, but when
present, they increase morbidity and mortality (4). Colonic
fistulization can happen between the 10th and 90th days after acute pancreatitis (3). In various studies, colonic complications and fistula rates are cited as between 15-27% and 310%, respectively (6).
CT and colonoscopy are the two most commonly used imaging modalities for colonic complications of acute pancreatitis, while ERCP is the most useful diagnostic and therapeutic
tool in management of pancreatico-colonic fistula, enabling
placement of an internal stent or nasobiliary drainage, as in
our case (7,8).
Proteolytic destruction of surrounding tissues by pancreatic
enzymes plays a role in the pathogenesis of pseudoaneurysm
formation. Embolization in visceral artery aneurysms can be
life-saving. This intervention can stop bleeding or be used as
a bridging therapy until definitive surgery. The success of radiological embolization is cited as 90-95% (9-11). Mortality
of bleeding pseudoaneurysms after pancreatitis ranges between 20% and 50% (12). Embolization reduces this risk to 6%.
Embolization can lead to infarction of the organ that the artery is supplying in 30% of cases (13). In our case, surgery
was undertaken after bleeding was stopped with embolization of the splenic artery pseudoaneurysm. A small area of the
spleen was infarcted secondary to the embolization procedure, but this was quite insignificant.
Massive lower gastrointestinal bleeding is quite rare after acute pancreatitis, although this can be seen after invasion of the
gastrointestinal tract by pancreatic tumors (14,15). The unique presentation of our case once again shows that acute pancreatitis affects neighboring organs and vascular structures,
causing unexpected complications.
Tartışma
Colonic complications of acute pancreatitis are rare, but when
present, they increase morbidity and mortality (4). Colonic
fistulization can happen between the 10th and 90th days after acute pancreatitis (3). In various studies, colonic complications and fistula rates are cited as between 15-27% and 310%, respectively (6).
CT and colonoscopy are the two most commonly used imaging modalities for colonic complications of acute pancreatitis, while ERCP is the most useful diagnostic and therapeutic
tool in management of pancreatico-colonic fistula, enabling
placement of an internal stent or nasobiliary drainage, as in
our case (7,8).
Proteolytic destruction of surrounding tissues by pancreatic
enzymes plays a role in the pathogenesis of pseudoaneurysm
formation. Embolization in visceral artery aneurysms can be
life-saving. This intervention can stop bleeding or be used as
a bridging therapy until definitive surgery. The success of radiological embolization is cited as 90-95% (9-11). Mortality
of bleeding pseudoaneurysms after pancreatitis ranges between 20% and 50% (12). Embolization reduces this risk to 6%.
Embolization can lead to infarction of the organ that the artery is supplying in 30% of cases (13). In our case, surgery
was undertaken after bleeding was stopped with embolization of the splenic artery pseudoaneurysm. A small area of the
spleen was infarcted secondary to the embolization procedure, but this was quite insignificant.
Massive lower gastrointestinal bleeding is quite rare after acute pancreatitis, although this can be seen after invasion of the
gastrointestinal tract by pancreatic tumors (14,15). The unique presentation of our case once again shows that acute pancreatitis affects neighboring organs and vascular structures,
causing unexpected complications.
Kaynaklar
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