e-ISSN: 1302-5422
Ağustos 2011
- Ana Sayfa
- Sayılar
- Ağustos 2011
- Akut pankreatiti takiben abondan gastrointestinal sistem kanaması: Olgu sunumu
Ağustos 2011 / (19 - 2)
Akut pankreatiti takiben abondan gastrointestinal sistem kanaması: Olgu sunumu
Sayfa Numaraları
59-61
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
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.
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.
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.
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.
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
1. Udd M, Leppäniemi AK, Bidel S, et al. Treatment of bleeding pseudoane urysms in patients with chronic pancreatitis. World J Surg 2007; 31:
504-10.
2. Balachandra S, Siriwardena AK. Systematic appraisal of the management
of the major vascular complications of pancreatitis. Am J Surg 2005;
190: 489-95.
3. Aldridge MC, Francis ND, Glazer G, et al. Colonic complication of severe acute pancreatitis. Br J Surg 1989; 76: 362-7.
4. Kriwanek S, Armbruster C, Beckerhinn P, et al. Improved result after aggressive treatment of colonic involvement in necrotizing pancreatitis.
Hepatogastroenterologica 1996; 43: 1627-32.
5. Nicolás de Prado I, Corral de la Calle MA, Nicolás de Prado JM, et al.
[Vascular complications of pancreatitis]. Rev Clin Esp 2005; 205: 32632.
6. Suzuki A, Suzuki S, Sakaguchi T, et al. Colonic fistula associated with severe acute pancreatitis: report of two cases. Surg Today 2008; 38: 17883. 7. Tüney D, Altun E, Barlas A, et al. Pancreato-colonic fistula after acute necrotizing pancreatitis. Diagnosis with spiral CT using rectal water so luble contrast media. J Pancreas 2008; 9: 26-9. 8. Shim KS, Suh JM, Yang YS, et al. Three-dimensional demonstration and endoscopic treatment of pancreaticoperitoneal fistula. Am J Gastroenterol 1993; 88: 1775-9. 9. Bergert H, Hinterseher I, Kersting S, et al. Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis. Surgery 2005; 137: 323-8.
10. Hyare H, Desigan S, Brookes JA, et al. Endovascular management of major arterial hemorrhage as a complication of inflammatory pancreatic disease. J Vasc Interv Radiol 2007; 18: 591-6.
11. Sethi H, Peddu P, Prachalias A, et al. Selective embolization for bleeding visceral artery pseudoaneurysms in patients with pancreatitis. Hepatobiliary Pancreat Dis Int 2010; 9: 634-8.
12. Nicholson AA, Patel J, McPherson S, et al. Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications. J Vasc Interv Radiol 2006; 17: 127985.
13. Piffaretti G, Tozzi M, Lomazzi C, et al. Splenic artery aneurysms: postembolization syndrome and surgical complications. Am J Surg 2007; 193: 70.
14. Molnar T, Kurucsai G, Tiszlavicz L, et al. How can a pancreatic neoplasm be diagnosed by colonoscopy? A case report. J Gastrointestin Liver Dis 2007; 16: 189-91.
15. Garcea G, Krebs M, Lloyd T, et al. Haemorrhage from pancreatic pseudocysts presenting as upper gastrointestinal haemorrhage. Asian J Surg 2004; 27: 137-40.
Hepatogastroenterologica 1996; 43: 1627-32.
5. Nicolás de Prado I, Corral de la Calle MA, Nicolás de Prado JM, et al.
[Vascular complications of pancreatitis]. Rev Clin Esp 2005; 205: 32632.
6. Suzuki A, Suzuki S, Sakaguchi T, et al. Colonic fistula associated with severe acute pancreatitis: report of two cases. Surg Today 2008; 38: 17883. 7. Tüney D, Altun E, Barlas A, et al. Pancreato-colonic fistula after acute necrotizing pancreatitis. Diagnosis with spiral CT using rectal water so luble contrast media. J Pancreas 2008; 9: 26-9. 8. Shim KS, Suh JM, Yang YS, et al. Three-dimensional demonstration and endoscopic treatment of pancreaticoperitoneal fistula. Am J Gastroenterol 1993; 88: 1775-9. 9. Bergert H, Hinterseher I, Kersting S, et al. Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis. Surgery 2005; 137: 323-8.
10. Hyare H, Desigan S, Brookes JA, et al. Endovascular management of major arterial hemorrhage as a complication of inflammatory pancreatic disease. J Vasc Interv Radiol 2007; 18: 591-6.
11. Sethi H, Peddu P, Prachalias A, et al. Selective embolization for bleeding visceral artery pseudoaneurysms in patients with pancreatitis. Hepatobiliary Pancreat Dis Int 2010; 9: 634-8.
12. Nicholson AA, Patel J, McPherson S, et al. Endovascular treatment of visceral aneurysms associated with pancreatitis and a suggested classification with therapeutic implications. J Vasc Interv Radiol 2006; 17: 127985.
13. Piffaretti G, Tozzi M, Lomazzi C, et al. Splenic artery aneurysms: postembolization syndrome and surgical complications. Am J Surg 2007; 193: 70.
14. Molnar T, Kurucsai G, Tiszlavicz L, et al. How can a pancreatic neoplasm be diagnosed by colonoscopy? A case report. J Gastrointestin Liver Dis 2007; 16: 189-91.
15. Garcea G, Krebs M, Lloyd T, et al. Haemorrhage from pancreatic pseudocysts presenting as upper gastrointestinal haemorrhage. Asian J Surg 2004; 27: 137-40.
