|
1
|
Iqbal N, Mazhar M, Noureen S, Shujaat E, Malik T, Seerat I. Pulmonary Embolism: A Rare Presentation of Acute-on-Chronic Pancreatitis in Children. Cureus 2025; 17:e76768. [PMID: 39897232 PMCID: PMC11786000 DOI: 10.7759/cureus.76768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/01/2025] [Indexed: 02/04/2025] Open
Abstract
Although splanchnic vein thrombosis may manifest as pancreatitis, it is rare to find venous thrombosis at other body sites. We present a rare case of acute-on-chronic pancreatitis in a patient who subsequently developed a deep venous thrombosis (DVT) of the right lower limb and pulmonary embolism (PE). A 14-year-old male presented with an acute history of upper abdominal pain, vomiting, and abdominal distension. Workup for pancreatitis was normal except for low hemoglobin and high serum pancreatic enzymes. The CT abdomen favored a diagnosis of acute-on-chronic pancreatitis with dilated pancreatic duct, multiple pseudo-pancreatic cysts, and saddle pulmonary embolus. He was treated with medical conservative therapy. For DVT and saddle PE, he was started on enoxaparin, which was later switched to rivaroxaban. A CT angiogram after three months of therapy with rivaroxaban showed the complete disappearance of the clot. Early detection of such life-threatening complications is important to achieve favorable outcomes in these patients.
Collapse
Affiliation(s)
- Nazia Iqbal
- Department of Paediatrics Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute, Lahore, PAK
| | - Maryam Mazhar
- Department of Paediatrics Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute, Lahore, PAK
| | - Sobia Noureen
- Department of Paediatric Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute, Lahore, PAK
| | - Eman Shujaat
- Department of Paediatrics Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute, Lahore, PAK
| | - Tahir Malik
- Department of Radiology, Pakistan Kidney and Liver Institute, Lahore, PAK
| | - Iqtadar Seerat
- Department of Paediatric Gastroenterology & Hepatology, Pakistan Kidney and Liver Institute, Lahore, PAK
| |
Collapse
|
|
2
|
Keller K, Sivanathan V, Farmakis IT, Schmitt VH, Espinola-Klein C, Schmidt FP, Münzel T, Konstantinides S, Hobohm L. Incidence and impact of venous thromboembolism in hospitalized patients with acute pancreatitis. Dig Liver Dis 2024; 56:2085-2094. [PMID: 38987040 DOI: 10.1016/j.dld.2024.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/13/2024] [Accepted: 06/23/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Acute pancreatitis (AP) and venous thromboembolism (VTE) remain common and potentially lethal disease entities. AP might be an important trigger of systemic inflammtion and may activate the coagulation system with increased VTE risk. METHODS The German nationwide inpatient sample was screened for patients admitted due to AP (ICD-code K85) 2005-2019. AP hospitalizations were stratified for VTE as well as risk-factors and the impact of VTE on in-hospital case-fatality rate were investigated. RESULTS Overall, 797,364 hospitalizations of patients due to AP (aged in median 56.0 [IQR 44.0-71.0] years), 39.2 % females) were detected in Germany 2005-2019. Incidence of VTE in hospitalized AP patients was 1764.8 per 100,000 hospitalizations (1.8 %) with highest VTE rate between 5th and 6th decade. Cancer (OR 1.656 [95 %CI 1.513-1.812], P < 0.001), any surgery (OR 4.063 [95 %CI 3.854-4.284], P < 0.001), and heart failure (OR 1.723 [95 %CI 1.619-1.833], P < 0.001) were independently associated with VTE occurrence. Case-fatality (8.8 % vs. 2.7 %, P < 0.001) was more than 3-fold higher in AP patients with than without VTE. VTE was associated with increased case-fatality in AP patients (OR 3.925 [95 %CI 3.684-4.181], P < 0.001). CONCLUSIONS VTE is a life-threatening event in hospitalized AP patients associated with an almost 4-fold increased case-fatality rate. Cancer, any surgery, thrombophilia and heart failure were important risk factors for occurrence of VTE in AP.
Collapse
Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Heidelberg, Germany.
| | - Visvakanth Sivanathan
- Department of Gastroenterology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Ioannis T Farmakis
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Volker H Schmitt
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Christine Espinola-Klein
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | | | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| |
Collapse
|
|
3
|
Alomar T, Somaratna A, Boddupalli D. Persistent Risk of Pulmonary Embolism in Acute Pancreatitis Despite Prophylactic Anticoagulation. Cureus 2024; 16:e74249. [PMID: 39717286 PMCID: PMC11663624 DOI: 10.7759/cureus.74249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2024] [Indexed: 12/25/2024] Open
Abstract
Acute pancreatitis, a sudden inflammatory condition, can lead to a hypercoagulable state resulting in complications such as deep vein thrombosis (DVT) or pulmonary embolism (PE). This case report discusses a unique presentation of a massive PE in a patient with acute pancreatitis despite being on appropriate prophylactic anticoagulation. A 27-year-old man presented with acute abdominal pain, nausea, and vomiting. He was diagnosed with diabetic ketoacidosis (DKA) and acute pancreatitis and admitted to the ICU. He was treated with prophylactic enoxaparin. On day 16, he experienced acute respiratory decompensation, and CT angiography revealed bilateral PEs, including a right main pulmonary artery saddle embolus. The patient underwent emergent thrombectomy with the immediate resolution of symptoms. He was transitioned to therapeutic heparin and later discharged on apixaban. A two-month follow-up showed no recurrence of PE. This case underscores the critical need to consider PE in patients with inflammatory conditions, even when on prophylactic anticoagulation. The hypercoagulable state induced by pancreatitis can overcome standard anticoagulation measures, leading to severe complications. Current guidelines may not adequately address the anticoagulation needs in such inflammatory states. Therefore, weight-based dosing of anticoagulants should be considered for patients with significant inflammation. This report highlights the necessity for vigilance in monitoring for PE in similar clinical scenarios to improve patient outcomes and inform future guidelines.
Collapse
Affiliation(s)
- Talal Alomar
- Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | - Anupama Somaratna
- Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| | - Deepti Boddupalli
- Internal Medicine, Creighton University School of Medicine, Phoenix, USA
| |
Collapse
|
|
4
|
Aponso T, Wanninayake A, Peiris R. An Atypical Case of Acute Pulmonary Embolism in a Sri Lankan Patient With Acute Severe Pancreatitis With Heterozygosity for the SPINK 1 Mutation. Cureus 2024; 16:e73800. [PMID: 39687810 PMCID: PMC11648039 DOI: 10.7759/cureus.73800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2024] [Indexed: 12/18/2024] Open
Abstract
Acute pancreatitis is a disease characterized by local destruction of the pancreatic gland due to premature activation of pancreatic enzymes within the acinar cells. Tissue damage can activate an inflammatory cascade, which can lead to systemic complications. Although vascular complications are uncommon, they significantly contribute to mortality and morbidity. Pulmonary embolism being an exceptionally rare complication of acute pancreatitis is reported in only a few cases, and cases of pulmonary embolism without associated deep vein thrombosis in the lower limbs are extraordinarily rare and unreported in the literature. This article presents the case of a 22-year-old Sri Lankan woman diagnosed with severe acute pancreatitis. On the fifth day of her illness, she developed sudden-onset dyspnea, and imaging revealed a large pulmonary artery embolism affecting the right pulmonary artery and segmental branches in the right lower lobe, with a normal venous duplex scan of the lower limbs. We started her on anticoagulation and supportive care for her acute severe pancreatitis. Her dyspnea and pancreatitis improved with time. She was later diagnosed as heterozygous for the serine peptidase inhibitor Kazal type 1 (SPINK 1) mutation.
Collapse
Affiliation(s)
- Tilan Aponso
- Gastroenterology and Hepatology, National Hospital of Sri Lanka, Colombo, LKA
| | | | - Ranjith Peiris
- Gastroenterology and Hepatology, National Hospital of Sri Lanka, Colombo, LKA
| |
Collapse
|
|
5
|
Zhang YL, Yang B, Yu F, Liu Y, Si GY, He QZ. Acute Pancreatitis Complicated by Thrombosis in the Right Brachiocephalic Veins and Superior Vena Cava: A Case Report. Curr Med Imaging 2024; 20:e060623217708. [PMID: 37282658 DOI: 10.2174/1573405620666230606125505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) is one of the most common digestive emergencies, and vascular complication is one of the primary reasons for death, with splanchnic venous thrombosis being the most common. Although extra-splanchnic venous thrombosis is rare, it carries the risk of life-threatening secondary pulmonary embolism. CASE PRESENTATION We have, herein, reported a case of AP complicated by rare brachiocephalic vein thrombosis and superior vena cava thrombosis. A 40 years old woman was diagnosed with severe AP for abdominal pain 21 days ago. The patient received symptomatic treatment, including acid suppression, enzyme suppression, lipid-lowering, fluid infusion, anti-infection, and continuous renal replacement therapy. The patient was discharged after symptomatic relief. Recently, the patient was admitted again for middle-upper abdominal pain and discomfort. On admission, her blood platelet, DDimer, fibrin degradation products (FDP), and triglyceride levels have been found to be increased; abdominal enhanced CT showed pancreatic necrosis and an accumulation of peripancreatic necrosis and fluid, while chest enhanced CT suggested thrombosis in the right brachiocephalic vein and superior vena cava. The patient, however, improved and was discharged after anticoagulation combined with insulin and trypsin inhibitors. CONCLUSION In diagnosing and treating AP, dynamic monitoring of D-dimer levels is necessary for the timely detection of the development of thrombotic complications.
Collapse
Affiliation(s)
- Yan-Li Zhang
- Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Bin Yang
- Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Fei Yu
- Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Yong Liu
- Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Guang-Yan Si
- Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| | - Qi-Zhou He
- Department of Radiology, The Affiliated Traditional Chinese Medicine Hospital of Southwest Medical University, Luzhou, China
| |
Collapse
|
|
6
|
Wang FJ, Mei X. Expression level of serum miR-347a-5p in patients with acute pancreatitis and its effect on viability, apoptosis, and inflammatory factors of pancreatic acinar cells induced by cerulein. Kaohsiung J Med Sci 2023. [PMID: 36912261 DOI: 10.1002/kjm2.12666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/20/2023] [Accepted: 02/02/2023] [Indexed: 03/14/2023] Open
Abstract
Acute pancreatitis (AP) is one of the life-threatening diseases of the digestive system. MicroRNA has been asserted to be a regulator of AP. This paper explored the miR-374a-5p expression in AP patients and investigated the efficacy of AR42J cells. In this study, 60 healthy people, 58 MAP patients and 58 SAP patients were included, and the serum miR-374a-5p levels of the subjects were detected by RT-qPCR technology. The pancreatitis cell model was structured by stimulating AR42J cells with cerulein. Next, cell viability and apoptosis were detected by CCK-8 assay and flow cytometry. ELISA was used to measure the concentration of cytokines, such as TNF-α, IL-6, and IL-1β. The data showed that miR-374a-5p was downregulated in samples from AP patients, while showing discriminative power for AP populations. Attenuated miR-374a-5p were negatively bound up with patients' Ranson score and APACHE II score. Besides, miR-374a-5p was declined in cerulein-treated AR42J cells and forced elevation of miR-374a-5p was beneficial to increase cell viability, and inhibit cell apoptosis and inflammation. The present study found that miR-374a-5p was reduced in AP serum samples, and up-regulated expression level of miR-374a-5p in cell models had a protective effect on cerulein-induced inhibition of cell function and inflammatory response.
Collapse
Affiliation(s)
- Fu-Jun Wang
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| | - Xue Mei
- Emergency Medicine Clinical Research Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Key Laboratory of Cardiopulmonary Cerebral Resuscitation, Beijing, China
| |
Collapse
|
|
7
|
Skaff Y, Jarrah M, Filippaios A, Sharkawi MA, Mehawej J. Emphysematous pancreatitis with pulmonary embolism: A case report. Respir Med Case Rep 2023; 42:101813. [PMID: 36691653 PMCID: PMC9860406 DOI: 10.1016/j.rmcr.2023.101813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/01/2022] [Accepted: 01/13/2023] [Indexed: 01/18/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Yara Skaff
- Division of Internal Medicine, Department of Medicine, Lebanese American University Medical Center Rizk Hospital, Beirut, Lebanon
| | - Mohammad Jarrah
- Division of Internal Medicine, Department of Medicine, Lebanese American University Medical Center Rizk Hospital, Beirut, Lebanon
| | - Andreas Filippaios
- Department of Medicine, University of Massachusetts Chan Medical School, MA, USA,Corresponding author. Department of Medicine, University of Massachusetts Chan Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA.
| | - Musa A. Sharkawi
- Division of Cardiology, Department of Medicine, Augusta University Medical Center, GA, USA
| | - Jordy Mehawej
- Department of Medicine, University of Massachusetts Chan Medical School, MA, USA
| |
Collapse
|
|
8
|
Yan LL, Jin XX, Yan XD, Peng JB, Li ZY, He BL. Combined use of extracorporeal membrane oxygenation with interventional surgery for acute pancreatitis with pulmonary embolism: A case report. World J Clin Cases 2022; 10:3899-3906. [PMID: 35647141 PMCID: PMC9100729 DOI: 10.12998/wjcc.v10.i12.3899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/16/2021] [Accepted: 03/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is an acute inflammatory process of the pancreas characterized by self-digestion of pancreatic tissue, which can trigger a systemic inflammatory response. Venous thrombosis, resulting from a hypercoagulable state, is a vascular complication of AP. AP complicated by pulmonary embolism (PE) is very rare, and the combined use of extracorporeal membrane oxygenation (ECMO) with a vascular interventional procedure for AP complicated by PE is even rarer.
CASE SUMMARY A 32-year-old man with a history of obesity developed rapidly worsening AP secondary to hypertriglyceridemia. During treatment, the patient developed chest tightness, shortness of breath, and cardiac arrest. Computed tomography (CT) scans of his upper abdomen were consistent with pancreatitis. PE was identified by chest CT angiography involving the right main pulmonary artery and multiple lobar pulmonary arteries. The patient’s D-dimer level was significantly elevated (> 20 mg/L). The patient received high-frequency oxygen inhalation, continuous renal replacement therapies, anti-infective therapy, inhibition of pancreatic secretion, emergent endotracheal intubation, and advanced cardiac life support with cardiopulmonary resuscitation. Following both ECMO and a vascular interventional procedure, the patient recovered and was discharged.
CONCLUSION PE is a rare but potentially lethal complication of AP. The early diagnosis of PE is important because an accurate diagnosis and timely interventional procedures can reduce mortality. The combined use of ECMO with a vascular interventional procedure for AP complicated by PE can be considered a feasible treatment method. A collaborative effort between multiple teams is also vital.
Collapse
Affiliation(s)
- Ling-Ling Yan
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai 317000, Zhejiang Province, China
| | - Xiu-Xiu Jin
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai 317000, Zhejiang Province, China
| | - Xiao-Dan Yan
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai 317000, Zhejiang Province, China
| | - Jin-Bang Peng
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai 317000, Zhejiang Province, China
| | - Zhuo-Ya Li
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai 317000, Zhejiang Province, China
| | - Bi-Li He
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai 317000, Zhejiang Province, China
| |
Collapse
|
|
9
|
Zheng CB, Zheng ZH, Zheng YP. Therapeutic plasma exchange for hyperlipidemic pancreatitis: Current evidence and unmet needs. World J Clin Cases 2021; 9:5794-5803. [PMID: 34368298 PMCID: PMC8316951 DOI: 10.12998/wjcc.v9.i21.5794] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/24/2021] [Accepted: 05/26/2021] [Indexed: 02/06/2023] Open
Abstract
With changes in lifestyle and diet worldwide, the prevalence of hyperlipidemic acute pancreatitis (HLAP) has greatly increased, and it has become the most common cause of acute pancreatitis not due to gallstones or alcohol. There are many available therapies for HLAP, including oral lipid-lowering agents, intravenous insulin, heparin, and therapeutic plasmapheresis (TPE). It is believed that the risk and severity of HLAP increase with rising levels of serum triglycerides (TG), thus a rapid decrease in serum TG level is the key to the successful management of HLAP. TPE has emerged as an effective modality in rapidly reducing serum TG levels. However, due to its cost and accessibility, TPE remains poorly evaluated until now. Some studies revealed its efficacy in helping to treat and prevent the recurrence, while some studies suggested that TG levels were not correlated with disease severity, mortality, or length of hospital stay. Thus TPE might have no beneficial effect for the outcome. This article gives an overview of the published evidence of TPE in the treatment of HLAP and outlines current evidence regarding individual outcome predictors, adverse effects of the procedure, and TPE in special occasions such as for pregnant patients and patients with diabetic ketoacidosis. Future direction of TPE research for HLAP is also discussed in this review.
Collapse
Affiliation(s)
- Can-Bin Zheng
- Department of Endocrine and Metabolic Disease, Shantou Central Hospital, Shantou 515031, Guangdong Province, China
| | - Zi-Hui Zheng
- Nursing College, Guangdong Pharmaceutical University, Guangzhou 510000, Guangdong Province, China
| | - Yong-Ping Zheng
- Department of Gastroenterology, Shantou Central Hospital, Shantou 515031, Guangdong Province, China
| |
Collapse
|