CASE 16790 Published on 17.06.2020

Percutaneous image guided management of pancreatic duct stones induced pancreatitis complicated with portal vein thrombosis

Section

Interventional radiology

Case Type

Clinical Cases

Authors

M.Mizandari, MD, PhD

Tbilisi State Medical University

New Hospitals LTD

12, Krtsanisi st, Tbilisi, 0144, Georgia

Patient

38 years, male

Categories
No Area of Interest ; Imaging Technique CT, Fluoroscopy, Ultrasound
Clinical History

38-years-old male patient presented with severe abdominal pain and fever in January 15, 2015. History of alcohol abuse and abdominal pain attacks in previous years has been reported. Laboratory data showed leucocytosis and severely  elevated  lipase concentration in serum. 

Imaging Findings

Pancreatic duct (PD) stones, severe upstream PD dilatation,  pancreatic pseudocyst and portal vein thrombosis (PVT) revealed. PD drainage attempted Jan 17, 2015; procedure finished with CT guided pancreatic pseudocyst drainage resulted in pancreatitis alleviation. As the PVT became symptomatic PV stent has been implanted  percutaneously  Jan 28,2015. Pancreatitis persisted, CT&Fluoroscopy guided PD external-internal drainage was performed March 27, 2015. Balloon Assisted Percutaneous Descending Litholapaxy, (BADPL procedure - PD stones are pushed down into duodenum using PD mature drainage track), performed  May 20, 2015; both catheters were withdrawn.

   PD dilation and pancreatitis recurred; pancreatic abscesses were drained - March 27, and Sept 07, 2017.  Dec 20, 2017 US&Fluoroscopy guided PD drainage was performed for BAPDL procedure planning.  3 consecutive attempts failed,  finally, BAPDL procedure was performed  Jul 26, 2018. Follow-up revealed restricture and patient finally underwent PD stent implantation Dec 12, 2018, using 8 mm diameter 6 cm partially covered self-expanding removable metal device.

Discussion

PD obstruction related chronic recurrent pancreatitis is a life-threatening condition, which may lead to significant morbidity and even mortality. Persistent high pressure in PD leads to acinar cells atrophy, islets aggregation and pancreatic parenchymal fibrotic changes which engender exocrine and endocrine insufficiency [ 1,2,3] Complications, such as peripancreatic fluid collection formation, portal vein thrombosis, biliary stricture with jaundice and cholangitis may develop in such patients. The main idea of adequate treatment of primary problem in such patients is the reestablishment of  PD and GI tract normal connection; the traditional way of it is surgery, including pancreatic duct surgical drainage, cysto-entero or pancreatic-enteroanastomosis [9, 13, 14].  In cases of concomitant complications, such as peripancreatic infected or painful cystic collections formation, PVT and biliary stricture, surgery is associated with high morbidity and low-invasive techniques should be widely used [15,17]. Low-invasive treatment means endoscopic techniques, including recently established EUS, guided PD interventions [10, 11,12] and  image-guided percutaneous techniques  [16, 18]

   The reported case shows percutaneous management of PD stone obstruction induced pancreatitis and it’s complications.  Although the drainage of  peripancreatic mass (pancreatic pseudocyst) improved the situation regarding pancreatitis , only PD to GI tract reconnection by BAPDL procedure and finally, by PD stent implantation enabled to finally withdraw the drainage catheters. Good clinical result regarding pancreatitis has been achieved shortly after PD drainages; in spite of two times performed BAPDL procedures, patient developed PD restricture, which was successfully managed by removable self-expanding metal stent percutaneous implantation, using PD drainage track. PVT also was successfully managed using percutaneous access.  The main problem-solving intervention is PD percutaneous drainage, which is  a novel approach and is performed in our clinic routinely in selected cases. In literature this procedure was reported as sporadic cases only [4,5,6,7,8]; the total number of of reported cases is 8.

   On follow-up studies (the most recent visit – Dec 18, 2019) patient is in a good general condition, presented with no pancreatitis, open PV.

Differential Diagnosis List
Recurrence of chronic calculous pancreatitis, complicated with PV thrombosis
Subhepatic abscess
Pancreatic cystic tumour
Acute pancreatitis
Recurrence of chronic calculous pancreatitis
Final Diagnosis
Recurrence of chronic calculous pancreatitis, complicated with PV thrombosis
Case information
URL: https://www.eurorad.org/case/16790
ISSN: 1563-4086