siddiqui-_Opmaak 1 25/02/13 15:17 Pagina 19

JBR–BTR, 2013, 96: 19-21.

NECROTIZING COMPLICATING NECROTIZED : LOOK OUT FOR INTESTINAL PNEUMATOSIS

M.A. Siddiqui 1, A. Jain 1, S.A.A. Rizvi 2, K. Ahmad 3, E. Ullah 1, I. Ahmad 1

Acute pancreatitis is a common cause of acute and is associated with a wide variety of complica - tions. Pancreatic is one of the most important complications and is considered to be the most important indicator of disease severity as the increased frequency of death in is directly correlated with the development and extent of pancreatic necrosis. In addition to pancreatic necrosis, wide spectrums of colonic com - plications have been described, including functional and mechanical , ischemic necrosis and fistula formation. In acute pancreatitis bowel usually involves the transverse colon or the hepatic and splenic flexures and may range in severity from mild superficial mural involvement totransmural colonic necrosis. This article reports a case of large bowel as a complication of severe necrotizing pancreatitis in a 35-year-old male patient.

Key-word: Pancreatitis.

Bowel ischemia is a devastating pancreatitis, , diverticuli - we report a patient who developed disease process encompassing a tis, and . Pancreatitis is colonic infarction as a complication wide spectrum of clinical and radio - associated with wide spectrum of of acute pancreatitis. logical findings, ranging from a mild colon lesions, including ileus, self-limiting form to ischemic necrosis and fistula Case report and perforation. The conditions most formation, the reported incidence frequently leading to bowel ischemia being 1-15% among adult cases (1). A 35-year-old man presented to include vascular occlusion due to In one series, 27% of patients with the emergency department with 1- arterial or venous disease and hypo- acute pancreatitis were complicated day history of sudden onset of perfusion associated with non- by ischemic (2). Early severe epigastric pain and profuse occlusive vascular causes. Many recognition of this particular compli - vomiting. On admission his vitals other diseases may also cause such cation of acute pancreatitis is impor - were stable. He had no previous hos - vascular changes, including abdomi - tant, as it is associated with very pital admissions and no previous nal inflammatory conditions such as high morbidity and mortality. Here similar episodes, but confessed hav -

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Fig. 1. — A. Frontal CT scout view shows focal dilatation of transverse colon with paucity of proximal and distal gas shadows con - sistent with colon cut-off sign (black arrows). An ill define speckled gas shad - From: 1. Department of Radiodiagnosis, 2. Department of , Jawaharlal Nehru ow was also present in right hypochon - Medical College, A.M.U. Aligarh, India, 3. Department of Radiodiagnosis, B.P. Koirala drium (white arrow). B. CT scan with lung Institute of Health Sciences, Dharan, Nepal. window confirmed these speckled gas Address for correspondence: Dr. M.A. Siddiqui, MD, House No.7, Lane B, Hamza shadow to be mural air within wall of Colony, New Sir Syed Nagar, Civil Lines, Aligarh, India-202002. ascending colon consistent with pneu - E-mail: [email protected] matosis intestinalis. siddiqui-_Opmaak 1 25/02/13 15:17 Pagina 20

20 JBR–BTR, 2013, 96 (1)

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Fig. 2. — A. CT scan at the level of pancreas showed necrosis in head and neck region along with peripancreatic fluid (black arrows). Bowel wall thickening along with mural air can be seen within ascending colon and hepatic flexure (white arrows). B. CT scan at the level of lung base revealed bilateral pleural effusion with basal atelectasis (white arrows).

ing binged on alcohol 3 days back. of ascending colon extending up to structural and functional normalcy revealed the level of hepatic flexure was also after the attack subsides, provided abdominal distention with mild present. There was evidence of water that no part of pancreas has been right-sided tenderness but no evi - halo sign along with air within bowel destroyed by necrosis. A number of dence of peritonism. However wall suggestive of pneumatosis conditions are responsible for this, patient appeared dehydrated. intestinalis (Fig. 1B). Bilateral small the most common being choledo - Laboratory examinations including pleural effusion was also present cholithiasis and alcohol abuse. Most urine analysis, complete blood (Fig. 2B). These findings were consis - patients present with , vomit - count, liver and renal functions were tent with diagnosis of severe acute ing and abdominal pain. The diagno - within normal range except for mild pancreatitis with necrotizing colitis. sis is usually established by the leucocytosis (WBC count- Patient’s condition was relatively detection of elevated levels of pan - 28,300/mm3). Serum amylase stable considering the severity of creatic enzymes in the blood, urine, [1614 U/L (normal value < 220 U/L)] radiologic findings and conservative or both. Once the diagnosis is estab - and serum lipase [815 U/L (normal management was advised. Patient lished, the treatment of the patients value < 30 U/L)] were elevated. C was shifted to intensive care unit is based on the assessment of dis - reactive protein was also elevated at and was monitored closely. ease stage and severity. CT is used 314 mg/L. Prophylactic intravenous not only to confirm the initial diag - On erect chest radiograph, there and fluids were started. Three days nosis but also to assess the severity was no free gas under diaphragm. after admission, the patient’s condi - of attack, and detect any complica - However small bilateral pleural effu - tion remained stable. A feeding tube tions. Modified CT severity index is a sion was present. Supine Abdominal was placed and enteral feeding start - very useful scoring system that radiograph revealed focal dilatation ed. Physiologic and biochemical grades the severity of pancreatitis of transverse colon with paucity of parameters continued to improve into mild, moderate and severe. In proximal and distal gas shadows and white cell count returned nor - this index patients are given an even (Fig. 1A). An ill define speckled gas mal. A repeat CT seven days after number from 0-10 on the basis of shadow was present in right admission showed resdiual pancre - presence or absence of acute fluid hypochondrium just below liver in atic necrosis without significant peri - collections, pancreatic parenchymal the region of hepatic flexure. pancreatic fluid collections. The necrosis and extrapancreatic find - Ultrasonography of the abdomen pneumatosisintestinalis had com - ings such as pleural fluid, ascites, demonstrated absence of pletely resolved notwithstanding extrapancreatic parenchymal abnor - and any dilatation of intrahepatic some residual thickening of the wall malities, vascular complications, or bile ducts or common duct. Pancreas of the ascending colon and hepatic involvement of the gastrointestinal and adjacent region was not visual - flexure. On day 10 oral feeding was tract. Patients with a score of 8-10 ized due to excessive bowel gas. started and patient was discharged are labeled as having severe acute Computed tomography (CT) of on day 18. Patient remained asymp - pancreatitis and have worst progno - the abdomen showed heteroge - tomatic at follow-up 2 months later. sis. neous diffusely enlarged pancreas A number of systemic and loco- with surrounding fat streakiness and Discussion regional complications are seen in free fluid (Fig. 2A). Non-enhancing patients of acute pancreatitis. area consistent with necrosis was Acute pancreatitis is an acute Morbidity and mortality in acute seen in the head and neck region of inflammatory process that is fol - pancreatitis is directly associated pancreas. Circumferential thickening lowed by complete restoration of with the presence or absence of siddiqui-_Opmaak 1 25/02/13 15:17 Pagina 21

NECROTIZING COLITIS COMPLICATING NECROTIZED PANCREATITIS — SIDDIQUI et al 21

complications. Pancreatic necrosis (48%), descending colon (43%), colon is determined, resection may and colonic lesions are two such ascending colon ((23%) and sigmoid be difficult and complicated. complications associated with poor colon (13%). In our patient, the Fortunately in our case patient clinical outcome. ischemic changes were most con - remained stable and responded well Colonic complications are uncom - spicuous in the ascending colon. CT to conservative management proba - mon in the patients of acute pancre - revealed thickening of the colonic bly because of good general health atitis. A recent analysis of pooled wall with water halo sign and and young age. data reports the incidence of colonic , findings complications from acute pancreati - characteristic of transmural colonic References tis and severe acute pancreatitis as necrosis. However no evidence of 3.3 and 15%, respectively (4). hepatic portal or portomesenteric 1. Aldridge M.C., Francis N.D., Glazer G., Although uncommon, colonic venous gas was seen. Dudley H.A.: Colonic complications of lesions are important as they There are many causes of severe acute pancreatitis. Br J Surg , indicate an extensive underlying pneumatosis intestinalis. It ranges 1989, 76: 362-367. 2. Gumaste V.V., Gupta R., inflammatory process (5). Colonic from infectious, inflammatory, neo - Wasserman D., Dave P.B., Vieux U.: abnormalities associated with acute plastic, or iatrogenic mucosal injury Colonic involvement in acute pancre - pancreatitis are divided into the to increased intraluminal pressure atitis. Am J Gastroenterol , 1995, 90: following two groups from a and asthma. Furthermore, it is 640-641. pathological viewpoint: (a) Peri- important to differentiate it from 3. Takahashi Y., Fukushima J., colitisshowing lesions mainly in the pneumatosis cystoides coli, a benign Fukusato T., Shiga J., Tanaka F., serosa and subserosa, in which pan - condition of idiopathic etiology. Imamura T., Fukayama M., Inoue T., creatic inflammation has extended Benign pneumatosis often appears Shimizu S., Mori S.: Prevalence of directly through the mesentry; as cystlike collections of gas in the ischemic enterocolitis in patients with acute pancreatitis . J Gastroenterol , (b) Ischemic colitis, i.e., ischemic bowel submucosa, while curvilinear, 2005, 40: 827-832. changes in mucosa, subucosa and more circumferential gas collections 4. Mohamed S.R., Siriwardena A.K.: tunica muscularis, developing into is often considered as characteristic Understanding the colonic complica - colonic necrosis and perforation in of bowel infarction. tions of pancreatitis. Pancreatology , severe cases (6). Ischemic colitis is The management of colonic 2008, 8: 153-158. considered to result from a number complications of severe acute 5. Thompson W.M., Kelvin F.M., of underlying patho-physiological pancreatitis relies on a high index of Rice R.P.: Inflammation and necrosis mechanisms like congestion of suspicion because the clinical of the transverse colon secondary to blood flow due to compression by presentation is varied, nonspecific, pancreatitis . AJR , 1977, 128: 943-948. 6. Yamagiwa I., Obata K., Hatanaka Y., severe in the mesentery, and could occur quite late in the Saito H., Washio M.: Ischemic colitis formation in the mesen - disease process (4). Because such complicating severe acute pancreati - teric vessels, disseminated intravas - cases mainly have been reported as tis in a child. J Pediatr Gastroenterol cular coagulopathy and, decreased case reports and series, there are no Nutr , 1993, 16: 208-211. blood pressure (7). Aldridge et al. evidence-based guidelines for 7. Wiesner W., Khurana B., Ji H., Ros P.: reported transverse colon as the management (4). Although surgical CT of Acute Bowel Ischemia. most common site of involvement intervention remains the choice of Radiology , 2003, 226: 635-665. (63%) followed by splenic flexure treatment when nonviability of the