A case of widespread aortic thrombosis secondary to acute severe pancreatitis

Abstract

A 29-year-old male was admitted with a 3-day history of increasing epigastric and back pain. With a raised serum amylase within the diagnostic limits for acute pancreatitis and with deranged liver function tests, the patient was started on the standard treatment for acute pancreatitis. This included intravenous fluids, oxygen, urine output monitoring with strict fluid balance charting, a proton-pump inhibitor, venous thromboembolism prophylaxis and antibiotics (in accordance with our local policy).An abdominal computer tomography (CT) scan performed two days after admission showed widespread necrotising pancreatitis. The patient deteriorated subsequently, becoming increasingly hypoxic and requiring intubation and ventilation. He was transferred to our unit for further care.The CT scan also revealed the presence of multiple thrombi throughout the length of the aorta. A CT aortogram was therefore performed after the patient was stabilised. This showed extensive arterial thrombus throughout the arch vessels and thoracic and abdominal aorta (Fig 1). The CT demonstrated thrombus present at the origin of the right innominate and left common carotid artery, and two separate large areas of thrombus present in the proximal and mid descending thoracic aorta. Further thrombus was present at the diaphragmatic hiatus, with yet more thrombus in the juxtarenal abdominal aorta, extending into the origin of the left renal artery. The coeliac trunk, splenic artery, common hepatic artery and superior mesenteric artery were unaffected. A thrombophilia screen was performed and was normal.The patient had a complicated past medical history, suffering from chronic pain syndrome since his early childhood, with widespread joint and muscle involvement. As such, he had been extensively investigated by rheumatologists, orthopaedic surgeons and psychiatrists. He was a heavy smoker and had been housebound for the previous two years.A CT scan had been performed one year prior to this episode as part of haematological investigations into the cause of a lymphocytosis. This did not show any evidence of aortic thrombus at that time (Fig 2). It would therefore seem likely that the cause of the widespread aortic thrombus formation was acute severe pancreatitis. The alternative is that the acute pancreatitis was secondary to the aortic thrombosis and visceral ischaemia. However, this is improbable as the coeliac trunk, superior mesenteric artery and their main branches were patent on the CT scan.The patient was anticoagulated with an intravenous heparin infusion on the basis that the risk from propagation of the aortic thrombus was greater than that of bleeding from his necrotic pancreas. The patient was successfully managed non-operatively on the intensive care unit for a total of eight days before being moved to the ward. Intravenous heparin infusion was then converted to subcutaneous low-molecular weight heparin at treatment dose. He continued to improve and was transferred back to the referring hospital for further management, including a cholecy...

Trombosis de arteria mesentérica superior y arteria hepática secundaria a pancreatitis aguda necrotizante: reporte de caso y revisión de la literatura

“…Las trombosis arteriales son la complicación vascular más infrecuente de la pancreatitis; un estudio prospectivo que buscó evaluar las complicaciones arteriales de 189 pacientes con pancreatitis aguda no encontró trombosis arteriales (10) y los reportes de estas complicaciones han sido limitados a series de casos. Durante la revisión de la literatura, se encontraron reportes de caso de trombosis de la arteria mesentérica superior (11,12) , arterias renales (13) , trombosis aórtica (14) y del tronco celíaco (15) . No se encontraron reportes de arteria hepática.…”

Clinical effects of low-molecular-weight heparin combined with ulinastatin in children with acute pancreatitis

“…Experimental and clinical studies [15,16] have found that LMWH can lower the expression of tumour necrosis factor-α and interleukin-6; reduce the risk of microthrombus formation; relieve microcirculatory issues in the pancreas, kidney, lung, and brain; and lower the fatality rate in patients with severe acute pancreatitis by down-regulating the expression of serum endothelin-I and the activity of NF-κB. Mishreki et al [17] compared the curative effects and safety of LMWH and unfractionated heparin in the treatment of deep venous thrombosis and found that LMWH had a better curative effect and better safety.…”

Vascular complications of pancreatitis

“…Cases reported thrombus development in the abdominal aorta and its branches, such as the superior mesenteric artery and renal arteries. A case report showed widespread aortic thrombi with sparing of the celiac trunk, splenic artery, common hepatic artery, and superior mesenteric artery[ 24 ]. Arterial thrombosis in pancreatitis can be unpredictable, with a case presenting with intracardiac thrombus following pancreatitis.…”