Large Bowel Obstruction, a Delayed Complication of Severe Gallstone Pancreatitis

Abstract

Colonic complications are rare after acute pancreatitis but are associated with a high mortality. Possible complications include mechanical obstruction, ischaemic necrosis, haemorrhage, and fistula. We report a case of large bowel obstruction in a 31-year-old postpartum female, secondary to severe gallstone pancreatitis. The patient required emergency laparotomy and segmental bowel resection, as well as cholecystectomy. Presentation of obstruction occurs during the acute episode or can be delayed for several weeks. The most common site is the splenic flexure owing to its proximity to the pancreas. Initial management may be conservative, stenting, or surgical. CT is an acceptable baseline investigation in all cases of new onset bowel obstruction. Although bowel obstruction is a rare complication of pancreatitis, clinicians should be aware of it due to its high mortality. Obstruction can occur after a significant delay following the resolution of pancreatitis. Those patients with evidence of colonic involvement on pancreatic imaging warrant further large bowel evaluation. Bowel resection may be required electively or acutely. Colonic stenting has an increasing role in the management of large bowel obstruction but is a modality of treatment that needs further evaluation in this setting.

Gastrointestinal tract involvement in acute pancreatitis: initial findings and follow-up by magnetic resonance imaging

“…Our results depicted the patterns and the evolution of gastrointestinal tract in AP by using MRI which may be helpful for early recognition and institution of appropriate therapy to improve the prognosis of AP. We found the prevalence of gastrointestinal tract abnormality was 63% which was higher than previous studies, in which gastrointestinal tract abnormality was exceedingly rare, and A B only isolated case reports had described them (11,12). Our results demonstrate that the prevalence of gastrointestinal tract abnormality is higher in MRI study than previous trials.…”

“…In clinical studies of intestinal complications of AP, González Jiménez et al (11) described five SAP patients who had duodenal stenosis. Lal et al (12) reported a case of large bowel obstruction in a 31-year-old postpartum female, secondary to severe gallstone pancreatitis, Liu et al (2) reported that intestinal mucosal function was injured in early phase of AP especially in patients with organ dysfunction, which may be a stimulus for development of multiple organ dysfunction and correlate with bad outcome in AP patients. Animal experiments (13) revealed that gastric emptying and intestinal peristalsis were decreased by acute necrotizing pancreatitis and undiagnosed gastrointestinal tract damage may lead to fatal outcome if an enterogenic infection occurs.…”

Gastrointestinal complications in acute and chronic pancreatitis

“…The pancreatic tail lies within the phrenoleinal and phrenocolic ligaments, which facilitates the direct extension of the pancreatic enzymes from the pancreatic tail to the splenic flexure . These enzymes, particularly lipase, cause fat necrosis, and the released fatty acids form complexes with calcium, leading to calcium deposits . Finally, fibrosis develops with progressive narrowing of the bowel lumen, resulting in proximal dilatation of the ascending and transverse colon, the “colon cut‐off sign”.…”

“…Technical advances in stenting have allowed the possible stenting of the splenic flexure region; however, placing uncovered stents in a benign condition will lead to difficulty in their subsequent removal. Self‐expanding stents may be used as a temporary measure until inflammation and obstruction improve; however, experience with other benign diseases suggests that surgery is eventually required due to primary or secondary failure of the stent …”

Colonic obstruction: a rare complication of acute pancreatitis

“…Colonic obstruction due to acute pancreatitis is rare. 1,2 The most common site for obstruction is the splenic flexure. 2 As paralytic ileus is a more frequent condition leading to similar clinical presentation, high index of clinical suspicion is required to make the diagnosis.…”