Pancreatic cancer presenting with acute pancreatitis complicated by Wernicke’s encephalopathy and a colonic fistula: a case report

Abstract

Introduction and Importance: This account details the case of a 39-year-old male patient who presented with acute necrotizing hemorrhagic pancreatitis. The comorbid conditions of Wernicke’s encephalopathy, and a pancreatic–colonic fistula developed during his care. This case is unique in that it illustrates the effects of these complications individually and through their interaction. Given that there are no firm guidelines regarding the nature and timing of interventions for a pancreatic–colonic fistula diagnosis, this case may provide helpful information. Case Presentation: As previously noted, this is the case of a 39-year-old male patient with a BMI of 46 kg/m2 who presented with acute necrotizing hemorrhagic pancreatitis. Complications developed as noted above. Multiple diagnostic imaging methods were utilized but failed to detect the presence of metastatic pancreatic adenocarcinoma. After a course of antimicrobial and nutritional therapy, we attempted surgical intervention for the pancreatic–colonic fistula and pancreatic abscess debridement. Unfortunately, during that procedure, we observed extensive carcinomatosis, at which point we did a gastrojejunostomy. Subsequently, the patient’s condition did not permit chemoradiotherapy. After completion, we transferred the patient to palliative care, where he died. Clinical Discussion: This case was complex due to the previously recounted results of the underlying condition, pancreatic adenocarcinoma, and the complications of Wernicke’s encephalopathy and pancreatic–colonic fistula. The presence of risk factors in patients increases the need to perform appropriate diagnostic tests. Even with tests and multiple imaging modalities, these particular events remain challenging to diagnose, given the nature of the development and presentation of the disease condition. It was only after the surgical intervention that the carcinoma became evident. Early screening and imaging could improve detection rates and prevent disease progression. Conclusion: In this case report of acute hemorrhagic necrotizing pancreatitis and its complications, we discuss the factors making this disease process particularly difficult to diagnose, detect, and manage. Even though the complications detailed herein are rare, in this case, the significance is the need to evaluate all patients with acute pancreatitis and acute confusion for Wernicke’s encephalopathy, which is preventable. In addition, suggestive findings on computed tomography signal the need for further investigation of the colonic fistula. Finally, at this time, there are no clear guidelines for the surgical management of these complications. We hope that this case report will contribute to their development.

Vitamin Nutritional Status in Patients with Pancreatic Cancer: A Narrative Review

“…Tabriz et al reported attainment of physiological plasma levels only 12 months after surgery [8]. Several case studies seem to indicate that after the Whipple procedure, vitamin B1 deficiency can early lead to Wernicke's encephalopathy [17] and its supplementation is necessary to restore normal cognitive functions and prevent permanent brain damage [18]. As reported in a recent case study, Wernicke's encephalopathy is an uncommon condition due to thiamine deficiency and is very rarely associated with acute pancreatitis, occurring late in the PaC course [19].…”

“…Preliminary studies suggest that thiamine deficiency may also be caused by fluorouracil-based chemotherapy [20], which is one of the most used chemotherapies for the treatment of PaC, even though these data still need to be confirmed. Furthermore, the preoperative nutrition status in pancreatoduodenectomy patients was reported to be significantly correlated with their prognosis [18].…”