Acute Portal Vein Thrombosis and Massive

Velayutham Vimalraj
1
, Satyanesan Jeswanth
1
, Devy Gounder Kannan
1
, Colonel S Krishnan
2
,
Rajagopal Surendran
1
1
Department of Surgical, Gastroenterology and Center for G.I. Bleed and Division of Hepato
Biliary Pancreatic Diseases, Government Stanley Medical College Hospital;
2
Department of
Medical Gastroenterology, Apollo Hospitals. Chennai, Tamilnadu, India
ABSTRACT
Context ERCP can provide information
which is invaluable in managing chronic
pancreatitis but it is associated with
infrequent,
although
significant,
complications and rare mortality. The
complications uniquely associated with
diagnostic ERCP include pancreatitis and
sepsis (primary cholangitis).
Case report A 32-year-old man presented
with severe upper abdominal pain radiating to
the back, associated with vomiting and
abdominal distension. The patient was
diagnosed as having had chronic calcific
pancreatitis recently and had undergone
ERCP with pancreatic duct stenting
elsewhere. Two days after the procedure, the
patient developed severe abdominal pain,
vomiting and abdominal distention, and
patient was referred to our hospital 7 days
after the procedure. Investigation revealed
massive liver necrosis and portal vein
thrombosis. This patient had a life-threatening
complication following pancreatic duct
stenting for chronic pancreatitis and was
managed medically.
Conclusion
Therapeutic
pancreatic
endoscopy procedures are technically
demanding and should be restricted to high
volume centers. There is a continuing need
for evaluation and comparison with
alternative strategies. In a good surgical
candidate, it is better to avoid stenting.
INTRODUCTION
ERCP can provide information which is
invaluable in managing chronic pancreatitis
but it is associated with infrequent, although
significant, complications and rare mortality.
The complications uniquely associated with
diagnostic ERCP include pancreatitis and
sepsis (primary cholangitis). We report an
unusual complication after stenting for
chronic pancreatitis, acute portal vein
thrombosis and massive necrosis of the liver.
CASE REPORT
A 32-year-old man presented with severe
upper abdominal pain radiating to the back,
associated with vomiting and abdominal
distension. The patient was diagnosed as
having had chronic calcific pancreatitis
recently (Figure 1) and had undergone ERCP
with pancreatic duct stenting elsewhere. Two
days after the procedure, the patient
developed severe abdominal pain, vomiting
and abdominal distention and patient was
referred to our hospital seven days after the
procedure.

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661
On admission, the patient was febrile,
dehydrated, and icteric. Abdominal
examination revealed distension, diffuse
tenderness and free fluid. Liver function tests
showed elevated bilirubin (18 mg/dL;
reference range: 0.4-0.8 mg/dL), SGOT (800
IU/L; reference range: 0-41 IU/L), SGPT
(1,000 IU/L; reference range: 0-31 IU/L),
serum alkaline phosphatase (400 IU/L;
reference range: 100-290 IU/L), serum total
protein (6.2 g/dL; reference range: 4.0-6.0
g/dL) and albumin (2.4 g/dL; reference range:
2.0-4.0 g/dL). Serum amylase was 1,400 IU/L
(reference range: 0-96 IU/L) and serum lipase
was 600 IU/L (reference range: 0-190 IU/L).
Upon trans-abdominal ultrasound examin-
ation, the liver showed a diffuse coarsening of
echo texture. The intra- and extra-hepatic
biliary passages were not dilated. The
pancreas was enlarged with multiple calculi in
the pancreatic duct. There was evidence of
peri-pancreatic fluid collections. A contrast-
enhanced computerized tomogram revealed
an enlarged pancreas, the pancreatic duct was
prominent and multiple peripancreatic fluid
collections were noted (Figure 2). The liver
showed an ill-defined hypodense area in
segments VI and VII. There was evidence of
thrombus in the right and the left branches of
the main portal vein and splenic vein (Figures
3 and 4). The superior mesenteric vein was
Figure 1. Pre-procedural magnetic resonance
cholangiopancreatography shows a dilated main
pancreatic duct and secondary ducts.
Figure 3. Abdominal CT scan showing massive liver
necrosis; splenomegaly is also noted.
Figure 2. Abdominal CT scan showing acute
pancreatitis with peripancreatic fluid collections.
Figure 4. Abdominal CT scan showing portal vein
thrombosis.

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JOP. J Pancreas (Online) 2006; 7(6):660-664.
JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 7, No. 6 - November 2006. [ISSN 1590-8577]
662
not thrombosed. Splenomegaly, gross ascites
and bilateral pleural effusion were noted.
Upper gastrointestinal endoscopy revealed no
varices but pus was pouring out of the
ampulla; hence, an ERCP was carried out and
a biliary stent was placed. There was no leak
noted in the pancreatic duct. Ascitic fluid
amylase was 200 IU/L. The patient was
managed medically by intravenous fluids, a
nasogastric tube, fresh frozen plasma and
broad-spectrum antibiotics. Fourteen days
after the procedure, the patient developed a
fever with rigidity and generalized edema of
both lower limbs. The ascitic fluid was sent
for culture and sensitivity, and appropriate
antibiotics given. The fever abated, but ascites
persisted. Fresh frozen plasma and antibiotics
were continued. Two months post-procedure,
the patient developed abdominal pain and
fever (high grade with rigors). An ultrasound
revealed a focal organized septate collection
in the umbilical region and the pelvis. The
collection was aspirated by ultrasound
guidance, pus was sent for culture and
sensitivity, and appropriate antibiotics were
started. The patient’s general condition
improved and abdominal distension
decreased. Liver function tests returned to
normal. Three months post-procedure, a
contrast-enhanced computerized tomogram
(CECT) was carried out; it revealed an
enlarged liver with an ill-defined hypodense
lesion in the right lobe of the liver. The rest of
the liver was normal. The hepatic veins were
normal. The spleen was enlarged. The portal
vein and splenic veins were not visualized.
Multiple collateral vessels were seen at the
splenic hilum, short gastric and left gastric
regions. The pancreatic parenchyma thinned
out with a dilated MPD and calculi. Upper
gastrointestinal endoscopy showed no varices.
Although this patient is asymptomatic at
present and is on follow-up, he may need
surgery after completely recovering from the
crisis.
DISCUSSION
ERCP plays an important diagnostic and
therapeutic role in the management of chronic
pancreatitis. The ultimate role of these
therapeutic interventions for chronic
pancreatitis will depend upon prospective
randomized data demonstrating their efficacy
and safety in comparison to surgery [1].
Although ERCP can provide information
which is invaluable in managing chronic
pancreatitis, it is associated with infrequent,
although significant, complications and rare
mortality. The complications uniquely
associated with diagnostic ERCP include
pancreatitis and sepsis (primary cholangitis).
Post-ERCP pancreatitis is associated with
multiple forceful pancreatic duct injections,
normally while the clinician is struggling with
a difficult cannulation [2].
The importance of post ERCP pancreatitis
cannot be overstated. Prospective studies have
reported an overall pancreatitis rate of 1-15%
[3, 4, 5, 6, 7, 8, 9]. Most cases are mild, but
severe, life-threatening pancreatitis can occur.
Diagnostic ERCP is associated with a 1.38%
complication rate and 0.21% mortality. On
the other hand, therapeutic ERCP was
associated with a 5.8% incidence of major
complications and a 0.49% mortality rate.
Other than pancreatitis and cholangitis, the
major complications seen after therapeutic
ERCP include hemorrhage, duodenal
perforation (with retro-peritoneal sepsis) and
several other rare complications [10].
Our patient developed severe acute
pancreatitis after ERCP and pancreatic duct
stenting, and developed a rare life-threatening
complication due to sequelae of acute
pancreatitis. Yamashita et al. reported hepatic
infarction together with a portal thrombus in a
patient with chronic pancreatitis and cirrhosis;
this patient died from hepatic failure and the
autopsy revealed splenic and portal vein
thrombosis, multiple hepatic infarction and
evidence of chronic pancreatitis. they reported
that the main risk factors of portal thrombosis
are liver cirrhosis and chronic pancreatitis;
our patient had chronic pancreatitis, but did
not have portal vein thrombosis in the pre-
procedural investigations [11].
We were the first to report another rare but
life-threatening complication presenting as
massive hemoptysis following ERCP and
ESWL in a patient with chronic pancreatitis,

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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 7, No. 6 - November 2006. [ISSN 1590-8577]
663
which was due to a splenic artery pseudo
aneurysm. This patient needed surgical
management for correction of the problem
[12].
The potential application of endoscopic
treatment is limited to a subgroup of patients
with amenable pancreatic ductal anatomy.
These are patients with dilated pancreatic
ducts who also have a single dominant
stricture or obstructing stone in the head of
pancreas, with dilation of the duct upstream to
the stone or stricture [13]. Our patient had
multiple stones and a dilated pancreatic ductal
system making him a good surgical candidate
and stenting was perhaps not the correct
choice.
In a surgical candidate, pre-operative
pancreatic stents increase operative mortality.
Patients undergoing pancreatic stenting who
require surgical drainage at a later point have
a threefold increased risk for peri-operative
complications. An increase in intra-abdominal
complications is related to stent associated
pancreatic duct injuries, stent occlusion and
bacterial colonization of the stent. [14].
Therapeutic pancreatic endoscopy procedures
are technically demanding and should be
restricted to high volume centers; there is a
continuing need for evaluation and
comparison with alternative strategies [15]. In
a good surgical candidate, it is better to avoid
stenting.
Received September 10
th
, 2006 - Accepted
October 2
nd
, 2006
Keywords
Cholangiopancreatography,
Endoscopic Retrograde; Massive Hepatic
Necrosis; Pancreatitis, Chronic
Correspondence
Rajagopal Surendran
Department of Surgical Gastroenterology
Government Stanley Medical college Hospital
Chennai 600001
Tamilnadu
India
Phone: +91-44.2528.1354
Fax: +91-44.2528.1354
E-mail: stanleygastro@yahoo.com
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