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Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0b013e31824cf56d
Images of the Month

Severe Ischemic Pancreatitis Following the Use of Extracorporeal Membrane Oxygenation

Akbar, Ali*; Baron, Todd H.*; Freese, Deborah K.

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*Division of Gastroenterology and Hepatology

Department of Pediatric Gastroenterology, Mayo Clinic, Rochester, MN.

Address correspondence and reprint requests to Todd H. Baron, MD, 200 First Street SW, Rochester, MN 55905 (e-mail:

The authors report no conflicts of interest.

Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal.

A previously healthy 6-year-old boy developed H1N1 pneumonia, acute respiratory distress syndrome, and multiorgan failure requiring extracorporeal membrane oxygenation (ECMO) for 54 days and a 2-year hospitalization. Episodes of acute pancreatitis subsequently developed complicated by pseudocyst formation. He presented 14 months later with continued acute recurrent pancreatitis. There was no family history of pancreatitis. Magnetic resonance cholangiopancreatography revealed dilated intra- and extrahepatic bile ducts with a distal filling defect, pancreatic atrophy, and ductal dilation (Fig. 1). Endoscopic retrograde cholangiopancreatography revealed severe chronic pancreatitis by Cambridge classification (1) with diffuse main duct and side branch irregularities with intraductal filling defects. Both biliary and pancreatic sphincterotomies were performed with removal of a biliary cast and small pancreatic duct stones, balloon dilation of the dominant pancreatic duct neck stricture (Fig. 2) followed by placement of a 7-F stent. He was clinically improved 2 months later.

Figure 1
Figure 1
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Figure 2
Figure 2
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ECMO is sometimes used in infants for respiratory distress and persistent pulmonary hypertension. Ischemic cholangiopathy (2) occurs in adults with hepatic artery thrombosis and in critically ill patients; some develop secondary sclerosing cholangitis (3). We believe this case may represent ECMO-induced ischemic acute and chronic pancreatitis. This has not been previously reported and clinicians should be aware of this potential association.

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1. Sarner M, Cotton PB. Classification of pancreatitis. Gut 1984; 25:756–759.

2. Deltenre P, Valla DC. Ischemic cholangiopathy. J Hepatol 2006; 44:806–817.

3. Gelbmann CM, Rümmele P, Wimmer M, et al. Ischemic-like cholangiopathy with secondary sclerosing cholangitis in critically ill patients. Am J Gastroenterol 2007; 102:1221–1229.

Copyright 2012 by ESPGHAN and NASPGHAN


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