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Abstracts: CLINICAL VIGNETTES/CASE REPORTS - BILIARY/PANCREAS

Hemodynamic Instability Secondary to Inferior Vena Cava Compression: A Rare Complication of Massive Walled-off Pancreatic Necrosis

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Javaid, Toseef MD1; Siddiqui, Nauman MD2; Hasan, Syed MD1; Saleh, Jamal MD2; Baskara, Arunkumar MD3; Nawras, Ali MD, FACG4

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American Journal of Gastroenterology: October 2015 - Volume 110 - Issue - p S114-S115
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Severe acute pancreatitis has significant morbidity and mortality and is often complicated by pancreatic necrosis. Walled-off pancreatic necrosis (WOPN) may form as a sequelae of acute pancreatitis over the following weeks. Most uncomplicated acute pancreatic fluid collections are managed conservatively unless symptomatic or infected. We present a rare complication of WOPN causing IVC compression leading to shock requiring emergent intervention.

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Figure 1

A 56 year old male with a history of alcoholism presented with right lower quadrant abdominal pain and a significant elevation of amylase and lipase. Initial CT scan showed moderate necrosis at the head of the pancreas with a moderate fluid collection in the right half of the abdominal cavity. MRCP showed a dilated main pancreatic duct proximally with distal tapering towards the tail of the pancreas and stone in the main pancreatic duct. Despite a week of conservative treatment with fluids, bowel rest and pain control, the patient continued to have worsening abdominal pain. A repeat CT scan showed an interval increase in fluid collection compared to prior exam. At this time, endoscopic intervention was deferred as pancreatic necrosis was not walled off. However, the patient developed progressively worsening abdominal distention over the following week followed by sudden onset respiratory distress and hemodynamic instability on 18th day from initial presentation. The patient was transferred to the intensive care unit and CT scan showed a massive walled-off pancreatic necrosis causing compression of inferior vena (image 1 a & b) and right hydronephrosis (image1c) with large amount of necrotic fluid in right retronephric space displacing right kidney anteriorly. An emergent CT guided percutaneous drainage was performed with significant improvement in fluid collection (image 2) and patient's vital signs and respiratory distress over next 24hours.

Fluid output from percutaneous drain slowly decreased over next few days as the patient continued to recover. Compression of IVC by a large walled-off pancreatic necrosis is a rare potential cause of hemodynamic instability in a patient with severe acute pancreatitis.

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