ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI An Unusual Cause of Abdominal Pain in an Elderly Woman Anupam Lal, Pankaj Gupta, and Saroj Kant Sinha Department of Radiodiagnosis and Imaging and Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Question: A 70-yearold woman presented with acute epigastric pain radiating to the back associated with difficulty in breathing. There were few episodes of vomiting over the last 2 days. There was no associated fever or jaundice. No similar episodes had been reported previously. On examination, there was mild pallor. No icterus was present. Abdominal examination revealed mild tenderness in the epigastrium. Other findings on systemic examination were a dull note on the left side of chest with added sounds on auscultation. Total (1.8 mg/dL) and direct bilirubin (1.2 mg/dL) were mildly elevated. Routine hematologic investigations were unremarkable except for mild anemia (10 g/dL). There was elevation of serum amylase (660 IU/L). A diagnosis of acute pancreatitis was considered. Abdominal ultrasonography failed to visualize the pancreas. However, there were no gallstones. Other workup for acute pancreatitis, including history of alcohol/ drug intake, lipid profile, and serum calcium, was negative. Contrast-enhanced multidetector (MD)CT of the abdomen revealed bulky pancreas (Figure A, B, arrows) in an abnormal position. Similarly, the collapsed stomach (Figure A, short arrows) and spleen (Figure A, B, arrow head) was found in an abnormal position. The superior mesenteric artery (Figure A, thin arrow) showed an abnormal orientation. There was mild dilatation of the common bile duct (Figure B, long thin arrow) and the main pancreatic duct (Figure B, long thick arrow). What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.11.036
Gastroenterology 2015;148:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 6: Paraesophageal Hiatal Hernia With Volvulus of Stomach and Pancreas Causing Acute Pancreatitis Hiatal hernia is characterized by transient or permanent migration of the stomach into the thoracic cavity via the esophageal hiatus of the diaphragm. Colon, small intestine, omentum, and spleen are the most commonly herniated organs and associated complications that have been reported include gastric volvulus with or without perforation, incarceration or strangulation of small or large bowel, and acute appendicitis in the setting of malrotation and splenic torsion.1 Herniation of pancreas has been described in a few case reports.2,3 Pancreatitis occurring secondary to this event are rare and is a rather uncommon cause of pancreatitis. Proposed mechanisms for acute pancreatitis in the setting of pancreatic herniation include vascular compromise related to abnormal pancreatic traction, total incarceration of pancreas without volvulus, parenchymal trauma caused by intermittent herniation, and main pancreatic duct folding and resultant obstruction to drainage.3 MDCT is the modality of choice in the preoperative evaluation. It allows the visualization of diaphragmatic defect and the contents of the hernia. As in the present case, unusual contents and complications are diagnosed easily on CT. Multiplanar reformatted images allow a detailed visualization of the anatomy. It is recommended that CT should be performed during a symptomatic period because spontaneous reduction of the contents, including pancreas, to their normal anatomic position is possible.3 The patient was managed conservatively for pancreatitis and improved within a weeks’ time with normalization of serum amylase and lipase levels. Patient refused any kind of operative intervention.
References 1. 2. 3.
e12
Boyce K, Campbell W, Taylor M. Acute pancreatitis secondary to an incarcerated paraoesophageal hernia: a rare cause for a common problem. Clin Med Insights Case Rep 2014;7:25–27. Kafka NJ, Leitman M, Tromba J. Acute pancreatitis secondary to incarcerated paraoesophageal hernia. Surgery 1994; 115:653–655. Chevallier P, Peten E, Pellgrino C, et al. Hiatal hernia with pancreatic volvulus: a rare cause of acute pancreatitis. AJR Am J Roentgenol 2001;177:373–374.
Question: A 70-yearold woman presented with acute epigastric pain radiating to the back associated with difficulty in breathing. There were few episodes of vomiting over the last 2 days. There was no associated fever or jaundice. No similar episodes had been reported previously. On examination, there was mild pallor. No icterus was present. Abdominal examination revealed mild tenderness in the epigastrium. Other findings on systemic examination were a dull note on the left side of chest with added sounds on auscultation. Total (1.8 mg/dL) and direct bilirubin (1.2 mg/dL) were mildly elevated. Routine hematologic investigations were unremarkable except for mild anemia (10 g/dL). There was elevation of serum amylase (660 IU/L). A diagnosis of acute pancreatitis was considered. Abdominal ultrasonography failed to visualize the pancreas. However, there were no gallstones. Other workup for acute pancreatitis, including history of alcohol/ drug intake, lipid profile, and serum calcium, was negative. Contrast-enhanced multidetector (MD)CT of the abdomen revealed bulky pancreas (Figure A, B, arrows) in an abnormal position. Similarly, the collapsed stomach (Figure A, short arrows) and spleen (Figure A, B, arrow head) was found in an abnormal position. The superior mesenteric artery (Figure A, thin arrow) showed an abnormal orientation. There was mild dilatation of the common bile duct (Figure B, long thin arrow) and the main pancreatic duct (Figure B, long thick arrow). What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.
Conflicts of interest The authors disclose no conflicts. © 2015 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2014.11.036
Gastroenterology 2015;148:e11–e12
ELECTRONIC CLINICAL CHALLENGES AND IMAGES IN GI Answer to Image 6: Paraesophageal Hiatal Hernia With Volvulus of Stomach and Pancreas Causing Acute Pancreatitis Hiatal hernia is characterized by transient or permanent migration of the stomach into the thoracic cavity via the esophageal hiatus of the diaphragm. Colon, small intestine, omentum, and spleen are the most commonly herniated organs and associated complications that have been reported include gastric volvulus with or without perforation, incarceration or strangulation of small or large bowel, and acute appendicitis in the setting of malrotation and splenic torsion.1 Herniation of pancreas has been described in a few case reports.2,3 Pancreatitis occurring secondary to this event are rare and is a rather uncommon cause of pancreatitis. Proposed mechanisms for acute pancreatitis in the setting of pancreatic herniation include vascular compromise related to abnormal pancreatic traction, total incarceration of pancreas without volvulus, parenchymal trauma caused by intermittent herniation, and main pancreatic duct folding and resultant obstruction to drainage.3 MDCT is the modality of choice in the preoperative evaluation. It allows the visualization of diaphragmatic defect and the contents of the hernia. As in the present case, unusual contents and complications are diagnosed easily on CT. Multiplanar reformatted images allow a detailed visualization of the anatomy. It is recommended that CT should be performed during a symptomatic period because spontaneous reduction of the contents, including pancreas, to their normal anatomic position is possible.3 The patient was managed conservatively for pancreatitis and improved within a weeks’ time with normalization of serum amylase and lipase levels. Patient refused any kind of operative intervention.
References 1. 2. 3.
e12
Boyce K, Campbell W, Taylor M. Acute pancreatitis secondary to an incarcerated paraoesophageal hernia: a rare cause for a common problem. Clin Med Insights Case Rep 2014;7:25–27. Kafka NJ, Leitman M, Tromba J. Acute pancreatitis secondary to incarcerated paraoesophageal hernia. Surgery 1994; 115:653–655. Chevallier P, Peten E, Pellgrino C, et al. Hiatal hernia with pancreatic volvulus: a rare cause of acute pancreatitis. AJR Am J Roentgenol 2001;177:373–374.
