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A case of chronic pancreatitis with difficult control of persistent pancreatic ascites
Abstracts / Pancreatology 16 (2016) S1eS192
patients underwent 13C-urea breath test. The study included 30 healthy persons. Results: Patients infected with Hp had more severe abdominal pain than in the absence of bacteria. We recorded significantly higher indices of a-amylase, urine pancreatic isoamylase, blood lipase. Frequency of reducing fecal elastase-1 was equal to 66.7% in the group Hp+ and 50.0% in the Hpgroup.Sonography in the group Hp+ frequently detected prevalence of low echogenicity on the background of heterogeneous structure of the pancreas, which was confirmed by the significantly lower L index upon ultrasound histography as compared with the group Hp-. Conclusions: Patients with CAP, infected with Hp, have more intense abdominal pain, “deviation” of enzymes to the blood, violation of exocrine pancreatic function and its more evident structural changes. This could be the substantiation for the inclusion of Hp eradication in a therapy.
P-260.
S161
patient's acute pancreatitis were seen. The pancreatic stones had not changed in size and position compared with the observations of the CT scans from two months previously. Endoscopy revealed a huge duodenal ulcer located on the inferior duodenal angle, which was not seen on ERCP two months previously and was compatible with the cause of the patient's abdominal pain. Fasting with PPI administration improved the duodenal ulcer. A combination study using endoscopy and contrast imaging confirmed the fistula between the duodenal ulcer and the pancreatic branch duct. The fistula was thought to be induced by hypertension of the branch duct. As the stricture of the pancreas head had caused ductal hypertension downstream including the branch duct, a 7-Fr plastic stent was inserted into the MPD. Fortunately, the patient's status gradually improved. After discharge from hospital, the patient has remained symptom-free with her duodenal ulcer improving at present. Conclusion: We encountered a case of duodenal ulcer thought to be induced by pancreatic ductal hypertension. A combination study using endoscopy and contrast imaging was useful for diagnosis. Dilation of the stenosis of the pancreatic head by a plastic stent was sufficient to enable the patient to recover.
Hemosuccus pancreaticus in chronic pancreatitis Hirotaka Okamoto 1, 2, Kazuo Miura 1, 3, Hiromichi Kawaida 1, Jun Itakura 1, Hideki Fujii 1 1 Department of Gastrointestinal Surgery, University of Yamanashi, Japan 2 Department of Surgery, Tsuru Municipal Hospital, Japan 3 Department of Surgery, Kanoiwa General Hospital, Japan
Background: Hemosuccus pancreaticus (HP) is a rare and potentially life threatening clinical entity. Its diagnosis is often difficult partly because of its rarity and its anatomical location and also because the bleeding is often intermittent. Purpose: In this study, we discuss the diagnosis and treatment of HP with a review of the literature including our clinical experience. Patients: Case-1:：A 47-year-old Japanese male had a past history of a lateral pancreaticojejunostomy (Puestow procedure) for chronic pancreatitis at age 31. He admitted our hospital with severe tarry stools. Emergent intestinal fiberscopy was performed, and no abnormal lesions were found in the upper and lower intestine. Case-2:：A 45-year-old Japanese male had been treated by medication for chronic pancreatitis and gastroduodenal peptic ulcer. The patient had a complaint of hematomesis and emergent gastrointestinal endoscopy revealed massive duodenal bleeding. Emergent distal gastrectomy was performed. However, he was re-admitted with a recurrent severe anemia. Results: Case 1:：The patient went into hemodynamic shock and subsequently underwent laparotomy. Intra-operative endoscopy through an incision in the reconstructed jejunal loop revealed massive bleeding. Longitudinal jejunotomy was performed and the bleeding point was sutured and ligated. Case 2:：Angiography revealed aneurysm of the distal pancreatic artery. Distal pancreatectomy and splenectomy were performed. The resected specimen revealed that the splenic artery had ruptured into the pseudocyst. Conclusion: There is no consensus on the need for surgery to achieve a complete cure. Emergent surgery is required in patients with recurrent bleeding or failed first-line therapy such as embolization, or stenting.
P-262. A case of chronic pancreatitis with difficult control of persistent pancreatic ascites Yu Sato, Yosuke Kawasaki, Takaaki Tokuda, Megumi Matsushita, Akira Kusakabe, Ayako Sakai, Hirotsugu Saiki, Mina Kato, Chihiro Hibino, Yuki Tokuda, Aya Ishimi, Tomoyo Kawai, Mina Hamano, Miho Chiba, Kosaku Maeda, Katsumi Yamamoto, Masafumi Naito, Toshifumi Ito Department of Gasteroenterology, JCHO Osaka Hospital, Japan Persistent pancreatic ascites is a rare complication in a chronic pancreatitis patient. There are supposed to be a fistula from either pancreatic ducts or pancreatic pseudo-cysts to abdominal cavity. It should be suspected when ascites amylase level rises more than 1000U/L. It is wellknown how difficult to treat such conditions using medical therapies, endoscopic procedures and surgical ones.We reported a case of 75 year-old male with alcoholic chronic pancreatitis with massive ascites. His ascites was diagnosed to be exudative with elevated amylase (6177U/L). Computed tomography showed a pancreatic pseudocyst in pancreatic tail. Under consideration to perform endoscopic approaches, we found intra-pseudocystic hemorrhage feeding from left gastric artery. 5 days after cease of the bleeding using interventional radiological embolization, endoscopic retrograde pancreatography (ERP) was done to show fistula from the pseudocyst to Winslow's foramen. First a short plastic stent was inserted through Papilla Vateri to the main pancreatic duct to reduce duct pressures. The pseudocyst was gradually reducing, but ascites was not appretnly decreased. 24 days after, endoscopic nasal pancreatic drainage was done. Following this procedure, ascites was getting smaller. Again short plastic stent was applied, and then the patient was discharged. One month after the discharge, computed tomography revealed neither pseudocyst nor ascites in this patient, then the plastic stent was removed. These serial endoscopic procedures for this case were effective to control persistent pancreatic ascites of a patient with chronic pancreatits.
P-261. Duodenal ulcer caused by pancreatic ductal hypertension with chronic pancreatitis Akira Imoto, Daisuke Masuda, Atsushi Okuda, Wataru Takagi, Saori Onda, Tatsushi Sano, Takeshi Ogura, Kazuhide Higuchi Second Department of Internal Medicine, Osaka Medical College, Japan Case: A 67-year-old woman complained of continuous upper abdominal pain. Her medical history included idiopathic chronic pancreatitis. From CT performed on the day of admission, no evident changes in the
P-263. A case of acute cholangitis caused by impaction of pancreatic duct stones in the ampulla of papilla Vater Eiji Kimura, Maiko Murata, Kazuhiro Kozumi, Saki Kitano, Fumihiko Sano, Eri Yoshida, Ryoutaro Uema, Eri Tsumano, Akinori Shimayoshi, Mai Horie, Taro Oshima, Syunsuke Yamamoto, Masanori Miyazaki, Satoshi Egawa, Masahide Oshita Osaka Police Hospital, Japan
patients underwent 13C-urea breath test. The study included 30 healthy persons. Results: Patients infected with Hp had more severe abdominal pain than in the absence of bacteria. We recorded significantly higher indices of a-amylase, urine pancreatic isoamylase, blood lipase. Frequency of reducing fecal elastase-1 was equal to 66.7% in the group Hp+ and 50.0% in the Hpgroup.Sonography in the group Hp+ frequently detected prevalence of low echogenicity on the background of heterogeneous structure of the pancreas, which was confirmed by the significantly lower L index upon ultrasound histography as compared with the group Hp-. Conclusions: Patients with CAP, infected with Hp, have more intense abdominal pain, “deviation” of enzymes to the blood, violation of exocrine pancreatic function and its more evident structural changes. This could be the substantiation for the inclusion of Hp eradication in a therapy.
P-260.
S161
patient's acute pancreatitis were seen. The pancreatic stones had not changed in size and position compared with the observations of the CT scans from two months previously. Endoscopy revealed a huge duodenal ulcer located on the inferior duodenal angle, which was not seen on ERCP two months previously and was compatible with the cause of the patient's abdominal pain. Fasting with PPI administration improved the duodenal ulcer. A combination study using endoscopy and contrast imaging confirmed the fistula between the duodenal ulcer and the pancreatic branch duct. The fistula was thought to be induced by hypertension of the branch duct. As the stricture of the pancreas head had caused ductal hypertension downstream including the branch duct, a 7-Fr plastic stent was inserted into the MPD. Fortunately, the patient's status gradually improved. After discharge from hospital, the patient has remained symptom-free with her duodenal ulcer improving at present. Conclusion: We encountered a case of duodenal ulcer thought to be induced by pancreatic ductal hypertension. A combination study using endoscopy and contrast imaging was useful for diagnosis. Dilation of the stenosis of the pancreatic head by a plastic stent was sufficient to enable the patient to recover.
Hemosuccus pancreaticus in chronic pancreatitis Hirotaka Okamoto 1, 2, Kazuo Miura 1, 3, Hiromichi Kawaida 1, Jun Itakura 1, Hideki Fujii 1 1 Department of Gastrointestinal Surgery, University of Yamanashi, Japan 2 Department of Surgery, Tsuru Municipal Hospital, Japan 3 Department of Surgery, Kanoiwa General Hospital, Japan
Background: Hemosuccus pancreaticus (HP) is a rare and potentially life threatening clinical entity. Its diagnosis is often difficult partly because of its rarity and its anatomical location and also because the bleeding is often intermittent. Purpose: In this study, we discuss the diagnosis and treatment of HP with a review of the literature including our clinical experience. Patients: Case-1:：A 47-year-old Japanese male had a past history of a lateral pancreaticojejunostomy (Puestow procedure) for chronic pancreatitis at age 31. He admitted our hospital with severe tarry stools. Emergent intestinal fiberscopy was performed, and no abnormal lesions were found in the upper and lower intestine. Case-2:：A 45-year-old Japanese male had been treated by medication for chronic pancreatitis and gastroduodenal peptic ulcer. The patient had a complaint of hematomesis and emergent gastrointestinal endoscopy revealed massive duodenal bleeding. Emergent distal gastrectomy was performed. However, he was re-admitted with a recurrent severe anemia. Results: Case 1:：The patient went into hemodynamic shock and subsequently underwent laparotomy. Intra-operative endoscopy through an incision in the reconstructed jejunal loop revealed massive bleeding. Longitudinal jejunotomy was performed and the bleeding point was sutured and ligated. Case 2:：Angiography revealed aneurysm of the distal pancreatic artery. Distal pancreatectomy and splenectomy were performed. The resected specimen revealed that the splenic artery had ruptured into the pseudocyst. Conclusion: There is no consensus on the need for surgery to achieve a complete cure. Emergent surgery is required in patients with recurrent bleeding or failed first-line therapy such as embolization, or stenting.
P-262. A case of chronic pancreatitis with difficult control of persistent pancreatic ascites Yu Sato, Yosuke Kawasaki, Takaaki Tokuda, Megumi Matsushita, Akira Kusakabe, Ayako Sakai, Hirotsugu Saiki, Mina Kato, Chihiro Hibino, Yuki Tokuda, Aya Ishimi, Tomoyo Kawai, Mina Hamano, Miho Chiba, Kosaku Maeda, Katsumi Yamamoto, Masafumi Naito, Toshifumi Ito Department of Gasteroenterology, JCHO Osaka Hospital, Japan Persistent pancreatic ascites is a rare complication in a chronic pancreatitis patient. There are supposed to be a fistula from either pancreatic ducts or pancreatic pseudo-cysts to abdominal cavity. It should be suspected when ascites amylase level rises more than 1000U/L. It is wellknown how difficult to treat such conditions using medical therapies, endoscopic procedures and surgical ones.We reported a case of 75 year-old male with alcoholic chronic pancreatitis with massive ascites. His ascites was diagnosed to be exudative with elevated amylase (6177U/L). Computed tomography showed a pancreatic pseudocyst in pancreatic tail. Under consideration to perform endoscopic approaches, we found intra-pseudocystic hemorrhage feeding from left gastric artery. 5 days after cease of the bleeding using interventional radiological embolization, endoscopic retrograde pancreatography (ERP) was done to show fistula from the pseudocyst to Winslow's foramen. First a short plastic stent was inserted through Papilla Vateri to the main pancreatic duct to reduce duct pressures. The pseudocyst was gradually reducing, but ascites was not appretnly decreased. 24 days after, endoscopic nasal pancreatic drainage was done. Following this procedure, ascites was getting smaller. Again short plastic stent was applied, and then the patient was discharged. One month after the discharge, computed tomography revealed neither pseudocyst nor ascites in this patient, then the plastic stent was removed. These serial endoscopic procedures for this case were effective to control persistent pancreatic ascites of a patient with chronic pancreatits.
P-261. Duodenal ulcer caused by pancreatic ductal hypertension with chronic pancreatitis Akira Imoto, Daisuke Masuda, Atsushi Okuda, Wataru Takagi, Saori Onda, Tatsushi Sano, Takeshi Ogura, Kazuhide Higuchi Second Department of Internal Medicine, Osaka Medical College, Japan Case: A 67-year-old woman complained of continuous upper abdominal pain. Her medical history included idiopathic chronic pancreatitis. From CT performed on the day of admission, no evident changes in the
P-263. A case of acute cholangitis caused by impaction of pancreatic duct stones in the ampulla of papilla Vater Eiji Kimura, Maiko Murata, Kazuhiro Kozumi, Saki Kitano, Fumihiko Sano, Eri Yoshida, Ryoutaro Uema, Eri Tsumano, Akinori Shimayoshi, Mai Horie, Taro Oshima, Syunsuke Yamamoto, Masanori Miyazaki, Satoshi Egawa, Masahide Oshita Osaka Police Hospital, Japan