Ungewöhnliche Komplikation eines akuten Schubs bei chronischer Pankreatitis

Atraumatic rupture of the spleen is a rare, but life-threatening complication of pancreatitis. We report a case of an atraumatic spleenic rupture in chronic pancreatitis. A 41 year old man presented in the emergency room with abdominal pain and typical signs of acute pancreatitis. His medical history showed a chronic pancreatitis due to alcoholism with recurrent acute pancreatitic episodes. He denied any trauma in the recent past. In the next few hours he showed clinical signs of a severe hemorrhagic shock. The haemoglobin level fell from 9.4 to 3.0 g/dl. Abdominal ultrasound and abdominal CT scan showed free fluid. In the following laparotomy a splenectomy was performed due to splenic rupture. A histological examination of the spleen revealed no reason, that could explain the splenic rupture. Hence we assumed a spontaneous rupture. The reported case demonstrates that in acute pancreatitis and signs of shock it is necessary to rule out rupture of the spleen e.g. via ultrasound and abdominal CT scan. If there are signs of spleenic rupture, the only therapy of this life-threatening complication is instant operation to save patient's life.     

Pathologic rupture of the spleen in hematologic malignancies: two additional cases

 Pathologic rupture of the spleen in hematologic malignancies is rare. We present two cases of splenic rupture which occurred in a man with a secondary high-grade non-Hodgkin's lymphoma and a woman with chronic lymphocytic leukemia (CLL). In a review of the literature, we have been able to identify 136 cases of pathologic splenic rupture since 1861; 34% have occurred in acute leukemias, 34% in non-Hodgkin's lymphomas, and 18% in chronic myelogenous leukemia (CML). We find a male-to-female ratio of 3 : 1, with considerable differences for the specific diseases encountered. Pathologic rupture of the spleen has happened almost exclusively in adults and the ruptured spleens are generally moderately to severely enlarged. It seems that, apart from splenic infiltration by a hematologic disease, splenic infarcts and coagulation disorders (which have previously been advanced as the most important pathophysiologic factors leading to rupture), male sex, adulthood, severe splenomegaly, and cytoreductive chemotherapy may increase the risk for pathologic splenic rupture. We briefly discuss symptoms preceding the event, diagnostic possibilities, and the outcome with operative and conservative approaches. Received: 24 July 1996 / Accepted: 30 September 1996     

Kyste hydatique primitif de la rate: deux cas. Peut-on être conservateurs ?

Introduction

Via two cases of hydatid cyst of the spleen, we discuss the management of this rare disease. The choice of open surgery or laparoscopy depends on the size of the cyst and its location.

Cases

The first case was a hydatid cyst type 1 occurring in a young patient, which was operated by celioscopy with splenic conservation. The second case was a modified multilocular cyst in a patient aged 38 years, where a splenectomy was necessary.

Results

In both cases, the evolution was satisfactory, except the splenectomy needed a ten-day hospitalization, whereas the length of hospitalization for the conservative approach was five days and did not require postsplenectomy immune care.

Conclusion

Hydatid cyst of the spleen should be treated surgically because of the high-risk of rupture, the most widely used approach in adults is standard splenectomy but the surgical technique should be chosen according to the size of the cyst and its location. In our opinion splenic conservation should be implemented in all cases of single, superficial cysts.     

Epidemiology and etiology of chronic pancreatitis in Brazil: a tale of two cities

We observed 797 consecutive cases of chronic pancreatitis from 1963 to 1987 in the cities of Belo Horizonte and S?o Paulo. Alcoholism was the main etiological agent, responsible for 714 cases (89.6%). Chronic calcifying pancreatitis from different etiologies, alcohol, idiopathic, nutritional, and familial, was the most important form of chronic pancreatitis, with 786 cases (98.6%). Only three cases of chronic obstructive pancreatitis were diagnosed. Eight cases of chronic pancreatitis, anatomicopathologically studied, have not showed the typical pancreatic changes of either chronic calcifying pancreatitis or of obstructive pancreatitis and were impossible to classify according to the 1984 Marseilles' classification.     

Subtotal splenectomy for the treatment of chronic lymphocytic leukemia

Although splenectomy is helpful in the management of selected patients with chronic lymphocytic leukemia (CLL), in most cases this procedure is accompanied by a greater morbidity and mortality, mainly due to sepsis. Thus, it may be proposed that a conservative procedure that reduces the spleen size may have an effect similar to that of total spleen ablation for the treatment of CLL. The present paper describes our experience with an 81-year-old patient submitted to subtotal splenectomy for treatment of CLL. Indications for surgery were uncontrolled leukemic activity and intense abdominal discomfort due to the huge spleen. The good results obtained with subtotal splenectomy in the present case indicate that this procedure may be a new alternative for the treatment of CLL when removal of the spleen is indicated.     

Lymphocyte subsets and HLA-DR expression in normal pancreas and chronic pancreatitis

In an attempt to study the mechanisms leading to fibrosis in chronic pancreatitis, an in situ immunohistochemical investigation of lymphocytes and of class II major histocompatibility complex expression (HLA-DR) by epithelial cells has been designed. Samples of normal pancreas (n = 8), chronic calcifying pancreatitis (n = 4), chronic obstructive pancreatitis (n = 6), and diffuse fibrosing pancreatitis (n = 6) have been studied. In normal pancreas, T-lymphocytes were rare and were located in the epithelial layer of pancreatic ducts and in the periductal connective tissue. Duct cells were constantly HLA-DR negative. In chronic calcifying pancreatitis and chronic obstructive pancreatitis, T cells were numerous and were located around ducts and in the spreading areas of fibrous septa. In chronic obstructive pancreatitis, the duct cells strongly expressed the HLA-DR antigen. In diffuse fibrosing pancreatitis, fibrous tissue was devoid of lymphocytes and duct cells never expressed the HLA class II antigen. These results suggest that lymphocytes are involved in the fibrosing process occurring in chronic calcifying pancreatitis and chronic obstructive pancreatitis but not in diffuse fibrosing pancreatitis. The significance of de novo expression of HLA-DR antigen by duct cells is discussed.     

Pancreaticoportal fistula: a rare complication of chronic pancreatitis

We report a patient with chronic alcoholic calcifying pancreatitis in whom a pancreaticoportal fistula was demonstrated by endoscopic retrograde pancreatography. No complications could be ascribed to this fistula except for thrombosis of the portal, splenic, and superior mesenteric veins. An expectant conservative management was adopted. A short review of the six other cases reported in the literature is presented.     

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.     

Acute abdomen caused by spontaneous rupture of splenic hydatid cyst

We report a rare case of acute abdomen caused by the spontaneous rupture of a splenic hydatid cyst into the abdominal cavity, causing a massive hemoperitoneum due to accompanying rupture of the spleen which required splenectomy. A review is made of the literature on this rare entity, its treatment and its consequences and their prevention and treatment.     

A case of haemosuccus pancreaticus

Haemosuccus pancreaticus (Wirsungorrhagia or pseudohaemobilia) is a rare complication of chronic pancreatitis. We describe a 48-year-old patient with alcohol-induced chronic calcific pancreatitis and recurrent episodes of severe upper gastrointestinal bleeding but without abdominal pain. Upper gastrointestinal endoscopy revealed fresh blood oozing from the ampulla of Vater. No pseudoaneurysms or pseudocysts were detected by arteriography or computerized tomography. The bleeding was attributed to pancreatic lithiasis. Following conservative treatment, there was no evidence of recurrence during a 24-month follow-up period. In conclusion, although a rare occurrence, haemosuccus pancreaticus should be considered in the differential diagnosis of all cases of obscure upper gastrointestinal bleeding in patients with chronic pancreatitis, whether or not accompanied by pain. A highly suggestive clinical history or X-ray findings and an endoscopic visualization of blood coming from the ampulla of Vater may suffice for the diagnosis, thus avoiding diagnostic and therapeutic errors. When haemosuccus pancreaticus occurs in patients without pseudoaneurysms or pseudocysts, it can be treated conservatively, thus obviating the need for pancreatectomy or arteriographic embolization.     

Clinical and epidemiological study of calcifying chronic pancreatitis in Goiania, GO, Brazil]

The authors studied, prospectively, 102 cases of calcifying chronic pancreatitis in Goiania, GO, Brazil, from 1985 to 1996. Alcohol was the major cause of calcifying chronic pancreatitis, responsible for 94.1% of the cases. In others 5.9% of the cases, not associated with alcohol, the etiologic diagnosis could not be confirmed. The average age of the patients was 39.8 +/- 9.8 years, and the first symptoms appeared with the average age of male sex in the proportion of 9.2/1. The average of alcoholic beverage ingested was 258 +/- 187.1 g/day of ethanol through an average period of 17.5 +/- years. The major complications found were: chronic diarrhea (malabsorption), pleural effusion, cysts, diabetes mellitus, jaundice and digestive hemorrhage. This study, when compared to others from other Brazilian cities, suggests that there are differences in the natural history of calcifying chronic pancreatitis among several regions of Brazil.     

Emergency laparoscopic partial splenectomy for ruptured spleen: A case report

Splenic rupture is a common consequence of blunt abdominal trauma. Emergency splenectomy is indicated when conservative management is not effective. With better understanding of the immunologic function of the spleen, surgeons have begun to perform the splenic-preserving surgery. However, it is technical challenge to perform emergency laparoscopic partial splenectomy for patient with spleen rupture. A 15-year-old male patient suffered from grade III spleen injury basing on the American association for the surgery of trauma splenic injury scale. Conservative treatment failed to success basing on the dramatically decreased hemoglobin level. During the laparoscopic exploration, we found that two individual ruptures were associated with the upper pole of spleen. An emergency laparoscopic partial splenectomy was successfully carried out. The operative time was approximate 150 min and the estimated blood loss was 200 mL. The post-operative course was uneventful and the patient was discharged on the 7^th post-operative day.     

Abscesses of the spleen： Report of three cases

Abscess of the spleen is a rare discovery, with about 600 cases in the international literature so far. Although it may have various causes, it is most usually associated with trauma and infections of the spleen. The latter are more common in the presence of a different primary site of infection, especially endocarditis or in cases of ischemic infarcts that are secondarily infected. Moreover, immunosuppression is a major risk factor. Clinical examination usually reveals a combination of fever, left-upper-quadrant abdominal pain and vomiting. Laboratory findings are not constant. Imaging is a necessary tool for establishing the diagnosis, with a choice between ultrasound and computed tomography. Treatment includes conservative measures, and surgical intervention. In children and in cases of solitary abscesses with a thick wall, percutaneous catheter drainage may be attempted. Otherwise, splenectomy is the preferred approach in most centers. Here, we present three cases of splenic abscess. In all three, splenectomy was performed, followed by rapid clinical improvement. These cases emphasize that current understanding of spleen abscess etiology is still limited, and a study for additional risk factors may be necessary.     

Juvenile idiopathic chronic calcifying pancreatitis: report of 10 cases from central Tunisia

A series of 10 cases of chronic calcifying pancreatitis from central Tunisia are reported. The mean age at presentation was 23 years and the male to female ratio was 1.5. The main clinical manifestations of the disease were abdominal pain (eight cases), weight loss (four cases), and diarrhea (three cases). Diabetes was recorded in four cases. The etiological investigations yielded negative results in all the patients. It is concluded that central Tunisia should be added to the regions where juvenile chronic calcifying pancreatitis of the "tropical type" may be observed.     

Spontaneous splenic rupture in two patients with a blastoid variant of mantle cell lymphoma

 Spontaneous rupture of the spleen is a rare complication of hematological malignancies, occurring most commonly in patients with acute leukemia, but it has been documented in chronic leukemias and also in lymphomas. We report two patients with histologically and immunohistochemically confirmed mantle cell lymphoma (MCL) who experienced a spontaneous splenic rupture. An 80-year-old woman and a 51-year-old man had a blastoid variant of MCL and responded poorly to conventional treatment. Both patients recovered after splenectomy. The woman died of progressive lymphoma 2 months later. An allogeneic bone marrow transplantation was performed in the man with a good initial result, but an aggressive relapse was seen only 6 months later and he died of progressive lymphoma. In view of our data, we suggest special caution when MCL is complicated by rapid progression and severe splenomegaly. Although it is a rare phenomenon, the risk of splenic rupture should be kept in mind. Received: 2 September 1996 / Accepted: 16 October 1996     

Spontaneous rupture of spleen in falciparum malaria.

Spontaneous rupture of spleen is an extremely rare complication of falciparum malaria. We report a 3 1/2-year-old girl with splenic rupture who was managed successfully with splenectomy and antimalarials.     

Sonographic controlled drainage of a fluid formation of the spleen in combination with pancreatitis

With regard to acute or chronic pancreatitis various complications involving the spleen can occur, hematoma of the spleen being a rare complication. We describe the case of a patient in reduced general condition with elevated pancreatic enzymes and signs of inflammation. During multiple examinations, hematoma of the spleen, as well as hematomas close to the left adrenal gland and a larger hematoma close to the gastric wall were detected. In computed tomography and due to the laboratory parameters a pancreatitis was diagnosed. After CT-controlled puncture a communication between both formations was considered possible which was in retrospect CT-assisted not successful. Subsequently an ultrasound controlled drainage was performed, finally resulting in a restitutio ad integrum, thereby avoiding splenectomy. The described percutaneous puncture of a fluid formation in the splenic area represents a non-surgical option in the therapy of intrasplenic pancreatic fluid formations.     

Splenic abscesses

Splenic abscesses are rare entities (autopsy incidence between 0.14-0.7%). The most frequent etiology is the septic emboli seeding from bacterial endocarditis (about 20% of cases) or other septic foci (typhoid fever, malaria, urinary tract infections, osteomielitis, otitis). The treatment of splenic abscesses was until recently splenectomy with antibiotherapy. The actual trends are more conservative (mini invasive or non-invasive) because the immunologic role of the spleen has been better understood over the last year     

Studies on pancreatic duct system. II Comparative study of histological features, and three-dimensional reconstruction of pancreatic ducts

Three-dimensional reconstruction of pancreatic ducts were made from specimens of pancreases from chronic pancreatic injury dogs following adjuvant injection, one patient with chronic non-alcoholic pancreatitis, and 2 patients with chronic alcoholic pancreatitis. The ductal alterations of alcoholic pancreatitis showed more apparent changes than those of non-alcoholic pancreatitis. The lesions in experiment such as uneven surface, irregular dilatation, tortuosity, and anastomosis, resembled to those of alocholic calcifying pancreatitis. Although gross appearance of the reconstructed ducts in advanced cases of experimental pancreatic injury revealed some resemblance to that of alcoholic calcifying pancreatitis, histologically, the epithelial changes of the former were different from those of the latter. Thus we concluded that more complicated factors than those considered in experiment play a role in combination in the pathogenesis of bead-like dilatation of the pancreatic ducts of chronic pancreatitis.     

Endoscopic pancreatic drainage in chronic pancreatitis associated with ductal stones: long-term results

Background: In severe chronic pancreatitis associated with intraductal stones, therapeutic endoscopy aims to reduce increased intraductal pressure by pancreatic sphincterotomy and stone clearance. Methods: Results of treatment were evaluated in 70 new patients who underwent pancreatic sphincterotomy and attempted stone removal. Technical results and frequency of pain relief and recurrence are compared. Results: Complete ductal clearance of calculi was obtained in 50% of cases. Immediate clinical improvement occurred in 95% of patients with painful attacks. No severe complications or mortality occurred. Fifty-four percent of all patients with painful chronic pancreatitis did not experience any pain recurrence within 2 years. Associations found to be statistically significant by multivariate analysis were ductal clearance and extracorporeal shock wave lithotripsy, pain disappearance and ductal clearance, pain recurrence and long evolution, and severe disease before treatment and presence of a ductal substenosis. Conclusions: In this subset of patients our results indicate that the pain of chronic pancreatitis is mainly related to increased intraductal pressure. Endoscopic management appears to be a safe, conservative, alternative to surgery. The best results are obtained when it is performed early in the course of calcifying chronic pancreatitis. (Gastrointest Endosc 1996;43:547-55.)