Case Presentation:

A 63–year–old man developed sudden onset of diffuse abdominal pain associated with nausea and non–bilious vomiting 12 hours after elective percutaneous transluminal coronary angioplasty (PTCA) with drug eluting stent placement in the mid left anterior descending coronary artery. There were no immediate post–procedure complications. Past medical history was significant for hypertension, angina pectoris and dyslipidemia. His daily medications were aspirin, clopidogrel, atorvastatin, metoprolol, and sublingual nitroglycerine as needed for chest pain. Physical examination was remarkable for tenderness in the epigastric region without rebound. Lab tests revealed amylase of 400 U/L, lipase of 840 U/L, and WBC of 14000 (85 % polymorphs). CT abdomen with contrast showed significant peripancreatic stranding and filling defect in the portal vein, consistent with acute pancreatitis and portal vein thrombosis. Patient was kept NPO, given IV fluids and was started on enoxaparin and coumadin. His symptoms improved and he was discharged home on the third day. After 3 months, follow up CT abdomen revealed complete resolution of pancreatitis and portal vein thrombosis and hence his coumadin treatment was discontinued.

Discussion:

Acute Pancreatitis is an extremely rare complication of PTCA procedure resulting from atheromatous embolization of the pancreatic vessels. Ischemia resulting from occlusion of vessels can lead to varying degrees of pancreatic necrosis ranging from subtle changes to necrotizing pancreatitis. Orvar and Johlin reported the largest series of acute pancreatitis after cardiac catheterization or abdominal angiographic procedures. They studied 21,000 patients undergoing angiographic procedures and pancreatitis was reported in only 0.4% of the cases. Our patient had no other risk factor for pancreatitis such as alcoholism or cholelithiasis. Pancreatitis accounts for only 3–5% of cases of portal vein thrombosis via either a contiguous inflammatory process, direct compression of the portal vein by a pseudocyst, or a combination of both. In our case, the acute pancreatitis served as a nidus for the development of portal vein thrombosis. Management of pancreatis is largely supportive and anticoagulation is considered for acute portal vein thrombosis.

Conclusions:

The triad of PTCA, acute pancreatitis and portal vein thrombosis is extremely rare and to our knowledge this is the first case ever reported in the literature. Although very rare, atheromatous embolization and acute pancreatitis should be considered as one of the possible causes of acute abdomen in patients who have undergone angiographic procedures. Supportive care for acute pancreatitis and anticoagulation for portal vein thrombosis result in complete resolution of both of these complications.

Figure 1CT abdomen with contrast showing portal vein filling defect (red arrow) consistent with portal vein thrombosis and acute pancreatitis (yellow arrow).