Case Presentation:
A sixty‐year old female presented to the Emergency Department with chest pain. She had a history of coronary artery disease and received three drug eluting stents. Her chest pain was similar to when she had experienced a myocardial infarction previously and was unrelieved with nitroglycerin. She was admitted to the hospital and started on medications for acute coronary syndrome. She then underwent a coronary angiogram and a stent was placed in the obtuse marginal branch of the left circumflex artery. Her chest pain was relieved and she was observed overnight with no complications. On the day she was to be discharged, however, she developed abdominal pain. A troponin and electrocardiogram were normal. A CT scan of her abdomen was done which revealed fat stranding around her pancreas. A lipase was drawn and was elevated to 700 units/L. She was given nothing by mouth and her pain was controlled with opioids. Her pain resolved soon thereafter. An evaluation for other causes of pancreatitis was negative. Therefore, it was determined she had developed ischemic pancreatitis as a complication of performing a coronary angiogram.
Discussion:
Coronary angiography is a common medical procedure performed routinely in the hospital, both as an elective procedure and urgent procedure in the setting of acute coronary syndrome. Common complications associated with coronary angiography include bleeding, infection, pain, and allergy to the IV contrast. Less common complications include arrhythmias, acute kidney injury, and thromboembolic disease, particularly leading to stroke. A very rare complication of angiography is the development of acute pancreatitis, with one case report identifying a frequency of 0.1%.
The pathophysiology of acute pancreatitis following angiogram is not well understood. Early case reports describing the development of acute pancreatitis demonstrated a component of cholesterol embolization. Orvar identified nine patients in a ten‐year span who developed pancreatitis following angiogram. Three of the nine developing necrotizing pancreatitis and ultimately died. Autopsies from these patients demonstrated significant cholesterol embolization to the liver, kidneys, and spleen, leading the authors to hypothesize that the severity of pancreatitis is related to the degree of pancreas infarction from the emboli.
Another recent case report by Gorges focused on the effects of contrast in leading to pancreatitis. They hypothesized that acute pancreatitis following cardiac catheterization is likely contrast‐induced, as the contrast leads to decreased oxygenation and impaired circulation of the pancreas, similar to the pathophysiology behind contrast‐induced kidney injury.
Conclusions:
While a rare complication of angiography, acute pancreatitis is an important diagnosis to identify post‐angiogram. As patients receiving cardiac catheterization already likely have severe atherosclerotic disease, they are at risk of developing cholesterol emboli causing complications post‐procedure.