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44 Case on Impaction of Enteral (Bezoars) During Enteral Feeding
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Fig. 44.2 During
laparotomy, ischemia/
necrosis small bowel
Fig. 44.3 Extraction of
bezoar from the bowel
241
Discussion
Several reports have described different complications in the early postoperative period
in relation to enteral synthetic feeding through jejunostomy. Not only intestinal obstruction but also bowel necrosis has been reported. In our patient, in the period between
fi fth and seventh postoperative days, an intestinal obstruction and a septic situation led
to a relaparotomy. At relaparotomy an impacted bezoar of enteral feeding was found as
cause for the obstruction and ischemia. This bezoar may have been caused by denatured nutrition formula distal to the catheter tip [ 1 ]. Possible relation with high fi ber
enteral feeding has been also discussed. Explaining the cause of mesenteric ischemia
with bowel necrosis proved more diffi cult. Mesenteric ischemia may present in up to
3.5 % of all enteral-fed surgical patients [ 2 ] and associated mortality approaches almost
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M.A. Cuesta
100 %. A high index of suspicion for diagnosis is necessary. As in our case, prompt
relaparotomy and bowel resection provided the only chance for survival.
References
1. Dedes KJ, Schiesser M, Schafer M, Clavien PA. Postoperative bezoar ileus after early enteral
feeding. J Gastrointest Surg. 2006;10:123–7.
2. Melis M, Fichera A, Ferguson MK. Bowel necrosis associated with early jejunal tube feeding:
A complication of postoperative enteral nutrition. Arch Surg. 2006;141:701–4.
Chapter 45
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Case on Gastric Bleeding Caused by a
Necrotizing Pancreatitis with Extensive
Pseudocyst Formation
Rutger J. Lely and Miguel A. Cuesta
Keywords Pancreatitis • Pseudocyst • Pancreatitis • Pseudoaneurysm • Splenic
artery • Gastroduodenal artery
Diagnosis and Indication for Surgery
A 32-year-old law student known with a severe systemic lupus erythematosus
(SLE- like) disease had been treated with high doses of prednisone and supportive
care. Now she was admitted in the hospital, at fi rst on the gastroenterology
Department and after on the Medium Care because of progressive abdominal pain,
hypotension, elevated amylase, and lipase in serum. After fl uid reposition, a CT
scan with double contrast was performed showing an extensive acute necrotizing
pancreatitis.
Course and Identifi cation of the Complication
After conservative treatment, there initially was clinical improvement. Because no
signs were seen of infection, she was conservatively treated by means of nasogastric
tube, initially total parenteral nutrition, and broad-spectrum antibiotics. Situation of
patient evolved unchanged for 4 weeks, with the usual ups and downs. Pneumonia
R. J. Lely , M.D. (*)
Department of Radiology , VU Medical Center , Amsterdam , The Netherlands
e-mail: r.lelij@vumc.nl
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_45,
© Springer International Publishing Switzerland 2014
243
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Fig. 45.1 Identifi cation
bleeding splenic artery during
angiography
R.J. Lely and M.A. Cuesta
was diagnosed and consequently treated. Moreover, CT scans showed the necrosis
with pseudocysts in lesser sac, along the pancreas in the direction of the spleen and
descending colon. Abdomen of the patient was distended and many doctors involved
with her treatment pushed surgeon and radiologist to drain the cysts because of
mechanical complaints such as abdominal distention and threatening respiratory
insuffi ciency. Pseudocysts were not drained, but 5 weeks after admission she developed an important hematemesis and melena with hypovolemic shock. Taking into
regard gastric bleeding from a rupture of a pseudoaneurysm of the splenic artery, a
CT angiography was performed, where a blush was seen at splenic artery and subsequently angiography was performed. A bleeding was observed at the middle level of
the splenic artery with leakage of blood at the level of the greater curvature, thereafter
being successfully coiled (Figs.
45.1 , 45.2 , 45.3 , and 45.4 ; Illustration 45.1 ). Bleeding
was under control, but patient stayed for 8 weeks, at fi rst admitted on medium care,
thereafter on intensive care because mechanical ventilation proved needed, and
fi nally back to the ward. She went on for revalidation because of an important neuropathy. After 4 months, she was again admitted with recurrent acute pancreatitis.
Currently, she can walk with crutches and she has partially reinitiated her activities,
still following physiotherapy.
Discussion
The lesson in this case is the need to think immediately about this complication.
Many times a warning bleeding will get ahead of the important bleeding.
Whatever, in any upper gastrointestinal bleeding experienced by a patient having
45 Case on Gastric Bleeding Caused by a Necrotizing Pancreatitis
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Fig. 45.2 Blush splenic
artery
Fig. 45.3 Starting coiling
245
an acute necrotizing pancreatitis, interventionist radiologists and surgeons have to
consider the likelihood of a rupture of a pseudoaneurysm at the level of splenic
artery or gastroduodenal artery. The role of the intervention radiologist is quite
crucial here. Identifying the blush and using coils to occlude the corresponding
artery will control the bleeding. If coiling is not possible, surgical intervention
will be necessary. Using packing and to identify bleeding point after suturing
should—if possible—come to form the treatment. Postoperative follow-up will be
very complicated.
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Fig. 45.4 Artery coiled
R.J. Lely and M.A. Cuesta
Coiling
Splenic artery
Illustration 45.1 Splenic artery pseudoaneurysm will cause bleeding thorough gastric erosion.
Angiography after identifi cation of the blush will fi x the complication by successful coiling of the artery
Aneurysm
Splenic artery
Chapter 46
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Case on Necrotizing Acute Pancreatitis:
“Infection Is Not Found But Patient Is
Becoming Worse ”
Marc Besselink
Keywords Acute Pancreatitis • Stones • Necrosectomy • Infected necrotizing
pabncreatitis • Fine needle aspiration
Infected necrotizing pancreatitis is a severe complication of acute pancreatitis and
occurs in 5–10 % of cases. Whereas the median mortality of sterile necrotizing
pancreatitis in the literature is 12 %, the mortality of infected necrotizing pancreatitis is 30 % [ 1 ]. Since intervention is only indicated in case of infection, it is of
utmost importance to distinguish between sterile and infected necrotizing
pancreatitis.
Patient
A 65-year-old male with a history of mild chronic obstructive pulmonary disease
and hypertension presented at the emergency room with severe upper abdominal
pain since 4 h. During physical examination the patient was in mild respiratory
distress, had tachycardia (110/min), experienced upper abdominal pain without
signs of peritonitis, and had a subfebrile temperature.
Laboratory analysis demonstrated that serum amylase and lipase levels were
both more than three times the upper limit of normal elevated, bilirubin was slightly
elevated but less than 40 μmol/L (2.3 mg/dL), and C-reactive protein was higher
than 150 mg/L. Imrie score was 5 and APACHEII score was 11. Abdominal ultrasound demonstrated multiple small stones in the gallbladder but no dilatation of the
common bile duct.
M. Besselink , M.D., Ph.D.
Department of Surgery , Academic Medical Center , Amsterdam , The Netherlands
e-mail: m.besselink@amc.uva.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_46,
© Springer International Publishing Switzerland 2014
247
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Fig. 46.1 CT 1 week after
onset of disease
demonstrating pancreatic
parenchymal necrosis as well
as signs of peripancreatic
necrosis. No walled-off
collection or impacted gas
bubbles are visible
Fig. 46.2 CECT 4 weeks
after onset of disease
demonstrating a walled-off
peri-pancreatic collection
with central viable pancreatic
parenchyma and surrounding
necrosis and fl uid
M. Besselink
Based on the above-mentioned fi ndings the patient was diagnosed with “ predicted
severe biliary pancreatitis without cholestasis or cholangitis.”
Since there was no apparent cholestasis, there was no urgent indication to perform
endoscopic retrograde cholangiography/sphincterotomy [ 2 ], and the patient was transferred to the medium care unit. There, despite optimal fl uid therapy with a goal diuresis
of more1 mL/kg/h, within 12 h he quickly deteriorated and was transferred to the intensive care unit for intubation and respiratory support. New physical examination revealed
no signs of peritonitis or abdominal compartment syndrome and it was decided to continue nonsurgical supportive management. After 1 week, the condition had not improved
and a contrast-enhanced computed tomography (CECT) was performed (Fig. 46.1 ).
The condition of the patient remained stable for 3 more weeks and the pulmonary condition improved somewhat, but patient remained intubated and ventilated.
Four weeks after initial presentation, the patient’s condition deteriorated with signs
of infection and vasopressors had to be started. A new CECT was performed under
the suspicion of infected necrosis (Fig. 46.2 ). This CECT did not demonstrate
impacted gas bubbles, a pathognomic sign of infection.
46 Case on Necrotizing Acute Pancreatitis: “Infection Is Not Found But Patient Is Becoming
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Fig. 46.3 CT-guided fi ne
needle aspiration of a
peripancreatic collection. The
patient is in prone position,
and the needle is placed
through the left
retroperitoneal, suprarenal
space
CECT underestimates necrosis in peripancreatic collections.
Fine needle aspiration of the collection was performed (Fig. 46.3 ), but no bacteria
could be demonstrated. There were no apparent other sources of infection (e.g.,
pneumonia, line sepsis) or intra-abdominal catastrophes (e.g., abdominal compartment syndrome, peritonitis). There was an extensive discussion as to whether intervention was indicated in this patient as the necrosis appeared to be sterile. Eventually,
it was decided that the culture results might have been false negative and the collection was drained percutaneously. The cultures of the drainage procedure did demonstrate infection with Escherichia coli . The patient’s condition improved without
further necrosectomy and, 2 months after admission, he was discharged in good
clinical condition.
249
Discussion
Diagnosing infected necrotizing pancreatitis requires insight not only in the
disease but also in the value of fi ne needle aspiration and CT imaging. Although
infection may occur as early as in the fi rst week of the disease, it is typically diagnosed after 3–4 weeks [ 3 ]. Fine needle aspiration may produce false-negative
results as is described in the current case. Although impacted gas bubbles are
pathognomic for infection in necrotizing pancreatitis, this is only seen in approximately 50 % of cases. Consequently, absence of gas bubbles does not exclude
infection.
In the fi rst randomized trial on intervention in infected necrotizing pancreatitis
(PANTER, a Dutch multicenter trial), no routine fi ne needle aspiration was used.
The decision to intervene was rather based on a clinical suspicion of infection (i.e.,
clinical deterioration despite maximal conservative support); the results of this strategy proved excellent with a 95 % infection rate, the highest ever reported [ 4 ].
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M. Besselink
Typically, the most diffi cult clinical scenario to diagnose infected necrotizing
pancreatitis is in the case as described in this chapter: a patient is admitted with
severe pancreatitis and needs transfer to the ICU where the condition of the patient
does not improve over several weeks. In these cases a fi ne needle aspiration may be
helpful. As described one should be aware that the test results may be false negative
as in our case [ 5 ].
Once infection is diagnosed, it is probably benefi cial to postpone intervention
with the help of antibiotics until such a time that the infected collection has become
“walled off,” typically seen after some 4 weeks [ 5 ]. After the infected collection has
“walled off,” up to half of all patients can be treated with only percutaneous catheter
drainage, without additional necrosectomy [ 6 ] .
References
1. Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol.
2006;101:2379–400.
2. Van Santvoort HC, Besselink MG, De Vries AC, et al. Early endoscopic retrograde cholangio-
pancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study.
Ann Surg. 2009;250:68–75.
3. Besselink MG, Van Santvoort HC, Boermeester MA, et al. Timing and impact of infections in
acute pancreatitis. Br J Surg. 2009;96:267–73.
4. Van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy
for necrotizing pancreatitis. N Engl J Med. 2010;362:1491–502.
5. Besselink MG, Verwer TJ, Schoenmaeckers EJ, et al. Timing of surgical intervention in necro-
tizing pancreatitis. Arch Surg. 2007;142:1194–201.
6. Van Baal MC, Van Santvoort HC, Bollen TL, et al. Systematic review of percutaneous catheter
drainage as primary treatment for necrotizing pancreatitis. Br J Surg. 2011;98:18–27.
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