Acute necrotizing pancreatitis as a rare complication of extracorporeal shock wave lithotripsy

Abstract

Extracorporeal shock wave lithotripsy (ESWL) is considered the standard treatment for most renal and upper ureteral stones. Some centers use ESWL to treat bile duct stones and pancreatic calculi. Although ESWL is generally considered safe and effective, major complications, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, rupture of an aortic aneurysm and intracranial hemorrhage, have been reported to occur in less than 1% of patients. Here, we present an extremely rare case of acute necrotizing pancreatitis occurring after ESWL for a rightsided urinary stone, which was treated by non-operative percutaneous interventions.Key words complication, extracorporeal shock wave lithotripsy, necrotizing pancreatitis. Case reportA 39-year-old man was referred to the Department of Urology at the Baskent University Faculty of Medicine for hematuria and right flank pain in May 2004. On computed tomography (CT) scan, the patient was found to have a 4 × 2 mm calculus in the right renal pelvic region. There also were dilatations of the right pelvicaliceal system and the proximal ureter ( Fig. 1). As the obstructing stone was non-opaque, we decided to treat it with extracorporeal shock wave lithotripsy (ESWL). ESWL (Siemens Lithostar Modularis, Siemens Medical Solutions, Iselin, NJ, USA) was performed with 3500 shocks at 15 kv. The procedure was uneventful. However, 6 h later, the patient complained of gradually increasing, serious abdominal and back pain, and was referred to general surgery.On physical examination, the patient's abdomen showed muscular defense and distension. Bowel sounds were hypoactive. The patient has neither history of biliary lithiasis nor chronic alcohol consumption. Laboratory data demonstrated an elevated white blood cell level of 21 × 10 3 /µL, serum amylase level of 3903 U/L (normal range, 30-110 U/L), and serum lipase level of 9250 U/L (normal range, 13-60 U/L). Liver function tests of transaminases, bilirubin, gama glutamyl transferase, lactic dehydrogenase were all in normal laboratory ranges. Serum calcium and parathormone levels were also normal. Results of abdominal and chest radiographs were normal and without signs of bowel perforation or obstruction. An abdominal CT scan was performed and demonstrated parenchymal edema of the pancreas. In addition, there were small areas of necrosis (25 × 24 mm) on the corpus and tail regions of the organ (Fig. 2). Intraabdominal fluid in perirenal, peripancreatic and pelvic regions was also determined. The gallbladder, and intrahepatic and extrahepatic biliary systems were completely normal. Also, a residual millimetric stone on the right renal pelvis with minimum pelvic dilatation was seen, suggesting that the lithotripter had been focused on the target stone correctly.The International Symposium on Acute Pancreatitis in 1992 defined pancreatic necrosis as the presence of one or more diffuse or focal areas of non-viable pancreatic parenchyma, 1 so based on the patie...

Shock Wave Lithotripsy Targeting of the Kidney and Pancreas Does Not Increase the Severity of Metabolic Syndrome in a Porcine Model

“…Others have also shown similar temporal profiles for serum lipase and amylase after renal SWL. 5,7,8 The rise in serum markers of pancreatic exocrine function observed in the present study likely reflects pancreatic trauma as collateral damage of renal SWL, but they remained within or close to normal limits. Regardless, we were able to confirm injury to the pancreatic tail histologically—sites of hemorrhage, chronic inflammation, loss of normal cell integrity, fibrotic regions and loss of insulin-immunoreactive beta cells.…”

Electromagnetic and Electrohydraulic Shock Wave Lithotripsy-Induced Urothelial Damage: Is There a Difference?

“…Several reports in the literature are present regarding the possible harmful effect of extracorporeal SWL on the kidneys and adjacent organs: the lungs, liver, pancreas, and intestine. [1][2][3][4][5] Perirenal hematoma with or without hematuria is the most common acute complication. Transient increase in intrarenal vascular resistance, diastolic blood pressure, and markers of tubular damage was reported after SWL.…”

“…12,13 Diabetes mellitus was reported as a late complication after SWL due to acute necrotizing pancreatitis. 2,11 The majority of the studies about the side effects of SWL investigated the parenchymal damage and renal function, however, only few studies investigated the possible effect of SWL on the peristaltic movement of the ureter. 14,15 Recently, we have published a study where the effect of electrohydraulic lithotripter on the urothelial and muscle layer of the ureter and kidney was investigated.…”

Extracorporeal shock wave lithotripsy for difficult common bile duct stones: a comparison between 2 different lithotripters in a large cohort of patients

“…10,27,28 In our series, we showed that the implementation of technical improvements (ie, location system and focusing) achieved with the latest generation of lithotripters further reduced the incidence of adverse events, particularly the incidence of serious adverse events.…”