Emphysematous pancreatitis associated with penetrating duodenal ulcer

Abstract

In the “proton pump inhibitors era”, a penetrating peptic ulcer (PPU) represents an exceptional cause of abdominal pain, and was more frequently observed in the past where there was not an effective antacid treatment. Ulcer-induced pancreatitis is very rare, too, and manifests with persistent, intense pain radiating to the back. A mild to severe pancreatitis with peripancreatic fluid collection can be observed at imaging. However, only a few cases of association between PPU and emphysematous pancreatitis (EP) have been published in the literature. EP is a rare but potentially fatal form of acute necrotizing pancreatitis in which gas grows in and outside the pancreas, and typically involves the whole parenchyma in diabetic individuals.Here we report an extremely rare case of a duodenal ulcer penetrating the pancreas and complicated with EP. Unlike the classic form of EP, which involves the whole parenchyma and has a poor prognosis, we found that the emphysematous involvement of the pancreas by PPU has a benign course if a conservative therapy is promptly established. Gas is confined to the site of penetration, usually the pancreatic head, and ulcers most often involve the duodenum.

Endoscopic Nasopancreatic Drainage Contributes to Early Resolution of Postgastrectomy Gastropancreatic Fistula

“…Shibukawa et al treated an ulcer with a PPI, and endoscopy on hospital day 31 demonstrated a decrease in the size of the ulcer and persistence of the mucosal defect, confirming the diagnosis of an open ulcer ( 10 ). Tana et al reported that symptoms improved after four weeks of conservative treatment with antibiotics and PPIs ( 11 ). Conservative treatments require prolonged healing periods compared with surgical approaches.…”

Massive emphysematous pancreatitis associated with duodenal microperforation

“…Previously described cases of EP associated with penetrating ulcer are exceedingly rare and typified by focal emphysema confined to the site of fistulation, often the head of pancreas [ 4 ]. We speculate that erosion into branches of the gastroduodenal artery and resulting ruptured pseudoaneurysm may account for the anomalous volume of this collection.…”

The Emphysematous Pancreatitis: A Rare Complication of Acute Necrotizing Pancreatitis

“…Other possible but less frequently encountered aetiologies are metabolic, medicinal and infectious causes, as well as autoimmune and genetic diseases. Gastroduodenal ulcer perforation can rarely occur in the pancreas with glandular superinfection [6] .…”