Peripartum Severe Acute Pancreatitis with Rare Complications: Case Report and Review of Literature

Abstract

Peripartum pancreatitis is a rare clinical condition that occurs usually in the third trimester of pregnancy. Pancreatitis is usually secondary to gallstones, and it can lead to life-threatening and rare complications. We report a case of necrotizing postpartum pancreatitis that developed abdominal compartment syndrome (ACS) in early course, posterior reversible encephalopathy syndrome (PRES), and splanchnic and extrasplanchnic thrombosis later on. Case. 31-year-old female, one week after delivery, presented to the emergency department with abdominal pain, nausea and vomiting, tenderness in the epigastrium, and raised pancreatic enzymes. Ultrasound (USG) showed bulky pancreas with gallstones. She was diagnosed as having acute biliary pancreatitis and started to be hydrated and was supplemented with analgesia. Her condition deteriorated on the 2nd day, and she was shifted to the surgical intensive care unit (SICU) where she developed abdominal compartment syndrome (ACS), respiratory distress, and acute kidney injury, requiring endotracheal intubation and ventilation. Computerized tomography (CT) showed pancreatic necrosis with multiple fluid collections and significant left-sided pleural effusion. Percutaneous drainage of pleural effusion was done, and she was stabilized to be weaned off from mechanical ventilation. On day 15, she underwent USG-guided drainage of the pancreatic collection and ERCP (endoscopic retrograde cholangiopancreatography) on day 19. Post-ERCP, she had tonic colonic convulsions which were treated with benzodiazepines and phenytoin. It was diagnosed by imaging studies as posterior reversible encephalopathy syndrome (PRES). Her abdomen was still distended and tender; CT showed a significant pseudocyst with splanchnic and extrasplanchnic thrombosis. She had laparotomy, gastrocystostomy, and cholecystectomy on day 28th. She made uncomplicated recovery and discharged in good health. Conclusion. Peripartum pancreatitis can be complicated by ACS, PRES, and splanchnic and extrasplanchnic thrombosis.

Posterior Reversible Encephalopathy Syndrome in the Setting of Asparaginase-associated Pancreatitis in 2 Pediatric Patients With Acute Leukemia

“…In the adult literature, there are case reports of PRES in the setting of pancreatitis, though the etiology of pancreatitis differs and includes: alcoholism, gallstones, pregnancy, biliary manipulation, malignancy, and acute intermittent porphyria (Table 1). 12,[16][17][18][19][20][21][22][23][24][25][26][27] Three cases of PRES and pancreatitis are reported in the pediatric literature; however, none are related to asparaginase (Table 1). [13][14][15] The pathophysiology of PRES is not fully understood but is related to disordered cerebral autoregulation and endothelial dysfunction, previously attributed to an acute rise in BP.…”

“…In the adult literature, there are case reports of PRES in the setting of pancreatitis, though the etiology of pancreatitis differs and includes: alcoholism, gallstones, pregnancy, biliary manipulation, malignancy, and acute intermittent porphyria (Table 1). 12,16–27 Three cases of PRES and pancreatitis are reported in the pediatric literature; however, none are related to asparaginase (Table 1). 13–15…”

Posterior Reversible Encephalopathy Syndrome Secondary to Asparaginase Associated Pancreatitis in Two Pediatric Patients with Acute Leukemia

“…Additionally, genome wide association studies have identified multiple genetic polymorphisms associated with pancreatitis in children with ALL including RGS6 , ULK2, CPA2, PRSS1 (10,19,20) PRES is an underappreciated complication of pancreatitis. In the adult literature, there are case reports of PRES in the setting of pancreatitis, though the etiology of pancreatitis differs and includes: alcoholism, gallstones, pregnancy, biliary manipulation, malignancy and acute intermittent porphyria (Table 1) (12,(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32). Three cases are reported in the pediatric literature, none of which are related to asparaginase (Table 1) (33)(34)(35).…”