Maggie Cheung, MD1, Dean Marella, MD1, Kalyani Dhar, BA, MS1, Manish S. Patel, MD2
1Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ; 2Rutgers Robert Wood Johnson School of Medicine, New Brunswick, NJ
Introduction: Spontaneous celiac artery dissection is a rare event. Due to similar presenting symptoms of abdominal pain, diagnosis of celiac artery dissection as a cause of acute pancreatitis can be easily missed.
Case Description/Methods: A 51 year old man with a history of cholecystectomy presented with severe epigastric pain radiating to bilateral upper quadrants. He denied nausea, vomiting, diarrhea and fevers. Physical exam was notable for epigastric, LUQ, and RUQ tenderness. Labs revealed lipase 35 U/L. CT A/P showed peripancreatic inflammatory changes with hyperdense peripancreatic fluid, concerning for hemorrhagic pancreatitis. Typical etiologies for acute pancreatitis were absent, including alcohol and gallstones, and IgG4 was negative, suggesting this was not autoimmune pancreatitis. MRCP was performed and identified a dissection of the celiac axis extending to the splenic artery. CT angiography confirmed celiac artery dissection and re-demonstrated peripancreatic fat stranding. Patient received aggressive IV fluids for the first 24 hours with improvement in pain. Vascular surgery recommended starting aspirin 81 mg daily without any surgical intervention and the patient was discharged home with close follow-up.
Discussion: Though our patient had a normal lipase, he had severe epigastric pain and peripancreatic stranding on imaging, satisfying 2 of the 3 criteria for acute pancreatitis. In the absence of other causes, imaging identified celiac artery dissection as the etiology of his pancreatitis. Of the visceral artery dissections, celiac artery dissection represent only 4% of cases, and only 5 reported cases have identified spontaneous celiac artery dissection as a cause of pancreatitis. In the setting of a dissection, the pancreas likely experienced an ischemia-reperfusion injury, where there was transient hypoperfusion from the celiac trunk, followed by reperfusion from collaterals from the superior mesenteric artery, resulting in exposure to oxygen-free radicals and cellular processes leading to inflammation. There is no standardized treatment, but conservative management with antiplatelet and/or anti-coagulation is pursued in mild cases of pancreatitis. Surgery is reserved for severe cases involving bowel ischemia, vessel rupture, or continued abdominal pain.
This case highlights a rare presentation of acute pancreatitis secondary to a spontaneous isolated celiac artery dissection.
Citation: Maggie Cheung, MD; Dean Marella, MD; Kalyani Dhar, BA, MS; Manish S. Patel, MD. P1906 - SPONTANEOUS ISOLATED CELIAC ARTERY DISSECTION: A RARE CAUSE FOR ACUTE PANCREATITIS. Program No. P1906. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.