Acute pancreatitis due to venous artery malformation

Pancreatic arteriovenous malformation (PAVM) is very rare. The vast majority of those diagnosed are asymptomatic and if the finding is not incidental, the most common symptom is gastrointestinal bleeding.^1–3

A 47-year-old man presented at our hospital complaining of an approximately 24-h history of abdominal pain. He had no history of substance abuse or other history of interest, apart from a cholecystectomy 2 years previously following an episode of mild acute pancreatitis of biliary origin. Biochemistry tests revealed amylase and lipase values 3 times the reference values. Acute pancreatitis was diagnosed and the patient was admitted.

The patient continued to present recurrent abdominal pain for which high doses of analgesia were not completely effective. The pain was accompanied by oral intolerance and a deterioration in laboratory test values (elevated acute phase reactants: C-reactive protein 25 mg/dL and white cell count 20,000 U/mL). A computed tomography (CT) scan revealed acute pancreatitis with “flash-filling” enhancement, with the PAVM involving the entire pancreas from head to tail (Figs. 1 and 2) and affecting branches of the gastroduodenal and splenic arteries.

Figures 1 and 2.

Pancreatic arteriovenous malformation affecting the pancreas head and tail, with foci of acute pancreatitis in the body and tail.

The patient responded poorly to medical treatment, showing no signs of clinical or analytical improvement. Given his radiological deterioration, surgery (total pancreatectomy) was performed as definitive treatment. The day before surgery, the upper duodenal pancreatic arcades, gastroduodenal artery and splenic artery were selectively embolized to minimize intraoperative bleeding risk and reduce comorbidity (Figs. 3 and 4). Histopathological analysis showed a vascular malformation affecting the head, body and tail of the pancreas, acute and chronic pancreatitis and a normal spleen.

Figure 3.

Selective arteriography of the celiac trunk: extensive areas of pathological artery filling, feeding mainly from the gastroduodenal and splenic arteries.

Figure 4.

Selective arteriography of the celiac trunk after embolization of the pancreaticoduodenal and splenic arteries with coils and Gelfoam.

Very few cases of acute pancreatitis secondary to PAVM have been described in the literature. Treatment should aim at preventing pancreatitis recurrence and complications. In our case, selective embolization combined with subsequent surgery resulted in a satisfactory outcome. The patient progressed well and is now asymptomatic.