Hemodynamic Instability in a 39-Year-Old Patient With Acute-on-Chronic Pancreatitis.

A 39-year-old male patient with a medical history of chronic pancreatitis was transferred from an outside hospital after presenting with 2 weeks of nausea, vomiting, and epigastric pain that worsened with oral intake. On admission to our facility, he was tachycardic to 110 beats/min, and his abdomen was tender on palpation. His WBC count was 29,400 cells/μL with 77% neutrophils, lipase was 107 U/L, creatinine 0.7 mg/dL, and albumin 2.3 g/dL; electrolytes and liver enzymes were unremarkable. His initial chest radiograph demonstrated an enlarged cardiomediastinal silhouette and a left-sided pleural effusion with left-sided pulmonary opacity. A CT scan of the abdomen with contrast was obtained (Fig 1), which demonstrated a well-defined fluid collection in the peripancreatic region with communication between the abdominal and pericardial fluid collections through the caval hiatus of the diaphragm. This fluid collection was abutting the gastroesophageal junction and displaced the stomach to the left of midline. The findings were consistent with a rapidly enlarging area of pancreatic walled-off-necrosis (WON). When IV contrast was administered, there was notable blush enhancement within the pancreas, suggestive of pseudoaneurysm formation. Embolization of the dorsal pancreatic artery was performed on hospital day 3, and repeat CT scan with contrast had a relatively unchanged size of the pancreatic collection without signs of continued hemorrhage. On hospital day 5, he developed hemodynamic instability, and a bedside echocardiogram was performed. Question 1: What is the differential diagnosis of hemodynamic instability in a patient with pancreatitis, and how can bedside echocardiogram be used to evaluate the cause?Question 2: What is shown in Video 1, and what physiologic changes can be appreciated? Answer 1: The differential diagnosis of hemodynamic instability in a patient with pancreatitis is broad, and it includes many of the causes of hypotension/shock encountered in the ICU. The differential includes severe volume depletion, systolic dysfunction (including stress cardiomyopathy), pulmonary embolism, cardiac tamponade, abdominal compartment syndrome, and sepsis. Point-of-care ultrasound can be invaluable in the rapid evaluation of this situation (Fig 2). By assessing for chamber dilation, inferior vena cava size, left ventricular ejection fraction, and estimated stroke volume, valuable information can be obtained to guide patient care. Answer 2: Video 1 shows the pancreatic walled-off necrosis as a large heterogeneous mass adjacent to the heart, best seen in the parasternal long-axis view. In the apical five-chamber and subcostal four-chamber views, an anechoic circumferential pericardial effusion with fibrinous stranding is noted. Pericardial tamponade physiology is demonstrated with significant right atrial wall collapse during systole. In the post-pericardiocentesis echo (Video 2), we see resolution of the effusion and resolution of tamponade physiology. The patient’s hypotension improved after pericardiocentesis. Pericardial fluid was significant for elevated lactate dehydrogenase and lipase of 742 U/L, confirming the pancreatic source of the effusion. Despite improvement in his hemodynamics, he subsequently developed respiratory failure caused by a bronchogastropancreatic fistula and ultimately died after a prolonged ICU stay. According to the 2012 revised Atlanta classification,1Foster B.R. Jensen K.K. Bakis G. Shaaban A.M. Coakley F.V. Revised Atlanta classification for acute pancreatitis: a pictorial essay.Radiographics. 2016; 36: 675-687Crossref PubMed Scopus (127) Google Scholar pancreatitis is now defined in two subtypes, necrotizing pancreatitis and interstitial edematous pancreatitis. In this patient, the fluid collection is attributable to pancreatic walled-off necrosis, which consists of necrotic peripancreatic tissue with liquefaction. Commonly, it can cause mass effect against the pancreatobiliary system. In this case, WON resulted in displacement of the stomach and became anatomically close to the mediastinal structures, including the heart and the lungs, leading to complications such as cardiac tamponade and bronchogastropancreatic fistula. There are approximately 50 case reports in the literature of mediastinal extension of pancreatic fluid collections.2Gupta R. Munoz J.C. Garg P. Masri G. Nahman Jr., N.S. Lambiase L.R. Mediastinal pancreatic pseudocyst: a case report and review of the literature.MedGenMed. 2007; 9: 8PubMed Google Scholar To the best of our knowledge, this is the fourth case of cardiac tamponade caused by pancreatic pericardial effusion3Veron Esquivel D. Aello G. Batiz F. Fernandez Barrera A. Cardiac tamponade, an unusual complication of acute pancreatitis.BMJ Case Rep. 2016; bcr2016214460Crossref Scopus (2) Google Scholar, 4Patil M. Shafiq S. Kurien S.S. Devarbhavi H. Lessons of the month 1: Cardiac tamponade: don't forget the pancreas.Clin Med (Lond). 2021; 21: e414-e416Crossref PubMed Google Scholar, 5Tan M.H. Kirk G. Archibold P. Kennedy P. Regan M.C. Cardiac compromise due to a pancreatic mediastinal pseudocyst.Eur J Gastroenterol Hepatol. 2002; 14: 1279-1282Crossref PubMed Scopus (23) Google Scholar and the first attributable to WON. The workup of hemodynamic instability in the setting of pancreatitis should include point-of-care ultrasound to exclude tamponade, and point-of-care ultrasound also can assist in the diagnosis of other common causes of hypotension or shock (Fig 2). Pericardial effusion may be an underrecognized complication of pancreatitis, with estimated incidence between 17%6Maringhini A. Ciambra M. Patti R. et al.Ascites, pleural, and pericardial effusions in acute pancreatitis.Dig Dis Sci. 2005; 41: 848-852Crossref Scopus (60) Google Scholar and 47%.7Variyam E.P. Shah A. Pericardial effusion and left ventricular function in patients with acute alcoholic pancreatitis.Arch Intern Med. 1987; 147: 923-925Crossref PubMed Scopus (18) Google Scholar In addition to the rare cause (pancreato-pericardial fistula) described in our case, other possible mechanisms for pleural effusion in pancreatitis include leakage of inflammatory pancreatic exudates containing digestive enzymes3Veron Esquivel D. Aello G. Batiz F. Fernandez Barrera A. Cardiac tamponade, an unusual complication of acute pancreatitis.BMJ Case Rep. 2016; bcr2016214460Crossref Scopus (2) Google Scholar as well as disruption of the thoracic duct causing a chylous pericardial fluid collection.8Arendt T. Bastian A. Lins M. Klause N. Schmidt W.E. Fölsch U.R. Chylous cardiac tamponade in acute pancreatitis.Dig Dis Sci. 1996; 41: 1972-1974Crossref PubMed Scopus (13) Google Scholar Even though WON with mediastinal extension is exceeding rare, it has high mortality and morbidity rates and often requires emergent surgical interventions. Bedside echocardiogram serves as an essential tool to identify complications that arise from acute pancreatitis. See Narration Video for a detailed explanation of Videos 1 and 2. 1.Even though exceedingly rare, pancreatic walled-off necrosis can enable a pancreatico-pericardial fistula or bronchogastropancreatic fistula to form and cause complications such as cardiac tamponade and respiratory failure.2.The differential diagnosis of hypotension or shock in a patient with acute pancreatitis is broad.3.Bedside echocardiogram serves as a helpful diagnostic tool to rapidly identify life-threatening complications from acute pancreatitis. Author contributions: M. R. L. had full access to all data in the study and takes responsibility for the integrity of the manuscript. T. T., I. T. D., M. P. R. R., E. S. G., D. L. S., K. C. H., and M. R. L. Figure and video creation: T. T., I. T. D., M. P. R. R., E. S. G., D. L. S., K. C. H., and M. R. L. Drafting of the manuscript: T. T., I. T. D., M. P. R. R., E. S. G., D. L. S., K. C. H., and M. R. L. Critical revision of the manuscript: T. T., I. T. D., M. P. R. R., E. S. G., D. L. S., K. C. H., and M. R. L. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: Videos for this case are available under “Supplementary Data.” eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxNjQyZGQyY2ZiODgzMzllMDNjOWFiZjRjN2I4MDI1MiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTE1fQ.d_Wo7BIsZDVpu2rtmSDn-06D8qoZ8AmuyeILrNQYXKxIZfUaAVGpl26snymT6Ne7bOCGtRlhlIS3K0R6anZGTugQRoaLAWwz-Br5s9KXe5nfqs_gVLz1NfLZaLFwdz1vKKxtvkUXUDdJw49I7_2xXKqqRXAOoA75WFsx6_EkzjGB730Okuz-ylITlS7_RF01YByt4fkzbI9RNjcG_e53XPUGiRYOOTQPtPGQTw-xaqgI6M82vWY82TF7k-h2GL-HcdynsQOQaj3aBbzsXPCHGoZCVBML_Q1IXFwzblUuKxzcwDN88SNOodoNLyhQWAv4L7rxT1_El3SuwUOM5_BJvQ Download .mp4 (6.03 MB) Help with .mp4 files Video 1(Clip 1) Parasternal long-axis view of the heart demonstrating the pancreatic walled-off necrotic fluid collection in close proximity to pericardial effusion and the left ventricle. (Clip 2) Apical 5-chamber and subcostal 4-chamber (Clip 3) views of the heart demonstrating a pericardial effusion with right atrial collapse, consistent with pericardial tamponade.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmMTg3NWY3NzRmZDk0MGUyNWUwMzc1ZTgwOGExZTY2ZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTE1fQ.W51tMm5sbyxY2yNLmFYzpsMRCt_crrT0Rby-LTTRMkEEQhpbCfL9cdE5tepXZs7SSJUcHMotU6CgwdS83QdrG3D0p-4TXKYE-EI0W8EQlP7cpHASwIzNm-9_6ztS4xoQm17txpwkJenvFTOyEHDR22lUwpQLs7wDlKUXE5VRZK0MmjF1fBKPa_AssCr5n5k30mFrfh3OWj27k79x99KvEXJ7tDK0ZIHrpyaq24-UYnnWSuHEHUu6G0-L7jAyS9CeJv1DL9dNEi56ltEJYjb-BueZwFJXTdaB32H23JyOJp4V_fSe66vF2IP5khxWVTCj60yWadwHoTE2KSQz4pLZlw Download .mp4 (6.49 MB) Help with .mp4 files Video 2(Clip 1) Parasternal long-axis view of the heart demonstrating the pancreatic walled-off necrotic fluid collection in close proximity to pericardial effusion and the left ventricle. (Clip 2) Apical 5-chamber and subcostal 4-chamber (Clip 3) views of the heart demonstrating a pericardial effusion with right atrial collapse, consistent with pericardial tamponade. (Clip 4) Apical four-chamber view of the heart obtained after pericardiocentesis demonstrating successful drainage of the pericardial effusion and resolution of tamponade physiology.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3OTlhOTI1ZDRkZWZmYmE2ZGY0OTQyODVmMThiMTU2ZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTE1fQ.LmtwH-Y2FdZ_m9mxvZdR0BC0RcfuY_CtYOCUgmgQUL2aDmmRSr3pnUpVlh4BJD2NLET8oSLXt4AFjT2X4g5Awlcbxan_soK-qWRfqDg2lWxxlOZSpajILaMlkq_C8Dkzvi2_nVLmaPV_IOJcgqL9jb778JWtItEUQ33EUyy2JMJFPTqT2QpVT-hZAGH-c-X5aJd_OYQzGX7_Qn5rP_33_PKtgnnt_TyG2CmrVKjdW3T-f7-ueRorD1VYsswXDukKRgATm1G3Iia3iPChZCsjL2vK-2O3bmsTFGCs5kHJOAscJ40HB34P6d4s1amc-10jfhn4IeDwZvlYtYOUHu08KA Download .mp4 (17.22 MB) Help with .mp4 files Videos 3- (Clip 1) Parasternal long-axis view of the heart demonstrating the pancreatic walled-off necrotic fluid collection in close proximity to pericardial effusion and the left ventricle. (Clip 2) Apical 5-chamber and subcostal 4-chamber (Clip 3) views of the heart demonstrating a pericardial effusion with right atrial collapse, consistent with pericardial tamponade. (Clip 4—Video 2 only) Apical four-chamber view of the heart obtained after pericardiocentesis demonstrating successful drainage of the pericardial effusion and resolution of tamponade physiology.