Anahat Kaur, MD1, Sheetal Bulchandani, MD1, Lyla Saeed, MD2
1University of Missouri, Kansas City, MO; 2University of Missouri Kansas City School of Medicine, Kansas City, MO
Introduction: Superior mesenteric arteriovenous fistula (SMAVF) is a rare entity. Most common cause of SMAVF is post-traumatic, however they may be congenital, iatrogenic or secondary to connective tissue disorders. We report a case of SMAVF in setting of acute on chronic pancreatitis.
Case Description/Methods: 62-year-old male with history of pancreas divisum, infrarenal abdominal aortic aneurysm, cholelithiasis and chronic calcific pancreatitis initially presented for elective Endoscopic Retrograde Cholangiopancreatography (ERCP) for obstructing pancreatic ductal stone with stent placement. After the procedure, patient had to be admitted and treated for acute post-ERCP pancreatitis. Patient underwent repeat ERCP in four weeks for stent replacement but had recurrence of pancreatitis after the second procedure. Computerized Tomography (CT) scan of the abdomen done at that time was consistent with pancreatic pseudocyst causing minimal mass effect on Superior Mesenteric Vein (SMV) without vascular thrombosis. Patient was discharged once stable but unfortunately returned to the hospital for a third time within two weeks complaining of nausea, vomiting, severe abdominal pain and diarrhea. CT Angiogram of the abdomen and pelvis was obtained this admission which showed changes consistent with colitis, increasing size of pancreatic pseudocysts with possible necrosis, new SMV thrombosis and SMAVF in region of middle colic artery. This was confirmed on mesenteric angiogram. Patient was started on anticoagulation to treat thrombosis and clinically improved after symptomatic management. The case was discussed at multidisciplinary conference and no acute intervention for SMAVF was recommended. Patient eventually underwent laparoscopic cholecystectomy few months later for cholelithiasis and SMAVF was noted to be stable on repeat CT scan at four-month interval.
Discussion: SMAVFs are extremely rare. As of 2005, only 40 cases of post-traumatic SMAVF and similar number of iatrogenic cases had been cited in literature. Clinical presentation can be asymptomatic or manifest as abdominal pain, anorexia, diarrhea, gastrointestinal bleed, portal hypertension and congestive heart failure. Splanchnic venous thrombosis, as seen in our patient, develops in 50 percent cases with necrotizing pancreatitis. Such thrombosis can further lead to development of SMAVF which was also noted in this case.
Citation: Anahat Kaur, MD; Sheetal Bulchandani, MD; Lyla Saeed, MD. P0039 - RARE CASE OF SUPERIOR MESENTERIC ARTERIOVENOUS FISTULA AS COMPLICATION OF RECURRENT PANCREATITIS. Program No. P0039. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.