Introduction

Vascular thrombosis and systemic hypercoagulable states are known complications of pancreatitis.[₁, ₂, ₃] We report a rare case of inferior vena cava (IVC) thrombosis associated with acute pancreatitis.

Case Report

A 24-year-old male alcoholic presented with severe upper abdominal pain and vomiting since the last five days. He also noticed a progressive swelling of both legs since two days. General examination revealed a pitting edema in both legs. On examination of the abdomen, there was diffuse tenderness with absence of bowel sounds.

The relevant laboratory findings on admission were: hemoglobin 16.3g/dl, total leukocyte count 16400, random blood sugar 95 mg/dl, serum creatinine 0.8mg/dl, serum lipase 709 U/L, serum amylase 1416 IU/L and serum albumin 3.8g/dl. The activated partial thromboplastin time was 31 seconds and the prothrombin time was 20 seconds with an International Normalised Ratio (INR) of 1.2.

Ultrasonography of the abdomen showed a 26x12mm sized hyperechoic thrombus in the infrahepatic part of in the inferior vena cava (IVC) (Fig. 1). Abdominal computed tomography revealed a central non-enhancing area within the infrahepatic part of the inferior vena cava extending up to the level of the left renal vein opening, suggestive of a thrombus along with a bulky pancreas with an ill-defined peripancreatic fat plane. The portal vein was normal (Fig. 2).

Figure 1

Figure 1: sonogram of the abdomen showing a hyperechoic thrombus in the infrahepatic part of the inferior vena cava

Figure 2

Figure 2: Abdominal Computed Tomography Showing An Inferior Vena Cava Thrombus Along With A Bulky Pancreas And Ill-Defined Peripancreatic Fat Planes.

The patient was managed conservatively with nil orally, nasogastric aspiration, intra-venous fluids, antibiotics and analgesics. Intravenous heparin was started at the dose of 5000 U 6-hourly with further dose adjustment maintaining an activated partial thromboplastin time between 50-80 seconds for five days.

The patient improved clinically with a reduction in the swelling of both legs.

Discussion

Isolated portal vein or combined superior mesenteric vein and portal vein thrombosis are known complications of acute pancreatitis. Isolated inferior vena cava (IVC) thrombosis is a very rare complication of acute pancreatitis, was first reported by Stringer[₄] et al. in 1988 and there have been very few descriptions about it.[₂,₃,₅,₆,₇]

The mechanism of formation of the IVC thrombus in acute pancreatitis[₆, ₇] is due to a cyst communicating with the pancreatic duct penetrating into the IVC.

Pancreatic juice entering the IVC and triggering the formation of athrombus secondary to vasculitis.

Inferior vena cava thromboses with renal vein thrombosis have also been reported with acute pancreatitis.[₆]

Virtually all radiological modalities have been applied to the diagnosis of IVC thrombosis in acute pancreatitis. Contrast venography, ultrasonography, contrast-enhanced CT scan and MRI of the abdomen all have defined roles in the diagnosis of IVC thrombosis.

Pulmonary thromboembolism is a dreadful complication of IVC thrombosis in acute pancreatitis, with the patient developing acute shortness of breath.[₅,₇]

Radionuclide 99mTc-venography and lung perfusion scintigraphy are useful in diagnosing pulmonary thromboembolism secondary to IVC thrombosis in pancreatitis, showing abnormal large hot spots at the level of the pancreas and pulmonary embolism.[₇]

Early treatment with intravenous heparin is effective.[₃] An IVC filter is sometimes used in the management of IVC thrombosis in acute pancreatitis to prevent pulmonary thromboembolism.[₈]

This case report describes a rare complication of acute pancreatitis. Familiarity with this complication will aid in its early diagnosis and prevent pulmonary thrombembolism, a rare but catastrophic phenomenon.

Correspondence to

Dr. Shantanu Kumar Sahu Assistant professor Department of General Surgery Himalayan Institute of Medical Sciences Swamiramnagar Dehradun Uttaranchal 248140 Email - lntshantanu@yahoo.co.in Mob. - 9412933868