A 52-year-old man with hypertension presented with sudden-onset lower back pain and numbness in both lower limbs. Imaging revealed a Stanford type A aortic dissection extending from the ascending aorta to the left common iliac artery, with compression of the celiac artery and partial thrombosis of the superior and inferior mesenteric arteries. The patient underwent ascending aortic replacement surgery. On postoperative day 3, he developed intestinal ischemia, requiring a subtotal colectomy. By postoperative day 10, he developed fever and hypotension, and subsequent imaging revealed ischemic pancreatitis localized to the pancreatic body. This was attributed to celiac artery stenosis due to false lumen compression and superior mesenteric artery dissection. He gradually recovered with conservative management, including fluid therapy and percutaneous cyst drainage. This case highlights the importance of recognizing ischemic pancreatitis as a delayed complication of aortic dissection, particularly in cases involving impaired visceral blood flow.

The occurrence of pancreatitis shortly after elective lumbar spine surgery in an adult is rare. We report a case of a 63-year-old female who developed, for the first time, acute pancreatitis within three days of elective lumbar (L) spine surgery that was performed for degenerative disk disease without significant deformity (i.e., no scoliosis or spondylolisthesis). The surgery was conducted using a lateral transpsoas approach and included interbody fusions at L3-L4 and L4-L5 levels and posterior instrumentation with pedicle screws and rods. Ten years prior, she had a cholecystectomy, and she was not diabetic or obese. She began experiencing significant nausea and malaise two days after that lumbar spine surgery, requiring hospitalization on the third postoperative day. Her pancreatitis became chronic, and a large pancreatic pseudocyst developed and persisted despite using an external drainage catheter for 52 days. At 126 days after the spinal surgery, an open Roux-en-Y pancreatic cystojejunostomy was performed to internally drain the cyst, which had enlarged to 19 cm. Significant pre-surgical risk factors for this first-time case of pancreatitis were not identified. The spine surgeon denied iatrogenic causes such as instrument plunging or complications associated with the use of a "lateral access retraction system," and surgical blood loss was only 50 ml during the elective lumbar spine surgery. However, during the lumbar spine surgery, hypotension occurred for 20 minutes (mean arterial pressure: 63-73 mmHg), which was associated with transient acute kidney injury. This might have contributed to the development of her pancreatitis because the pancreas is more sensitive to ischemia than the kidney. During the initial week after the onset of pancreatitis, her symptoms were mainly believed to be due to an acute postoperative infection. However, there was no growth in cultures from aspirations of the pleural effusion, retroperitoneal effusion, and deeper incision area. Despite extensive workup, the cause of the patient's pancreatitis was not determined. We report this case not only because of its rarity but also to help surgeons and other healthcare providers in the workup and management of similar situations.

Acute pancreatitis is a common gastrointestinal condition worldwide with variable severity and complications. Alcohol and gallstones are the leading causes of acute pancreatitis, while pancreatic ischemia is uncommon. Although venous thrombosis, especially adjacent to the inflamed pancreas, is a common complication of acute pancreatitis, arterial thrombosis secondary to pancreatitis has rarely been described. On the other hand, arterial thromboembolic events, secondary to cardiovascular diseases, are a rare cause of pancreatic ischemia. Herein, we present an interesting case of acute ischemic pancreatitis secondary to aortic atheromatosis complicated with multi-organ infarcts.

An 80-year-old male patient presented with nausea, abdominal pain, and vomiting accompanied by peripheral edema and ascites. Clinical, laboratory, and imaging investigation showed acute moderate to severe pancreatitis with multiple splenic and renal infarcts. An intraluminal free-floating aortic thrombus, secondary to atheromatosis of the descending aorta, was the cause of the complications. A conservative approach was successfully implemented, including supportive measures, antiplatelets, and vasodilators.

Identification of acute pancreatitis' cause, especially in the setting of a systemic disease like atheromatosis, is a challenging task and of great importance, given the implications on treatment decision-making and prevention of recurrent episodes. HIPPOKRATIA 2021, 25 (3):138-140.

A 72-year-old man who had been on continuous ambulatory peritoneal dialysis treatment for 10 years underwent cardiopulmonary bypass for aortic valve replacement due to aortic valve stenosis. After surgery, he experienced pancreatitis, and rupture of a splenic artery aneurysm. He went into cardiopulmonary arrest but was successfully treated by transcatheter arterial embolization (TAE) with cardiopulmonary resuscitation. At three weeks after TAE, CT showed heterogeneous enhancement and the accumulation of pancreatic fluid in the pancreatic tail. At 4 months after TAE, he had sepsis and CT showed greater fluid collection with emphysema in comparison to 3 months previously. We diagnosed infected walled-off necrosis (WON). Conservative therapy with antibiotics was not sufficiently effective; thus, we performed endoscopic ultrasound-guided drainage (EUS-D). Contrast imaging revealed WON with colonic fistula. The WON remarkably decreased in size on CT after EUS-D. We experienced a rare case of ischemic acute pancreatitis (AP) caused by cardiopulmonary bypass complicated with infected WON with a colonic fistula. Ischemic AP more frequently shows a severe course with a fatal outcome in comparison to AP of other causes. However, in our case, ischemic AP with infected WON was successfully treated by EUS-D despite the presence of a WON with a colonic fistula.

We report a case of a 56-year-old woman who presented with worsening abdominal pain located in the left upper quadrant together with abdominal distention, nausea and anorexia. One month prior to this admission, she had presented and had been diagnosed with concurrent acute pancreatitis and rapidly expanding abdominal aortic aneurysm. The aneurysm was prioritised over the pancreatitis and she underwent uncomplicated endovascular repair. Cross-sectional imaging was consistent with infected pancreatic necrosis and also revealed a large collection located in the anterior pararenal space with extensive gas formation. An image-guided fluid aspiration revealed Clostridium perfringens as the causative organism. She was treated by placement of large bore drains along with irrigation and targeted intravenous antibiotic for 6 weeks. The collections resolved completely and at 6 months follow-up she was well and symptom free.