Pancreatic Arteriovenous Malformation Involving Adjacent Duodenum with Gastrointestinal Bleeding: Report of a Case

An Update of Treatment of Pancreatic Arteriovenous Malformations

Pancreatic arteriovenous malformation is a rare entity (0.9%). There are about 200 articles available in PubMed. This review article includes 86 published articles, with 117 cases published after 2000. The median age at diagnosis was 51, and most of the patients were male (87.0%). The symptoms included pain, bleeding, pancreatitis, ulcers in the duodenum or stomach, varix formation, jaundice, and ascites. The diagnostic modalities were angiography, contrast-enhanced CT, MRI, and/or Ultra Sound. The most common treatments were surgery and embolization. The clinical success rate of embolization reported was 57.7%. The tailored embolization based on each agio-architecture had a clinical success rate of 80%. If embolic therapy is ineffective, surgical intervention should be considered.

Endoscopic Management of Nonvariceal, Nonulcer Upper Gastrointestinal Bleeding

Nonvariceal, nonulcer upper gastrointestinal hemorrhage (UGIH) is a less common cause for acute upper gastrointestinal bleeding. However, nonvariceal, nonulcer UGIH is an important entity to identify and treat appropriately to prevent bleeding-related morbidity and mortality. Over the past 40 years, there has been a revolution in gastrointestinal endoscopy and a similar revolution in the management of UGIH. The aim of this article is to focus on the endoscopic management of nonvariceal, nonulcer UGIH, with a focus on the newer diagnostic and treatment modalities currently available.

Pancreatic arteriovenous malformation

BACKGROUND

Pancreatic arteriovenous malformation is very rare, but may cause significant clinical symptoms such as catastrophic bleeding. Herein, we discuss the clinical presentation and management of patients pancreatic arteriovenous malformations.

METHODS

The data pool for the analysis was collected from pancreatic arteriovenous malformation cases encountered by our institution and sporadic case reports in the English literature.

RESULTS

A total of 89 cases of pancreatic arteriovenous malformation were collected for this study, including 59 cases of arteriovenous malformation in the pancreatic head (62.3 %) and 30 in the pancreatic body-tail (33.7 %). The most commonly associated complications for overall cases of pancreatic arteriovenous malformation were bleeding (50.6 %), pancreatitis (16.9 %), portal hypertension (6.7 %), and pseudocyst (3.4 %). The most common presenting symptom of pancreatic arteriovenous malformation was gastrointestinal bleeding (47.2 %), followed by epigastric pain (46.1 %). Surgery (43.8 %) was the most common treatment for pancreatic arteriovenous malformation cases, followed by transarterial embolization (11.2 %), a combination of surgery and transarterial embolization (10.1 %), and radiotherapy (2.2 %). No intervention was done for 29.2 % of the cases of pancreatic arteriovenous malformation.

CONCLUSIONS

Pancreatic arteriovenous malformation occurs most commonly in the pancreatic head; gastrointestinal bleeding is the main symptom. Surgical resection or transarterial embolization appears to be indicated in patients with symptomatic pancreatic arteriovenous malformation.

A Case of Recurrent Acute Pancreatitis due to Pancreatic Arteriovenous Malformation

Pancreatic arteriovenous malformation (AVM) is an extremely rare condition with various clinical manifestations. We report herein a case of recurrent acute pancreatitis due to pancreatic AVM in a 49-year-old man. This patient presented with epigastric pain that had developed after consuming alcohol 2 days prior to admission. Serum amylase and lipase levels were elevated and computed tomography revealed focal low-attenuation lesions with peripancreatic infiltrations in the pancreatic tail and multiple collateral vessels around the low-attenuation lesions. He was diagnosed with acute pancreatitis and pancreatic AVM. Although he had stopped drinking after the first attack of acute pancreatitis, his pancreatitis recurred twice within 3 months. He underwent a distal pancreatectomy after the third attack of acute pancreatitis. He was free of symptoms for 2 years after the pancreatectomy.

Institutional indications for islet transplantation after total pancreatectomy

BACKGROUND/PURPOSE

This study was designed to establish institutional indications for pancreatic islet transplantation by examining patients with total pancreatectomy as candidates for islet allotransplantation.

METHODS

In 12 patients who underwent total pancreatectomy, we compared pre-and postoperative plasma glucose level, body mass index, HbA1c, and daily insulin use; we examined candidacy for islet allotransplantation based on the guidelines of Japan's islet transplantation registry.

RESULTS

Eight of the 12 patients with total pancreatectomy were operated for intraductal papillary mucinous neoplasm. At our institution, the 5-year survival of patients with intraductal papillary mucinous neoplasm was far better (76.3%) than that of patients with pancreatic cancer. Postoperatively, plasma glucose level, HbA1c, and daily insulin use were increased in all patients with total pancreatectomy. Of the 12 patients treated with total pancreatectomy, 4 (intraductal papillary mucinous neoplasm, n = 2; islet cell tumor, n = 1; and acute pancreatitis due to arteriovenous malformation, n = 1) showed deteriorated diabetic control and therefore were considered to be candidates for islet allotransplantation according to the guidelines.

CONCLUSIONS

Islet allotransplantation could be indicated for patients with favorable postoperative survival who have had a total pancreatectomy for either benign or neoplastic disease.