The management of multi-site, bleeding, visceral artery pseudoaneurysms, secondary to necrotising pancreatitis

We present the case of a 45-year-old man, who presented to his local casualty department with severe epigastric pain following an alcohol binge, and was subsequently diagnosed with acute pancreatitis. Pancreatic necrosis with multiple collections ensued, necessitating transfer to an intensive care unit (ITU) in a tertiary hepatopancreaticobiliary centre. Initially, the patient appeared to slowly improve and was discharged to the ward, albeit following a prolonged ITU admission. However, during his subsequent recovery, he suffered multiple episodes of haematemesis and melaena associated with haemodynamic instability and requiring repeat admission to the ITU. Computerised tomographic angiography, followed by visceral angiography, was used to confirm the diagnosis of multisite visceral artery pseudoaneurysms, secondary to severe, necrotising pancreatitis. Pseudoaneurysms of the splenic, left colic and gastroduodenal arteries were sequentially, and successfully, radiologically embolised over a period of 9 days. Subsequent sequelae of radiological embolisation included a clinically insignificant splenic infarct, and a left colonic infarction associated with subsequent enterocutaneous fistula formation. The patient made a prolonged, but successful, recovery and was discharged from hospital after 260 days as an in-patient. This case illustrates the rare complication of three separate pseudoaneurysms, secondary to acute pancreatitis, successfully managed radiologically in the same patient. This case also highlights the necessity for multidisciplinary involvement in the management of pseudoaneurysms, an approach that is often most successfully achieved in a tertiary setting.

Circulating anti-(xanthine oxidoreductase) antibodies in healthy human adults

Levels of free anti-(xanthine oxidoreductase) (XOR) antibodies in the serum of normal healthy human subjects were determined, using both human and bovine enzyme as antigen, in an enzyme-linked immunosorbent assay (ELISA). Levels of IgM class anti-(human XOR) antibodies were found to be particularly high (mean values representing approximately 3% of total IgM) and to be significantly higher than levels of IgM anti-(bovine XOR) antibodies, indicating that endogenous XOR, rather than ingested bovine milk XOR, is the immunogen. IgM anti-XOR antibody levels were significantly higher in women under 50 years than in age-matched men, or in older women. Levels of IgG class anti-XOR antibodies were much lower and showed no correlation with gender or age. Affinity-purified anti-(human XOR) antibodies only partially inhibited enzymic activities of XOR. The majority of both IgM and IgG anti-(human XOR) antibodies in serum occurred as immune complexes, suggesting that the specific antibodies have a protective role in removing potentially damaging XOR from the circulation.