A 50-year-old woman was admitted with a history of melena in the last 24 h. She reported
having suffered intermittent mild mid-epigastric pain, postprandial nausea, and bilious
emesis during the past 3 months. She was taking nonsteroidal anti-inflammatory drugs
up to 1200 mg per day. On examination she was pale, afebrile, with a regular heart
rate at 100 beats/min and a blood pressure of 110/60 mm Hg. She had abdominal tenderness
with no signs of guarding. Laboratory data showed the hemoglobin concentration at
7 g/dL and leukocytosis (23 × 109/L). Plain abdominal and chest radiographs were normal. After stabilization, gastroscopy
revealed a large duodenal ulcer covered by a nonremovable blood clot and oozing that
was effectively controlled by injection therapy with ethanolamine. After endoscopy
the patient was in severe pain, and a CT scan of the abdomen revealed pneumopancreas
([Fig. 1]). She responded promptly to conservative medical therapy. The follow-up CT 14 days
later showed a marked reduction of the pneumopancreas, with a thin, air-filled fistulous
tract between the gastric lumen and the pancreatic duct ([Fig. 2]). Complete healing of the ulcer was achieved with antisecretory therapy. The patient
presented 3 months later with jaundice as a result of stricture of the distal common
bile duct. Surgical hepaticojejunostomy was performed and she recovered uneventfully
and is cholangitis-free, 1 year after the operation.
Fig. 1 Contrast-enhanced CT scan of the abdomen revealed a markedly distended gas-filled
pancreatic duct, with no inflammatory changes in the pancreas, peripancreatic collections,
or pneumoperitoneum.
Fig. 2 Follow-up CT 14 days later showing a marked reduction of pneumopancreas and loss of
fascial planes, with a thin, air-filled sinus tract (white arrow) between the adjacent
bowel wall and the head of the pancreas.
Pancreatic gas is a rare finding, usually complicating phlegmonous pancreatitis or
fistulization from pancreatic pseudocyst rupture [1]. Fistulization into the main pancreatic duct as a complication of penetrating ulcer
should be also considered [2]. In our patient, despite recurrent abdominal pain the diagnosis remained elusive
until pneumopancreas occurred after gastroscopy, because of the considerable volume
of air entering the pancreatic duct during endoscopic air insufflation. The majority
of these fistulas heal with a conservative approach. However, surgery may be eventually
required in patients with biliary sequelae, as in our case.
Endoscopy_UCTN_Code_CPL_1AH_2AC
