Spontaneous Celiac Artery Dissection Leading to Acute Pancreatitis

Abstract

Introduction: Spontaneous celiac artery dissection accounts for 4% of all visceral artery dissections. If symptomaticpatients may present with abdominal pain due to complications such as bowel ischemia and infarction. We report an unusual case of a 65-year old male who developed acute pancreatitis secondary to progression of a chronic celiac artery dissection. CASE PRESENTATION: 65-year old male with a history of hypertension presented with 2 days of gnawing epigastric pain without radiation associated with nausea, dyspnea and diaphoresis. On physical examination-blood-pressure (BP) 188/88mmHg and epigastric tenderness without any guarding or rebound was noted. Laboratory values included amylase 294U/L and lipase 385U/L with leukocytosis of 25.3k/mcl. Common etiologies of pancreatitis were ruled out. Computer tomography angiography (CTA) was significant for peripancreatic stranding consistent with acute pancreatitis and focal dissection in the celiac artery with occlusion of the splenic artery origin. He was managed conservatively with pain and BP control along with IV hydration and bowel rest. His symptoms resolved within 5 days and he was discharged on aspirin 81mg daily. Vascular surgical follow up with repeat CTA was arranged. DISCUSSION: The pancreas is sensitive to ischemia. The pancreatic head has a dual blood supply from celiac artery and the superior mesenteric artery (SMA). In contrast, the splenic artery (arising from celiac trunk) largely provides flow to the body and tail. Common etiologies of arterial dissection include hypertension, atherosclerosis, trauma and vasculitis. Hypo-perfusion of the pancreas is known to cause acute pancreatitis secondary to ischemia/reperfusion injury.Our patient had a focal dissection at the origin of the celiac. Fortunately, distal splenic artery demonstrated flow originating from large collateral pathways of gastro-duodenal artery maintaining flow to the body of the pancreas. Collateral circulation via the perigastric arteries limited deterioration of the pancreatic tail resulting in a mild pancreatitis.Conservative management is advised for patient without signs of hemorrhage and intestinal ischemia. Blood pressure control is vital to limit progression and antiplatelet therapy is advised to prevent thrombosis. Surgical and endovascular intervention is advised if patients are hemodynamically unstable and if dissection is progressing. Conclusions: Vascular ischemia is a rare cause of pancreatitis. If common etiologies of pancreatitis such as ethanol, gallstones, and hypertriglyceridemia are ruled out-CTA abdomen maybe warranted to look for ischemia.