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Clinical Case: Large Bowel Obstruction as a Delayed Complication of Pancreatitis - want to learn more about it?

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Clinical Case: Large Bowel Obstruction as a Delayed Complication of Pancreatitis

In this article, we describe a case of a woman who presented to the ER with abdominal distention, constipation, epigastric tenderness, and absent bowel sounds. Her diagnosis was a bowel obstruction which developed as a complication of a previous episode of pancreatitis. We will follow her journey from admission and history all the way to prognosis and evolution. We will also look at the mechanism of bowel obstructions following pancreatitis, together with possible management options and relevant anatomical considerations.

Key facts
Cholelithiasis & Pancreatitis Blockage of the Ampulla of Vater (combined terminal pathways from the liver bile and pancreatic enzymes) results in liver and pancreas dysfunction (pancreatitis)
Mechanism of Colonic Strictures Pancreatitis can lead to colonic strictures via the spread of pancreatic enzymes and inflammatory mediators into the mesocolon and mesentery via the peritoneal reflections, or ischemia of the splenic flexure (watershed region)
Absent Bowel Sounds Bowel sounds represent peristaltic waves, hence their absence indicates paralysis (ileus).
Radiological Features of Bowel Strictures Bowel segments proximal to the obstruction swell with gas, fluid or intestinal contents, appearing dilated. Segments distal to the obstruction become constricted because no contents can flow past the obstruction.
Air-Filled Fluid Levels In Radiology Abnormal presence of fluid

After reviewing this case you should be able to describe the following:

  • The relationship between gallstone disease (cholelithiasis) and pancreatitis.
  • The possible anatomic/pathologic mechanisms to explain the development of a colonic stricture from pancreatitis, and suggest why this is likely to occur at the splenic flexure.
  • Why the patient did not have bowel sounds.
  • The physiological basis for why there were dilated bowel loops proximal to the splenic flexure in this patient.
  • What is an air-fluid level in a radiologic image, why does it occur and why it can be radiologically significant.
  • Explain why anatomical identification and radiological diagnosis from cross-sectional images typically require a series of images rather than a single image.

This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.

It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Case Description

History & Physical Exam

A 31-year-old woman presented to the ER with a brief history of abdominal distention and constipation. She had previously been hospitalized for pancreatitis resulting from blockage of the hepatopancreatic ampulla (Ampulla of Vater) by a gallstone. A CT scan at the time of the first admission showed an inflamed pancreas and dilated bowel proximal to the splenic flexure. A radiographic study at the time showed a possible stricture at the splenic flexure. At that admission, she responded well to non-surgical treatment and was released from the hospital. On subsequent readmission, her abdomen was distended, there was epigastric tenderness and there was an absence of bowel sounds.

Imaging

A radiograph confirmed a bowel obstruction at the splenic flexure (Figures 1; note that this radiograph is not presented in standard orientation because it was not presented as such in the original report; in standard orientation a radiograph is presented as if you were looking at the front of the patient; the student should thus be prepared for non-standard presentations in some reports).

Figure 1. AP abdominal radiograph after injection of barium into the rectum. Note that the barium is not apparent beyond the splenic flexure. (This presentation is as in the original case report. IT IS NOT A STANDARD PRESENTATION in that it is not presented as if the observer is looking at the front of the patient, but rather as if the observer is looking at the patient’s back; see text).

The published case report stated that CT imaging demonstrated pancreatitis and dilated bowel segments and referred to Figure 2 (the student should realize that this single CT image, by itself, is not sufficient for a definitive diagnosis of pancreatitis and dilated bowel segments – from this image alone it is not possible anatomically to know that whether the distended tubular structures are bowel segments or parts of the stomach; however, the whole series of abdominal CT slices likely provided a sound basis for diagnosis of both of these conditions).

Figure 2. Axial CT showing possible pancreatitis and air-fluid levels which could be in the stomach or distended large bowel segments (see text).

Management & Evolution

At laparotomy (surgical opening of the abdomen to explore for pathology), a large intestinal obstruction was identified at the splenic flexure resulting from a densely adherent inflammatory peri-pancreatic mass. A segmental colonic resection was done as well as a retrograde cholecystectomy (surgical removal of the gallbladder). Complications required a re-laparotomy, which was followed by a slow recovery in the patient.

Histological Examination & Final Diagnosis

Histologic examination of the obstruction revealed pericolonic lymphocytic and inflammatory tissue with areas of fibrosis around distinct areas of pancreatic fat necrosis, which compressed and occluded the colonic wall (Figure 3).

Figure 3. Histologic section of obstruction showing pericolonic scarring and inflammatory changes around pancreatic fat necrotic foci.

Anatomical Considerations

Colonic complications from pancreatitis are rare but include bowel obstruction, ileus (absence of, or, slowing in bowel peristalsis), bowel necrosis, fistulae, obstruction and perforation; the close anatomical relationships between the pancreas and the bowel account for these potential complications. 

Figure 4. Hepatopancreatic ampulla (ampulla of Vater) - ventral view

Explanations to Objectives

Objectives

  • The relationship between gallstone disease (cholelithiasis) and pancreatitis.
  • The possible anatomic/pathologic mechanisms to explain the development of a colonic stricture from pancreatitis, and suggest why this is likely to occur at the splenic flexure.
  • Why the patient did not have bowel sounds.
  • The physiological basis for why there were dilated bowel loops proximal to the splenic flexure in this patient.
  • What is an air-fluid level in a radiologic image, why does it occur and why it can be radiologically significant.
  • Explain why anatomical identification and radiological diagnosis from cross-sectional images typically require a series of images rather than a single image.

Relationship Between Cholelithiasis and Pancreatitis

Because the Ampulla of Vater (Figure 4) is typically the combined terminal pathway by which both liver bile and pancreatic enzymes enter the second part of the duodenum, any blockage at this location will cause liver and pancreas dysfunction (Figure 5). The liver dysfunction will produce jaundice, chills, tachycardia, and lighter-colored stools. The pancreas dysfunction results in pancreatitis, which causes abdominal pain, nausea and vomiting. The patient underwent cholecystectomy (surgical removal of the gallbladder) to reduce the possibility of a recurrence of this condition via gallstone blockage of the Ampulla.

Figure 5. Anatomical dissection showing the joining of the pancreatic and common bile ducts as they enter the second part of the duodenum. Note that this photograph is viewed from the posterior aspect of the body in order to highlight these structures. Thus, in this image the spleen is to the right and the liver is to the left.

Mechanism of Colonic Strictures Following Pancreatitis

Many pathological hypotheses have been suggested to explain the development of colonic obstruction following pancreatitis. External compression by the inflamed mesentery of the transverse colon on the pancreas can lead to necrosis of fatty tissue, which can combine with calcium to form deposits that, in turn, cause the blockage.

Additionally, the peritoneal reflections on the anterior surface of the pancreas provide a potential pathway for the spread of both pancreatic enzymes and inflammatory mediators within the transverse mesocolon and the small bowel mesentery. This can result in fat necrosis and fibrosis, which can cause narrowing of the bowel lumen. This latter process provides a plausible explanation for why the stenosis frequently occurs in the splenic flexure region, which is in close proximity to the tail of the pancreas.

Additionally, the splenic flexure is a watershed region (Figure 6) between the vascular supply areas of the middle and left colic arteries, and is therefore sensitive to low arterial flow during acute pancreatitis. The resulting ischemia may result in an obstruction.

Figure 6. Anatomical dissection showing the watershed area of supply of large colon, near the splenic flexure. The watershed area is the part of the colon between areas of supply of middle colic and left colic arteries.

Absence of Bowel Sounds in Bowel Obstruction

The gut normally makes noises (gurgling, growling sounds) associated with peristalsis. The absence of such sounds can indicate intestinal paralysis (ileus), which in this patient was due to the bowel obstruction. 

Basis of Dilated Bowel Loops Proximal to the Splenic Flexure

Whenever there is a bowel obstruction, the bowel segments proximal to the obstruction swell as they fill with gas, fluid and intestinal contents, whereas the segments distal to the obstruction become constricted because they no longer are functional due to the absence of intestinal contents flowing past the obstruction.

Air-Filled Fluid Levels in Radiological Images

Fluids in anatomical structures are gravity dependent; thus, if the fluid does not completely fill the structure as in a cyst, air-fluid levels may appear on radiologic images as in Figure 2. Because the position of these levels is gravity dependent it can be concluded that this patient was supine when the CT imaging was done. These air-fluid levels have diagnostic value; for example, demonstrating the abnormal presence of fluid in the lung.

Multi-Layered Cross-Sectional Images

Although in anatomy courses students are often asked to identify structures in a single CT image, this is not the manner that radiologists commonly use to provide diagnoses. Rather, radiologists typically can only provide definitive identification of structures and diagnoses by following structures in a series of images because anatomical structures do not typically lie solely within orthogonal (perpendicular) planes and often meander in and out of any single plane. Thus, based on Figure 2 alone, it is unclear whether the partially fluid-filled tubular structures are large bowel or stomach segments.

Clinical Case: Large Bowel Obstruction as a Delayed Complication of Pancreatitis - want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top results faster.

Sign up for your free Kenhub account today and join over 1,086,160 successful anatomy students.

“I would honestly say that Kenhub cut my study time in half.” – Read more. Kim Bengochea Kim Bengochea, Regis University, Denver

Show references

Reference:

  • Neeraj L, Whiting J, Hejmadji Raman, S. Large bowel obstruction, a delayed complication of severe gallstone pancreatitis. Case Reports in Surgery, Volume 2016, Article ID 1034929, http://dx.doi.org/10.1155/2016/1034929.
  • Modified by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.

Authors:

  • Joel A. Vilensky 
  • Carlos A. Suárez-Quian
  • Aykut Üren

Layout:

  • Abdulmalek Albakkar
  • Adrian Rad

Illustrators:

  • Hepatopancreatic ampulla (ampulla of Vater) - ventral view - Irina Münstermann
© Unless stated otherwise, all content, including illustrations are exclusive property of Kenhub GmbH, and are protected by German and international copyright laws. All rights reserved.

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