Porcu Alberto, Tilocca Pier Luigi, Pilo Luca, Ruiu Francesca, Dettori Giuseppe
Department of General Surgery, University of Sassari, Faculty of Medicine, Sassari, Italy.
Ann Ital Chir. 2010 May-Jun;81(3):215-20.
We describe the case of a 38 year old man, with a story of alcohol abuse, who developed a very painful nodular subcutaneous fat necrosis, fever and polyarthritis, denying any abdominal symptoms due to a pancreatic pseudocyst-inferior vena cava fistula.
The authors discuss the unusual and protracted course with intermittent hyperamylasemia and hyperlipasemia related to clinical manifestations such as subcutaneous fat necrosis, polyarthritis, pleural effusion and dysfibrinogenemia, and vascular complications as inferior vena cava stenosis and left renal vein thrombosis without abdominal symptomatology.
After ultrasonograms and CT Scans showing a 3-4 cm cyst at the pancreatic head with a solid bud protruding into the pseudocystic cavity, and an ERCP showing a communication between the pancreatic duct and the pseudocyst but failing in demonstrating the vascular fistula, the patient underwent a Roux-en-y pseudocyst-jejunostomy and suture of the caval communication leading to complete recovery with normalization of laboratory findings.
In our case, the locally sclerosing activity of the enzymes in the endothelium led to a communication between the inferior vena cava and the pseudocyst and to a complete thrombosis of the left renal vein and to a stenosis of the inferior vena cava itself The fluctuance of the symptomatology severity was probably due to an intermittent opening of the passage between pseudocyst and vena cava. Such a clinical case, to the author knowledge, has never been reported.
When in presence of very high levels of amylasemia and lipasemia in spite of the paucity of abdominal symptomatology, and the onset of unusual complications such as panniculitis, pleural effusion, arthritis and coagulative disorders, a pancreatic pseudocyst-inferior vena cava fistula should be kept in consideration during diagnosis.
我们描述了一名38岁有酗酒史的男性病例，他出现了非常疼痛的结节性皮下脂肪坏死、发热和多关节炎，否认因胰腺假性囊肿 - 下腔静脉瘘而有任何腹部症状。
作者讨论了该病例不寻常且病程迁延，伴有间歇性高淀粉酶血症和高脂肪酶血症，与皮下脂肪坏死、多关节炎、胸腔积液和纤维蛋白原血症等临床表现相关，以及血管并发症如下腔静脉狭窄和左肾静脉血栓形成，但无腹部症状。
超声检查和CT扫描显示胰头部有一个3 - 4厘米的囊肿，有一个实性芽突入假性囊肿腔，ERCP显示胰管与假性囊肿相通，但未能显示血管瘘，患者接受了Roux - en - y假性囊肿空肠吻合术以及腔静脉交通口缝合，术后实验室检查结果恢复正常，患者完全康复。
在我们的病例中，内皮中酶的局部硬化活性导致下腔静脉与假性囊肿相通，左肾静脉完全血栓形成以及下腔静脉本身狭窄。症状严重程度的波动可能是由于假性囊肿与腔静脉之间的通道间歇性开放所致。据作者所知，这样的临床病例从未有过报道。
当尽管腹部症状不明显但存在非常高的淀粉酶血症和脂肪酶血症水平，且出现不寻常的并发症如脂膜炎、胸腔积液、关节炎和凝血障碍时，诊断时应考虑胰腺假性囊肿 - 下腔静脉瘘。
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