Hrev_master [page 124] [Emergency Care Journal 2018; 14:7617] Emergency Care Journal 2018; volume 14:7617 Abstract Acute pancreatitis is an acute inflammation of the pancreas and, according to the 2013 Revised Atlanta Classification, the majority of cases have only a mild clinical course without organ dysfunction. The primary objectives in the treatment of acute pan- creatitis are essentially relief of pain, electrolyte and fluid support and energy intake other than removal of the causal agent. Even if in Italy gallstones especially are the predominant etiological factor, there are also less frequent causes associated with acute pancreati- tis and we believe that the case of acute pancreatitis associated with massive incarcerated paraesophageal hernia involving the presence of the body and tail of the pancreas in the thorax is worth reporting. Introduction Acute pancreatitis is an acute inflammation of the pancreas and, according to the Revised Atlanta Classification released in 2013 it is classified as mild (no presence of organ dysfunction), moderate (with transient less than <48 hours organ dysfunction) or severe (with persistent organ dysfunction).1 The primary objectives in the treatment of acute pancreatitis are essentially: pain control, electrolyte and fluids support, energy intake, and removal of the causal agent, attenuation of inflammation, and prevention and eventual treatment of local and systemic complications in necrotiz- ing forms.2 Gallstones are the predominant etiological factor espe- cially in Italy followed by alcohol abuse.3 However, there also less frequent causes associated with acute pancreatitis and we believe that the case we describe is worth reporting. Case Report A 27-year-old male was admitted to our Emergency Room (ER) suffering from extensive abdominal pain which was dull and crampy in nature and associated with nausea and episodes of vomiting with- out blood. On the four days prior to admission, the pain with the same characteristics had been spasmodic but, after physical exertion in the swimming pool became continuous and intense with a value of eight on the visual analogue scale from 0-10.4 His past medical history was unremarkable. In ER, blood pressure was normal (120- 80 mm/Hg), temperature was 36°C, heart rate 78 bpm, respiratory rate 18, O2 saturation 90% in ambient air. On physical examination the abdomen was soft with mild epigastric tenderness and normal bowel sounds. Both cardiovascular and pulmonary examinations were normal. Blood tests revealed an increase of WCC (23,340 mmc), amylase 677 U/L (upper reference limit 100 U/L), lipase 1,602 U/L (upper reference limit 67 U/L); liver and kidney functions were normal as were serum electrolytes and C-reactive protein level. Chest and abdominal x-rays revealed the presence of a large hiatal hernia containing some intestinal loops in the thorax (Figure 1A); marked gastric dilation was also present (Figure 1B). Thorax and abdominal contrast enhanced computed tomography was performed confirming the hiatal hernia, the presence of the stomach with air fluid level, the first part of the duodenum, spleen, body and tail of the pancreas in the thorax (Figure 2); a peripancreatic fluid collec- tion was also present. Laboratory and imaging examinations were highly compatible with acute pancreatitis. The APACHE II score was less than 8 and the pancreatitis was classified as clinically mild.5 The patient underwent medical treatment with fluids and analgesics for the first 48 hours and the pain progressively subsided; subse- quently a surgical approach was carried out consisting of the reduc- tion of viscera in the abdomen and the reconstruction of the diaphragm by direct plastic surgery. The patient’s clinical course was uneventful (Figure 3) and one year after, he had no further attacks of pancreatitis. Discussion We have reported a rare case of a massive incarcerated parae- sophageal hernia involving the presence of the stomach, the first part of the duodenum, the spleen and the body and tail of the pan- creas in the thorax causing acute pancreatitis. The past medical his- tory of the patient was unremarkable, thus it is impossible to say whether he had a congenital Bockdaleck or a hiatal hernia. Correspondence: Raffaele Pezzilli, Department of Gastroenterology, Sant’Orsola-Malpighi Hospital, Via Massarenti 9, 40138 Bologna, Italy. E-mail: raffaele.pezzilli@aosp.bo.it Key words: Acute pancreatitis; Type IV paraesophageal hernia; Computed tomography. Contributions: the authors contributed equally. Conflict of interest: the authors declare no potential conflict of interest. Funding: none. Received for publication: 12 June 2018. Revision received: 30 October 2018. Accepted for publication: 2 November 2018. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright B. Barakat et al., 2018 Licensee PAGEPress, Italy Emergency Care Journal 2018; 14:7617 doi:10.4081/ecj.2018.7617 Acute pancreatitis associated with massive paraesophageal hernia involving the presence of the pancreatic body and tail Bahjat Barakat,1 Lucia Calculli,2 Raffaele Pezzilli3 1Emergency Department; 2Department of Radiology; 3Department of Gastroenterology, Sant’Orsola- Malpighi Hospital, Bologna, Italy Non -co mmerc ial us e o nly [Emergency Care Journal 2018; 14:7617] [page 125] Anyway, the pathogenesis resulted from the obstruction of the dis- tal pancreatic duct after displacement of the pancreatic head and body into the thorax as part of a type IV paraesophageal hernia.6 The traction on the pancreas, due to acute distension and volvulus of the stomach, might have had also a role in the genesis of pan- creatitis.7 Hiatal hernias are usually classified into the following types depending on the extent of herniation and the position of the gastroesophageal junction: type I, sliding hernias; type II, parae- sophageal hernias; type III, mixed sliding and paraesophageal her- nia (with elements of both types I and II) and type IV, herniation of Case Report Figure 1. (A) Chest x-ray showing the presence of the bowel in the mediastinum; (B) Chest x-ray presence of gastric air bubble in the thorax. Figure 2. Contrast-enhanced computed tomography, coronal plane. (A) Hiatal hernia; (B) herniation of the stomach, the body and tail of the pancreas (arrow), and the first part of the duode- num. Non -co mmerc ial us e o nly additional organs (such as colon, spleen, pancreas and small intes- tine, which enter the hernia sac).8,9 Type IV paraesophageal hernias account for 0.1% of all types of hiatal hernias10 and it is also known as giant hiatal hernia. Our patient initially underwent medical treat- ment according to the guidelines on acute pancreatitis.2 Subsequently, to remove the cause of further pancreatitis attacks we decided to operate in order to repair the hernia according to the guidelines which suggest that all symptomatic paraesophageal hiatal hernias should be repaired and this constitutes a strong evi- dence.6 Post-surgery imaging showed how successful the operation had been. Complications such as volvulus, occlusion, ischemia, or even perforation can, however, occur.8,11 Some cases of this rare cause of acute pancreatitis have been reported in literature in the past.12-24 Migration of pancreas in the thorax has been also reported not associated with acute pancreatitis25-29 or with symptoms of mechanical cholestasis such as mild jaundice, pruritus, diarrhea and fatigue.30 In the majority of cases a herniated pancreas may be the body and the tail and in fewer cases the tail alone. Standard pre- operative investigations include a CT scan of the chest/abdomen,12,18,20,22,23 magnetic resonance of the abdomen,24 an upper gastrointestinal contrast study and upper gastrointestinal endoscopy.31,32 Magnetic resonance may offer the opportunity to investigate the pancreatic and bile ducts in these rare cases.24 The Case Report Figure 3. Contrast-enhanced computed tomography, coronal plane: imaging after surgical repair of the hernia. [page 126] [Emergency Care Journal 2018; 14:7617] Ta bl e 1. C lin ic al c ha ra ct er is ti cs o f th e re po rt ed c as es o f ac ut e pa nc re at it is a ss oc ia te d w it h hi at al h er ni a. Ye ar o f Au th or R ef er en ce Y ea r of G en de r A ge Ty pe o f T yp e of T re at m en t O ut co m e R ec ur re nc e of pu bl ic at io n p ub lic at io n h er ni at io n pa nc re at it is * a t d is ch ar ge p an cr ea ti ti s in th e fo llo w u p 19 81 Cu sc hi er i a nd W ils on 12 1 2 19 81 M al e 19 B oc hd al ek h er ni a Se ve re S ur gi ca l A liv e NR 19 90 O liv er e t a l.1 3 1 3 19 90 M al e 5 Bo ch da le k he rn ia M ild S ur gi ca l A liv e NR 19 94 Ka fk a et a l.1 4 14 19 94 Fe m al e 71 P ar ae so ph ag ea l h er ni a S ev er e S ur gi ca l A liv e NR 20 07 Ta ga ya e t a l.1 7 17 20 07 Fe m al e 68 P ar ae so ph ag ea l h er ni a M ild S ur gi ca l A liv e No a fte r 2 9 m on th s 20 10 M ak so ud e t a l.1 6 1 6 20 10 M al e 68 P ar ae so ph ag ea l h er ni a S ev er e S ur gi ca l A liv e No ( un sp ec ifi ed p er io d of ti m e) 20 10 Ro za s an d Go nz ál ez 19 1 9 20 10 Fe m al e 78 H ia ta l h er ni a S ev er e M ed ic al A liv e No a t 6 m on th s 20 14 Bo yc e et a l.2 0 2 0 20 14 Fe m al e 61 P ar ae so ph ag ea l h er ni a M ild S ur gi ca l A liv e NR 20 15 Lu e t a l.2 1 2 1 20 15 M al e 88 P ar ae so ph ag ea l h er ni a M ild M ed ic al A liv e Ye s af te r o ne m on th 20 16 Pa te l e t a l.2 2 22 20 16 M al e 65 H ia ta l h er ni a M ild M ed ic al A liv e NR 20 17 Sh af iq e t a l.2 3 23 20 17 Fe m al e 90 H ia ta l h er ni a M ild M ed ic al A liv e NR 20 17 W an g et a l.1 7 2 4 20 17 Fe m al e 10 2 Hi at al h er ni a Ty pe IV M ild M ed ic al A liv e NR 20 18 Do e t a l.7 7 2 01 8 M al e 65 P ar ae so ph ag ea l h er ni a M ild M ed ic al A liv e NR 20 18 Pr es en t c as e 2 01 8 M al e 27 P ar ae so ph ag ea l h er ni a M ild S ur gi ca l A liv e No a fte r 1 ye ar *A cc or di ng to th e re vis ed A tla nt a cr ite ria .1 Non -co mmerc ial us e o nly [Emergency Care Journal 2018; 14:7617] [page 127] causes postulated for acute pancreatitis are repetitive trauma asso- ciated with pancreatic movement across the hernia, ischemic com- promise of the vascular pedicle, and intermittent folding of the main pancreatic duct.12,13,18 The majority of patients have under- gone surgery to repair their hernia and only a small number of patients have undergone conservative treatment as they have refused surgery.19,22-24 Conclusions In conclusion, this is rare case of acute pancreatitis may be due to an incarcerated paraesophageal hernia involving the presence of the pancreas. As reported in Table 1, the association of acute pan- creatitis and hiatal hernia is very rare; to our best knowledge only 13 cases have been reported in literature and their number increas- es over the years; there were mainly patients of advanced age and the clinical course of pancreatitis was usually mild, according to the revised Atlanta criteria.1 However, the causes of acute pancre- atitis are not well-defined and may be due to repetitive trauma associated with pancreatic movement across the hernia, ischemic pancreatitis secondary to the vascular pedicle and intermittent folding of the main pancreatic duct. A conservative treatment is the preferred therapeutic approach in acute pancreatitis, but when the condition has a mechanical cause the possibility of emergency sur- gery should also be considered, in order to prevent both the conse- quences of a prolonged pulmonary collapse and further pancreati- tis attacks. References 1. Banks PA, Bollen TL, Dervenis C, et al. 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