A 69-year-old man with HCC complicating hepatitis B virus-related cirrhosis (Child-Pugh class A) was admitted for 25th TACE. On admission, the patient had no clinical symptoms, and clinical examination was normal except mild hepatomegaly. Laboratory findings were as follows: hemoglobin 11.3 g/dL, white blood cell count 4,000/µL, platelet count 144,000/µL, Albumin 3.0 g/dL, AST 38 IU/L, ALT 20 IU/L, alkaline phosphatase 150 IU/L, GGT 127 IU/L, total bilirubin 1.02 mg/dL, prothrombin time 15.9 seconds. Abdominal computed tomography (CT) confirmed the presence of viable HCCs in segment 1, 3 and 7, and occlusion of both hepatic arteries was seen due to repetitive TACE. TACE was performed with selective catheterization of the dorsal pancreatic artery branches feeding the tumors with a mixture of lipiodol (4 mL), cytotoxic agent (adriamycin 15 mg), and gelfoam ().
Figure 1 (A) Selective angiography of the parasite tumor-feeding vessel from the dorsal pancreatic artery (arrow) demonstrating the tumor nodule, and regurgitation of the embolic material into the dorsal pancreatic artery (arrowhead). (B) The patient's 25th TACE, (more ...)
After TACE, the patient complained of poor appetite, nausea, and abdominal pain. On the post-procedure day, the patient had fever, and his laboratory results showed mildly increased AST (50 IU/L), ALT (23 IU/L), and total bilirubin 2.03 mg/dL. The patient's symptoms were treated conservatively; hydration, pain and fever control, accordance with post embolization syndrome. On the 5th day, because his fever and abdominal pain were controlled by oral medications and the patient was discharged.
Five days later, the patient was re-admitted for abdominal pain. His vital sign was stable and abdominal examination revealed severe epigastric tenderness with palpable tender mass. The liver enzyme levels were similar as before admission, but the white blood cell count 10,900/µL, C-reactive protein 90.62 mg/L, serum amylase 200 IU/L and lipase 153 IU/L levels were elevated. Abdominal CT images demonstrated swelling of the pancreas and focal areas of low density in the pancreas body, suggesting necrosis. Peripancreatic fluid collection with thick, enhancing wall is noted. Necrotizing pancreatitis with infected pseudocyst was diagnosed ().
Figure 2 Abdominal CT image showing pancreatic swelling and a low-density area in the pancreas (arrowhead), suggesting necrosis. Dense Lipiodol accumulation in the dorsal pancreatic artery (arrow) and peripancreatic fluid collection (asterisk) with a thick enhanced (more ...)
The patient was treated for 5 days with general management of acute pancreatitis: pain control, hydration, fasting and total parenteral nutrition. The patient's symptoms improved, and serum amylase and lipase level decreased to 102 IU/L, 49 IU/L, respectively and oral diet was permitted.
Two weeks later, the follow up abdominal CT showed that slightly decreased fluid collection of the peripancreatic space, but a 2.4 cm sized fluid collection in the posterior aspect of stomach was newly developed. Because of pancreatic duct amputation was identified in the abdominal CT scan, this could have caused the evolution of the new lesion. The patient's condition was stable after oral diet, scheduled ERCP was performed with the object of pancreatic duct stenting. The guide-wire was not able to pass into the main pancreatic duct (MPD) of the body portion due to the acute angulation of the MPD of the neck. Since stent insertion through the pancreatic duct failed, two 10 F pigtail-tipped drainage catheters were inserted into the abscess cavities to enable percutaneous catheter drainage (PCD) (). Blood and bile culture were taken and empirical antibiotics (ciprofloxacin 200 mg per 12 hour) were started. Klebsiella pneumoniae that was resistant to quinolone and sensitive to 3rd generation cephalosporin, was identified from the culture of the abscess pocket drainage through the PCD catheter and we changed the antibiotics from ciprofloxacin to cefotaxime. Two weeks after the antibiotic was changed, extended-spectrum beta-lactamase producing Klebsiella pneumoniae and cefotaxime resistant Citrobacter freundii were identified in the repeated abscess culture. Since both of the bacteriaes were sensitive to carbapenem, the antibiotic was changed to ertapenem. Abdominal CT scan was performed again on hospital day 30, and fluid collection in the body portion of the pancreas was decreased. The amount of drainage through PCD was decreased and the drainage catheters were removed.
Pigtail-tipped catheters for percutaneous drainage were inserted into the abscess cavities of the patient.
After a week, the superficial cystic lesion was palpable in the drainage catheter removal site of the patient. Abdominal CT showed fluid collection along the previous drainage catheter insertion tract continuous with the previous fluid collection between the stomach and the pancreas. The patient underwent recanalization and percutaneous drainage catheter was reinserted. Methicillin-resistant Staphylococcus aureus was identified from the culture of the fluid drainage through the PCD catheter, and vancomycin was added to ertapenem. Two weeks later, the patient's symptoms were improved, the amount of drainage through PCD was decreased, and the serum amylase level was normalized. Finally, on the 71st hospital day, the patient was discharged. The necrotizing pancreatitis with abscess formation was improved but the patient's liver function deteriorated. Patient was still alive, but the further active treatment of HCC could not be possible because of deterioration of liver function.