Author Affiliations: Division of Gastroenterology (Sawada T, Adachi Y, Noda M, Akino K, Kikuchi T, Mita H and Endo T) and Department of Pathology (Ishii Y), Sapporo Shirakaba-dai Hospital, Sapporo, Japan

 

Corresponding Author: Yasushi Adachi, MD, PhD, Division of Gastroenterology, Sapporo Shirakaba-dai Hospital, 2-18 Tsukisamu-Higashi, Toyohira-Ku, Sapporo 062-0052, Japan (Tel: 81-11-852-8866; Fax: 81-11-852-8194; Email: yadachi@sapmed.ac.jp)

 

© 2013, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(13)60015-6

 

Contributors: AY proposed the study. ST wrote the first draft. All authors contributed to clinical works and analysis. ET is the guarantor.

Funding: None.

Ethical approval: Not needed.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

BACKGROUND:Hepatic portal venous gas (HPVG) is a rare entity commonly associated with intestinal necrosis and fatal outcome, and various underlying diseases have been reported. Pancreatic solitary metastasis without local extension is also rare in esophageal squamous cell carcinoma.

 

METHODS: This report describes an interesting and unusual case of HPVG arising from pancreatic tumor. Autopsy revealed pathogenesis of HPVG and synchronous tumors of the esophagus and pancreas.

 

RESULTS: A 73-year-old man developed synchronous double tumor in the esophagus and pancreas several months before acute abdomen and his death, which were generated by HPVG. Autopsy revealed that HPVG was caused by gastric wall infarction owing to expansion of an isolated pancreatic metastasis from esophageal squamous cell carcinoma.

 

CONCLUSIONS:This is the first case of HPVG that was derived from pancreatic tumor infiltration. If he had been diagnosed with solitary pancreatic metastasis from esophageal squamous cell carcinoma in the first time, he might have an option for chemotherapy, which could let him live longer.

 

(Hepatobiliary Pancreat Dis Int 2013;12:103-105)

 

KEY WORDS: hepatic portal venous gas; solitary pancreatic tumor; metastasis

Hepatic portal venous gas (HPVG) is a rare condition frequently associated with bowel necrosis, and various underlying diseases, benign or lethal, have been recently reported.^[1] However, pancreatic diseases are seldom reported as a cause of HPVG.^[2]

 

It is sometimes difficult to distinguish solitary metastasized tumor from primary pancreatic carcinoma. Although solitary pancreatic metastasis is often originated from renal cell carcinoma, several other primary sites have been reported.^[3] Distant metastasis to the pancreas without local extension is also infrequent, especially in esophageal carcinoma. We report here an extremely rare case of HPVG which is associated with solitary pancreatic metastasis from esophageal cancer.

 

 

A 73-year-old man was admitted to our hospital for a two-month history of anorexia, dysphagia, and back pain. Endoscopy revealed an ulcerated tumor in the lower esophagus (Fig. 1A), diagnosed by biopsy as poorly differentiated squamous cell carcinoma. Computed tomography (CT) showed a large mass in the pancreas (Fig. 1B). Although an endoscopic ultrasound-guided biopsy or diagnostic laparotomy of the pancreatic mass was recommended, the patient demanded immediate discharge and supportive care. Three months later, he suddenly suffered from severe abdominal pain, fell into shock, and was re-admitted into the emergency department of the hospital. CT revealed the air in the pancreatic mass and liver, indicative of HPVG (Fig. 2). He died in the next day.

 

Postmortem examination revealed an esophageal tumor, distinct from a pancreatic tumor, without thoracic/abdominal lymph node swelling. The pancreatic tumor adhered to the gastric posterior wall. Neither intestinal necrosis nor intra-abdominal abscess was observed. Microscopic examination revealed that carcinoma cells had invaded the muscularis propria of the esophagus, with lymphatic vessel involvement. The pancreatic tumor consisted of poorly differentiated squamous cell carcinoma similar to the esophageal carcinoma (Fig. 3A, B), indicating a solitary pancreatic metastasis from the esophagus. This was confirmed by immunostaining (Fig. 3C-E). Additionally, there was massive infiltration of cancer cells into the gastric serosa, and hemorrhagic infarction of the gastric wall caused by arterial obliteration with the tumor, resulting in gastric perforation, gastropancreatic fistula, and bacterial peritonitis in turn.

 

 

It is generally accepted that intestinal ischemia and/or necrosis is the most common cause for HPVG, with concomitantly poorer prognosis. Other non-ischemic underlying conditions such as intestinal dilatation, intraperitoneal abscess, inflammatory bowel disease and intraperitoneal tumor have been described,^{[1, 4]} in addition to various gastric pathogeneses of HPVG like peptic ulcer, malignancy, and gastroscopic biopsy.^[5] HPVG is associated with pancreatic diseases, radiochemotherapy for esophageal cancer, and endo-scopic procedures.^{[2, 6-8]} In this report we first report that gastric infarction owing to tumor infiltration into the gastric serosa can cause HPVG. Although the precise mechanism for HPVG is uncertain, the pathogenic factors for HPVG might include mucosal damage, sepsis, and intestinal distention.^[4] The former two factors would be decisive in this case.

 

Though metastatic pancreatic tumors are infrequent, but can be seen in the colon, lung, breast, and kidney.^[3,9] Pancreatic solitary metastasis is extremely uncommon and accounts for less than 2% of all pancreatic malignancies.^[9] Moreover, distant metastases of esophageal cancer are commonly seen in the distant lymph node, liver, and lung, but extremely rare in the pancreas.^{[10, 11]} Most patients with metastatic pancreatic tumor are not candidates for surgical resection since they have widespread systemic disease at the time of diagnosis. However, the efficacy of surgical excision of isolated pancreatic metastases has been reported with a long-term survival rate.^{[3, 12]} In the present case, systemic chemotherapy might have been an option, which may provide a surgical treatment.

 

 

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