A 38 y.o. diabetic presents with abdominal pain

What does the CT show?

hint: there is some air where it does not belong.

The patient originally had pancreatitis secondary to hypertriglyceridemia from his diabetes with triglycerides of 4,000 . He presented with sepsis and biliary obstruction.

CT shows severe pancreatitis with biliary duct dilation and thick walled gallbladder.  There is pneumatosis of the loops of transverse colon and a large amount of air in the peripancreatic fluid collection concerning for fistulization of the collection to the adjacent colon. His original biliary stent had migrated and because of duodenal stenosis, ERCP could not be performed and a bilary stent was placed percutaneously by IR. Portal, splenic and mesenteric vein occlusions were noted.

inflamed pancreas above the duodenum

Pancreatitis results in arterial and venous complications as well as localized necrosis and inflammation of the bowel. Thrombosis of the splenic vein, portal vein or SMA can occur. This is thought to be due to venous congestion/stasis and mass effect of the inflamed pancreas with damage to the vessel wall by pancreatic enzymes. Severe pancreatitis can be associated with multiple organ failure and death.

The most common cause of pancreatitis is gallstones (40%) with alcohol consumption at 24-27%

Alpha Oumar Toure, Sosmane K, Ibrhima K et al. Isolated superior mesenteric vein thrombosis in acute pancreatitis: a case report. Case Rep Clin Med. 2015;4.

Chua T, Walsh M, Baker M, Stevens T. Necrotizing pancreatitis: diagnose, treat ,consult. Cleveland clinic Journal of Medicines. 2017 Aug ;84(8):639-648.

Boumitri C, Brown E, Kahaleh M. Necrotizing Pancreatitis: Current Mangement and Therapies. Clin Endosc. 2017 Jul 50(4):357-365.