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An unusual case of intra-abdominal apoplexy.

SUMMARY

Abdominal apoplexy is an uncommon disorder, typically due to atheromatous vascular disease, inflammatory processes such as pancreatitis eroding into large blood vessels or vasculitis. We describe an unusual case due to unrecognised syphilis masquerading as pancreatitis.

Key Words: pseudoaneurysm, syphilis, lipase, apoplexy

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Abdominal apoplexy is an uncommon disorder most typically due to atheromatous disease. Other rarer causes of intra-abdominal vascular rupture, including inflammatory phlegmons eroding into large blood vessels or vasculitis, should be considered as part of the diagnostic workup.

CASE HISTORY

A 60-year-old man presented with acute onset epigastric pain following an alcohol drinking binge. Initially this was a vague supra-umbilical pain, progressing over the next few hours to become a severe epigastric pain radiating through to the back. There were no symptoms of gastrointestinal bleeding or bowel obstruction. His medical background included a long history of alcoholism, undiagnosed chronic airways disease and a single episode of alcohol-related atrial flutter.

Initial investigations demonstrated a white cell count of 16.6x[10.sup.9]/l, a lipase of 3070 U (<100), alkaline phosphatase 117 IU (0 to 40) and gamma glutamyl transpeptidase 123 IU (0 to 50). The serum urea and electrolytes were within normal limits and a troponin-I was undetectable. The electrocardiogram, abdominal and chest radiographs were unremarkable. He was admitted under general surgery with a provisional diagnosis of pancreatitis secondary to alcohol.

His condition deteriorated during the course of the evening, with progressive tachycardia, hypotension and respiratory distress. A medical emergency call was raised when his pulse reached 140 bpm and systolic blood pressure fell to 70 mmHg. He responded well to fluid resuscitation and was transferred to the high dependency unit for stabilisation and further investigation. An urgent CT scan of the abdomen with portal venous phase contrast (Figure 1) showed the possibility of haemorrhage in the right iliac fossa with a small area of active bleeding anterolateral to the duodenum and medial to the ascending colon. The pancreas appeared only mildly inflamed in the region of the head and uncinate process, but was otherwise unremarkable.

[FIGURE 1 OMITTED]

Over the next few hours, the patient's haemoglobin level showed a progressive fall and his respiratory function deteriorated. In view of this, the patient was intubated and ventilated and an angiogram was performed (Figure 2). This demonstrated a false aneurysm arising from the right colic branch of the superior mesenteric artery. The aneurysm was embolised with several 3 and 4 mm Tornado coils. Blood supply to the colon was preserved (Figure 3). He remained intubated and ventilated in the intensive care unit for a further five days while his respiratory function improved.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

Investigating the cause of the pseudoaneurysm, the antinuclear antibodies including anti-DNA and extractable nuclear antigens and antinuclear cytoplasmic antibodies were found to be negative. The Rapid Plasma Reagin for syphilis was reactive with a 1:1 titre; Treponema passive particle agglutination and syphilis enzyme immune assay were also reactive suggesting either latent, previously treated or early treponemal infection.

Follow up with the Infectious Diseases Department was organised. The patient's general practitioner was able to confirm that the patient had been diagnosed with syphilis in the 1980s but was not aware of whether treatment had been given as the patient was not with the practice at that time. There were no other clinical signs of syphilitic infection and his chest X-ray was within normal limits. He was discharged back to the surgical ward after eight days and left hospital three days later against medical advice.

DISCUSSION

This patient presented following an alcohol binge and developed classical symptoms and signs of acute pancreatitis with a highly elevated serum lipase. Serum lipase is the preferred diagnostic test for acute pancreatitis with sensitivity between 60 to 100% and specificity between 70 to 85%, peaking later (24 hours) and remaining elevated longer (eight to 14 days) after the onset of abdominal pain than serum amylase (1-5). Serum levels greater than three to five times the upper normal limit are normally considered diagnostic of acute pancreatitis, especially in alcoholics (5). However, any intra-abdominal inflammatory event including visceral perforation and intra-abdominal bleeding may cause an elevation of serum lipase as do renal insufficiency and macromolecules due to immune complexes (6). Additional uncommon disorders elevating the serum lipase in the absence of pancreatitis include circulatory failure (7), septic shock (7), diabetic ketoacidosis (8) and anorexia nervosa and bulimia (9). In our case, the diagnosis of pancreatitis based upon the presentation with abdominal pain and an elevated lipase distracted from the intra-abdominal bleeding.

Notifications of syphilis have risen in Australia some tenfold between 1999 and 2003, the increase largely being confined to homosexual men. Its incidence is 0.78 per 100 person years in HIV negative homosexual men (10). The clinical stages of syphilis are summarised elsewhere (11). Syphilis may affect the vasculature in a number of ways (12-14). Widespread vasculitis may be a feature of secondary syphilis, presenting with syndromes including hepatitis, iritis, stroke and meningovascular disease. Cardiovascular syphilis classically affects the major vessels and usually occurs 15 to 30 years after initial infection. It causes ascending aortitis, aortic regurgitation, coronary ostial stenosis and aortic medial necrosis and can therefore present with heart failure, angina pectoris and aortic aneurysm. Gummatous syphilis can appear in two years, though a period of 10 to 15 years is more usual. It causes destructive granulomas which can occur anywhere in the body, most commonly the skin and bones. These granulomas represent the body's inability to fully clear the organism. Apoplexy may be caused by gumma eroding blood vessels.

The precise aetiology of the bleed from the superior mesenteric artery pseudoaneurysm cannot be fully determined. Possible causes include previous damage caused by vasculitis during the secondary phase of syphilis with subsequent rupture of the artery, or granuloma formation and atypical cardiovascular syphilis affecting small vessels. The low titre of RPR syphilis antibodies suggests that the bleeding was the result of aneurysm formation from previous active disease (15).

CONCLUSION

The presentation of an elevated lipase in the setting of abdominal pain is not specific for pancreatitis and can be associated with abdominal apoplexy. Although uncommon, syphilis should be considered as a treatable cause.

Accepted for publication on December 3, 2007.

REFERENCES

(1.) Gumaste V, Dave P, Sereny G. Serum lipase; a better test to diagnose acute alcoholic pancreatitis. Am J Med 1992; 92:239-242.

(2.) Treacy J, William A, Bais R, Willson K, Worthley C, Reece J et al. Evaluation of amylase and lipase in the diagnosis of acute pancreatitis. ANZ J Surg 2001; 71:577-582.

(3.) Tietz NW, Shuey DF. Lipase in serum-the elusive enzyme; an overview. Clin Chem 1993; 39:746-756.

(4.) Keim V, Teich N, Fiedler F, Hartig W, Thiele G, Mossner J. A comparison of lipase and amylase in the diagnosis of acute pancreatitis in patients with abdominal pain. Pancreas 1998; 16:45-49.

(5.) Smotkin J, Tenner S. Laboratory diagnostic tests in acute pancreatitis. J Clin Gastroenterol 2002; 34:459-462.

(6.) Yadav D, Agarwal N, Pitchumoni CS. A critical evaluation of laboratory tests in acute pancreatitis. Am J Gastroenterol 2002; 97:1309-1318.

(7.) Pezzilli R, Morselli-Labate AM, Romboli E, Dibenedetti F, Massa M, Migliori M et al. Pancreatic involvement during the early phase of shock. JOP 2002; 3:139-143.

(8.) Yadav D, Nair S, Norkus EP, Pitchumoni CS. Nonspecific hyperamylasemia and hyperlipasemia in diabetic ketoacidosis: incidence and correlation with biochemical abnormalities. Am J Gastroenterol 2000; 95:3123-3128.

(9.) Gwirtsman HE, Kaye WH, George DT, Carosella NW, Greene RC, Jimerson DC. Hyperamylasemia and its relationship to binge-purge episodes: development of a clinically relevant laboratory test. J Clin Psychiatry 1989; 50:196-204.

(10.) Jin F, Prestage GP, Kippax SC, Pell CM, Donovan BJ, Kaldor JM et al. Epidemic syphilis among homosexually active men in Sydney. Med J Aust 2005; 183:179-183.

(11.) Redmond AM, Dancer CM, Doolan AR, Rowling DF, Woods ML. Epidemic syphilis exhibits diverse manifestations. Aust Fam Physician 2007; 36:747-748.

(12.) Saloojee H, Velaphi S, Afadapa N, Steeen R, Lincetto O. The prevention and management of congenital syphilis; an overview and recommendations. Bull World Health Organ 2004; 82:424-430.

(13.) French P Syphilis: A clinical review. BMJ 2007; 334:143-147.

(14.) Pattman R, Snow M, Handy P, Sankar K N, Elawas B eds. Oxford Handbook of Genitourinary Medicine, HIV and AIDS. Oxford University Press 2006.

(15.) Larsen S, Pope V, Johnson R, Kennedy E, eds. A Manual of Tests for Syphilis. Washington DC: American Public Health Association 1998.

N. MAKRIS *, J. BELLAPART ([dagger]), R. J. BOOTS ([double dagger])

Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia

* M.B., B.Chir., M.R.C.P., Registrar, Intensive Care Unit.

([dagger]) M.D., J.F.I.C.M., Staff Specialist.

([double dagger]) M.B., B.S., Ph.D., F.R.A.C.P, F.J.F.I.C.M., M.Med.Sci., M.Health.Admin.I.T., Deputy Director and Thoracic Physician.

Address for reprints: A/Prof R. J. Boots, Deputy Director, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Herston Road, Herston, Qld. 4029.
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Article Details
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Author:Makris, N.; Bellapart, J.; Boots, R.J.
Publication:Anaesthesia and Intensive Care
Article Type:Clinical report
Geographic Code:8AUST
Date:Mar 1, 2008
Words:1512
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