PMC5801570_01
Noncontrast axial computed tomography of the abdomen demonstrating characteristic findings of acute pancreatitis, including indistinct pancreatic margins, edema, and fat stranding.
JCIS-8-4-g002.jpg
PMC5801570_01_JCIS-8-4-g002.jpg
F1
Computed tomography (CT) imaging demonstrated findings of acute pancreatitis, including an edematous pancreas, peripancreatic edema, and fat stranding [Figure 1].
(a) Axial fat-suppressed T2-weighted image demonstrating a dilated fluid-filled pancreatic duct (blue arrow) anterior to a T2-hyperintense tubular structure [red arrow] which on the axial fat-saturated postcontrast T1-weighted image (b) corresponds to an expanded portal confluence lacking normal enhancement and containing a filling defect consistent with portal venous thrombosis (green arrow).
JCIS-8-4-g003.jpg
PMC5801570_01_JCIS-8-4-g003.jpg
F2
Abdominal magnetic resonance imaging (MRI) showed a dilated pancreatic duct as well as thrombosis of the portal vein, splenic vein, superior mesenteric vein, and the majority of the intrahepatic portal vein branches [Figure 2].
Coronal magnetic resonance cholangiopancreatography image demonstrating fistulization between the portal vein (green arrow), pseudocyst (red arrow), and pancreatic duct (blue arrow).
JCIS-8-4-g004.jpg
PMC5801570_01_JCIS-8-4-g004.jpg
F3
An adjacent fluid collection was also noted consistent with a pseudocyst, with the suggestion of fistulous communication between the pseudocyst, the portal vein, and the main pancreatic duct at the head region raising suspicion for a PPVF [Figure 3].
Endoscopic retrograde cholangiopancreatography fluoroscopic image demonstrating cannulation of the pancreatic duct (blue arrow) with abnormal contrast passage into the portal vein (green arrow) and associated intervening pseudocyst (red arrow) confirming the presence of the pancreatic-portal vein fistula.
JCIS-8-4-g005.jpg
PMC5801570_01_JCIS-8-4-g005.jpg
F4
However, there was also opacification of the portal vein in the same injection of contrast, confirming the MRI suspicion of a PPVF [Figure 4].
(a) Coronal fat-suppressed T2-weighted image demonstrating hyperintense fluid signal in the splenoportal confluence (green arrow) (b) Coronal fat-suppressed post-contrast T1-weighted image demonstrating nonenhancement of the portal venous confluence, consistent with thrombosis. Numerous enhancing collaterals (red arrow) are present in the porta hepatis region confirming the chronic nature of the thrombus and cavernous transformation of the portal vein. (c) A more posterior coronal fat-suppressed postcontrast T1-weighted image revealing a prominent pancreatic duct (blue arrow).
JCIS-8-4-g006.jpg
PMC5801570_01_JCIS-8-4-g006.jpg
F5
Over the next 4 months, the patient's symptoms improved and anticoagulation was subsequently stopped once collateral circulation was identified on follow-up imaging [Figure 5].