Ischemic Pancreatitis Secondary to Progression of Splenic Artery Thrombosis - A Rare Manifestation of Antiphospholipid Antibody Syndrome

Introduction: Ischemic pancreatitis is rare and is most commonly see in pancreatic malignancy. Antiphospholipid antibody syndrome (APS) is a hypercoagulable state that can cause major abdominal vascular thrombosis and organ infarction. We present a rare case of pancreatic ischemia in a patient with APS. Case Description/Methods: This is a case of a 63-year-old male with past medical history of recent splenic artery thrombosis with splenic infarction attributed to APS on Coumadin presented to the hospital with epigastric abdominal pain that had started acutely 4 hours prior to presentation. Review of systems was negative for fever, vomiting, diarrhea. Patient denied alcohol use. He reported compliance to warfarin expect for the last 2 days as it was held in anticipation of screening colonoscopy. Physical exam was significant for epigastric tenderness. Laboratory analysis showed elevate lipase of 280 IU/L. Contrast enhanced CT abdomen/pelvis showed chronic splenic infarcts, progressive occlusion of the splenic artery with progression towards the celiac axis, with development of distal pancreatic body/tail necrosis. This was presumed to be secondary to ischemia from the propagating splenic artery thrombosis. Hematology/oncology was consulted, and patient was started on intravenous (IV) heparin drip with rapid resolution of patient’s symptoms. Patient was diagnosed with APS during his prior hospitalization when he was found to have splenic artery thrombosis and splenic infarction on imaging that warranted hypercoagulable work up. He was started on warfarin for APS. As patient’s splenic artery thrombosis had progressed resulting in pancreatic ischemia while on warfarin he was switched to apixaban instead for lifelong anticoagulation (Figure 1). Discussion: We present a case of ischemic pancreatitis and splenic artery thrombosis and infarction in a patient with APS. This case highlights APS as an uncommon risk factor for Acute ischemic pancreatitis. A retrospective study conducted by kaushik et al that reviewed abdominal CT scan of 215 patients with APS reported 3 cases of ischemic pancreatitis in this patient population, whereas splenic infarction was seen in 6 patients 1. To our knowledge there has been 1 case report describing this 2. Hence, acute abdominal pain with an elevated lipase in patients with APS should raise concern for pancreatic ischemia and physicians should have high index of suspicion to prevent delay of diagnosis and treatment.Figure 1.: CT abdomen/pelvis with contrast demonstrating a new focus of pancreatic necrosis.