Teaching Case

A 30-year-old obese female with intragastric balloon implantation five months ago. She was admitted with sudden outset of abdominal pain in the left hypochondria and left flank. She did not claim nausea, vomiting, weight loss or fever. Biochemistry revealed leucocytosis, neutrophilia,  C-reactive protein, lipase and amylase increase.

Ultrasound (US) was initially performed.  A small quantity of free fluid was observed in the left anterior pararenal space. No cholelithiasis was found in the gallbladder (Fig 1 and 2).

Contrast-enhanced computed tomography (CT) was performed to confirm the findings.

CT revealed a well-placed intragastric balloon and peripancreatic inflammatory changes, consisting of a moderate quantity of free fluid and fat stranding adjacent to pancreatic body and tail. Inflammatory changes extended toward the whole left anterior pararenal space. Pancreas displayed homogeneous enhancement and Wirsung’s duct showed normal calibre. Splenic artery and vein appeared permeable. Ischemia signs of the gastric wall were not appreciated. Gastro-pancreatic space was reduced (Fig 3 and 4).

Acute edematous pancreatitis due to intragastric balloon compression was the final diagnosis.

Patient was hospitalized and liquid diet was administered. Finally, gastroscopy was performed and balloon was successfully removed.  Inflammatory parameters reduced after the procedure.

Morbid obesity has become a severe health problem, and the prevalence of the disease has gradually increased. Treatment includes several methods, such as dietary programs, exercising, medical therapy, intragastric balloon implantation or surgery. Balloon device implantation in the stomach helps with weight loss by generating a sense of fullness and reducing the available volume for food. Balloon placement is less invasive than surgery and more effective than medical treatment.  Nonetheless, procedure may develop several complications such as gastric perforation, bowel obstruction or more rarely, acute pancreatitis. Pancreatitis can be caused by dislodgement of the balloon to the second portion of the duodenum or pancreatic compression by the device. The second mechanism is present in our case. [1]

Clinical features of acute pancreatitis include abdominal pain, fever, nausea, vomiting, hyporexia and abdominal distension. Biochemistry reveals inflammatory parameter increase and amylase and lipase levels growth.

US is the first imaging technique used. Findings include inflammatory changes in the peripancreatic area, consisting on free fluid and fat hyperechogenicity.

Contrast-enhanced CT is the most accurate image modality. Features include free fluid and fat stranding in the peripancreatic area, mostly adjacent to pancreatic body and tail, extending to the anterior pararenal space. Gastro-pancreatic space is reduced and intragastric balloon can be seen well-placed but compressing the distal body and tail of the pancreas.  Wirsung’s duct ectasia shifts more towards device displacement rather than pancreatic compression, as the cause of acute pancreatitis.

Treatment method in cases of gastric balloon complications is the removal of the device. Liquid diet and acute pancreatitis sustaining treatment may be administered before the procedure. [2]

Morbid obesity is a severe and increasing health problem. Treatment includes several options. Intragastric balloon implantation is less invasive and safer option for short term weight loss. Acute pancreatitis due to pancreatic compression is a rare complication of this procedure. CT is the most accurate image modality. Findings include pancreatic body and tail inflammatory changes and gastro-pancreatic space reduction. Ultimate treatment of balloon complications is device removal.

Written informed patient consent for publication has been obtained.