Minsu Kim, et al.. 2,3 (Wernicke encephalopathy) (thiamine),,,,. 4 WOPN, 1. 증례 , , 80/50 mmhg, 80 /, 20 /, 36.8 C.,. 24,590/mm 3 ( 75.

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1 Case Report The Korean Journal of Pancreas and Biliary Tract 2016;21: pissn eissn WOPN 을동반한급성괴사성췌장염환자에서내시경적췌장괴사제거술후발생한 Wernicke Encephalopathy 1 예 가천대학교길병원 1 내과, 2 진단검사의학과, 3 국민건강보험일산병원내과 김민수 1 강은경 1 김수영 1 김지연 1 문송미 1 서일혜 2 조재희 1 박윤수 1,3 Wernicke Encephalopathy after Endoscopic Necrosectomy in Acute Necrotizing Pancreatitis with WOPN: A Case Report Minsu Kim 1, Eun Kyung Kang 1, Su Young Kim 1, Ji-Yeon Kim 1, Song Mi Moon 1, Yiel-Hea Seo 2, Jae Hee Cho 1, Yoon Soo Park 1,3 Departments of 1 Internal Medicine, and 2 Laboratory Medicine, Gachon University Gil Medical Center, Incheon; 3 Department of Internal Medicine, National Health Insurance Service Ilsan Hospital, Goyang, Korea Infected walled-off pancreatic necrosis (WOPN) is dangerous complication of acute pancreatitis. Open necrosectomy and post-operative irrigation of necrotic cavity have been conventional treatment for infected pancreatic necrosis, however, recently minimally invasive techniques such as endoscopic necrosectomy has been regarded as preferred treatment method for infected WOPN. Endoscopic necrosectomy provides a targeted approach with a reduction in the systemic inflammatory response and avoidance of wound complications. Non alcohol related Wernicke encephalopathy is rare disease caused by thiamine deficiency due to intravenous feeding, and presented an encephalopathy, oculomotor dysfunction, gait ataxia. We report herein a case of Wernicke encephalopathy after successful endoscopic necrosectomy for infected WOPN. Keywords: Pancreatitis, Acute necrotizing, Endoscopic necrosectomy, Wernicke encephalopathy, WOPN Received Aug. 28, 2015 Revised Oct. 27, 2015 Accepted Oct. 30, 2015 Corresponding author : Yoon Soo Park Department of Internal Medicine, Gachon University Gil Medical Center, 21 Namdong-daero 774beon-gil, Namdong-gu, Incheon 21565, Korea Tel Fax ; This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2016 by The Korean Journal of Pancreas and Biliary Tract 서론 (walled-off pancreatic necrosis, WOPN). WOPN,, , 34 Copyright 2016 by Korean Pancreatobiliary Association

2 Minsu Kim, et al.. 2,3 (Wernicke encephalopathy) (thiamine),,,,. 4 WOPN, 1. 증례 , , 80/50 mmhg, 80 /, 20 /, 36.8 C.,. 24,590/mm 3 ( 75.4%, 16%, 7.5%), 15.6 g/dl, 457,000/ mm 3. (AST) 21 U/L, (ALT) 14 U/L, (ALP) 76 IU/L, 7.3 g/dl, 4.5 g/dl, 1.3 mg/dl, (amylase) 7,414 U/L, (lipase) > 15,000 U/L C mg/dl.,, (Fig. 1A). Ranson s score 2, APACHE-2 score 13, BISAP (bedside index of severity in acute pancreatitis) score 0 (revised atlanta classification). 1 (endoscopic ultrasound), (endoscopic retrograde cholaniopancreatography) (endoscopic sphincterotomy)., C (Fig. 1B).,. (endoscopic ultrasound guided cystogastrostomy).. 25, (Fig. 1C). A B C D E Fig. 1. (A) On the admission day, CT showed diffuse pancreas swelling, peripancreaic inflammation. (B) On the third admission day, CT showed extensive pancreatic necrosis with peripancreatic fluid collections in body and tail. (C) Before necrosectomy, CT showed walled-off pancreatic necrosis (WOPN) and air forming at necrotic pancreas fluid collection. (D) After the 11th session of necrosectomy, CT showed marked decreased WOPN and fluid collection. (E) After discharge, the pancreas was nearly restored and distal pancreas disappeared. CT, computed tomography. 35

3 Werniche Encephalopathy after Endoscopic Necrosectomy (pancreas uncinate process), 27,, (Fig. 2A).. 29, 15 mm (endoscopic necrosectomy).,,,, 2 7 (Fig. 2B). Candida albicans, multi-drug resistant Acinetobacter baumanni Enterococcus faecalis., (Fig. 3C) A B C D Fig. 2. (A) On the 27th admission day, endoscopic necrosectomy was started (endoscopic and fluoroscopic view). (B) On the third session of necrosectomy, there was large amounts of pus and pancreatic necrotic tissues in the WOPN (endoscopic view). (C) On the 7th session of necrosectomy, endoscopy showed improved status of necrotic cavity. (D) On the last endoscopic necrosectomy, endoscopy showed clean cavity with minimal yellowish discharge in the WOPN. WOPN, walled-off pancreatic necrosis. A B Fig. 3. Axial FLAIR image in brain diffusion MRI. (A) Enhancement reveals abnormal high signal in the dorsal midbrain (white arrow), bilateral medial thalami (black arrow). (B) abnormal enhancement is dorsal medulla oblongata (white arrow) in image. FLAIR, fluid attenuated inversion recovery; MRI, magnetic resonance imaging. 36

4 Minsu Kim, et al. Fig. 4. Chart flow of patient management. ESBL, extended-spectrum beta-lactamase; HD, hospital day; EUS, endoscopic ultrasound; WBC, white blood cell; hscrp, high sensitive C-reactive protein; WOPN, walled-off pancreatic necrosis., 13,, ,. 62,,,, nmol/l ( nmol/l). fluid attenuated inversion recovery (FLAIR) (dorsal midbrain), (bilateral medial thalami), (dorsal medulla oblongata) (Fig. 3). 63, 500 mg 3, 250 mg 5, 100 mg 3 (Fig. 2D). 102 (Fig. 4)., (Fig. 1E) 고찰 4 (acute necrotic collection) % ,7 37

5 Werniche Encephalopathy after Endoscopic Necrosectomy,., (colonization),.,. 1,8-10,,,,,, ,. Candida albicans, imipenem resistant Acinetobacter baumanni Enterococcus faecalis,. (vitamin B1) 17-20%, Wernicke-Korsakoff. 4 18,, , , (34%), (18%), (17%), (6%), (5%). 13,. 14.,,,,,. 4 (ophthalmoplegia), (ataxia),. 500 mg thiamine mg % 25%. 4, 14.,, 38

6 Minsu Kim, et al..,. 요약 (walled-off pancreatic necrosis).,,., (Wernicke encephalopathy) 1. 국문색인 : 췌장염, 급성괴사성, 내시경적괴사제거술, 베르니케뇌병, 구역성췌장괴사 Conflicts of Interest The author has no conflicts to disclose. REFERENCES 1. Talreja JP, Kahaleh M. Endotherapy for pancreatic necrosis and abscess: endoscopic drainage and necrosectomy. J Hepatobiliary Pancreat Surg 2009;16: Jae Hee C, Yoon Jae K, and Yeon Suk K. Paradigm shift away from open surgical necrosectomy toward endoscopic interventions for necrotizing pancreatitis. Gastrointestinal Intervention 2014;3: Kahaleh M. Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis. Clin Endosc 2012;45: Paik CH, Yeum JY, Han DS. [Wernicke encephalopathy during total parenteral nutrition due to acute necrotizing pancreatitis]. Korean J Gastroenterol 2005;46: Lee NK, Park DH, Park S, Park S, Jeung S, Oh JS, Seo B. Utility of Fully Covered Esophageal Metal Stent in Percutaneous Endoscopic Necrosectomy. kpba 2015;20: Seifert H, Biermer M, Schmitt W, Jurgensen C, Will U, Gerlach R, Kreitmair C, Meining A, Wehrmann T, Rosch T. Transluminal endoscopic necrosectomy after acute pancreatitis: a multicentre study with longterm follow-up (the GEPARD Study). Gut 2009;58: Kawakami H, Itoi T, Sakamoto N. Endoscopic ultrasound-guided transluminal drainage for peripancreatic fluid collections: where are we now? Gut Liver 2014;8: Bakker OJ, van Santvoort HC, van Brunschot S, et al. Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis: a randomized trial. Jama 2012;307: Trikudanathan G, Navaneethan U, Vege SS. Intra-abdominal fungal infections complicating acute pancreatitis: a review. Am J Gastroenterol 2011;106: Kim TH. Endoscopic Management in Patients with Acute Pancreatitis. Korean J Med 2013;85: Koo JE, Park DH, Oh J, et al. EUS-Guided Multitransgastric Endoscopic Necrosectomy for Infected Pancreatic Necrosis with Noncontagious Retroperitoneal and Peritoneal Extension. Gut Liver 2010;4: Lee YD, Lee SJ, Choi JK, Lee ST, Ahn DS. Two Cases of Wernicke s Encephalopathy During Management of Acute Pancreatitis. Korean J Gastroenterol 2001;37: Scalzo SJ, Bowden SC, Ambrose ML, Whelan G, Cook MJ. Wernicke- Korsakoff syndrome not related to alcohol use: a systematic review. J Neurol Neurosurg Psychiatry 2015;86: Jihyun A, Jeong Wook K. Wernicke s encephalopathy in a patient with acute alcoholic pancreatitis. Korean J Med 2008;75: Kim HY, Lee HK, Lee KS, Joe KH, Choi SW, Seo JS. Korean Addiction Treatment Guidelines Series (II): Pharmacological Treatment of Alcohol Withdrawal. J Korean Neuropsychiatr Assoc 2013;52:

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