Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis

[Pseudoaneurysm of the hepatic artery: rare complication of chronic pancreatitis]

Bleeding from a pseudoaneurysm is a rare complication of chronic pancreatitis. We present two cases of ruptured pseudoaneurysms of the hepatic arteries. The first case involved a pancreatic pseudocyst that ruptured in the duodenum and the second resulted in an intrahepatic hematoma that compressed the bile tract causing secondary hemobilia. Angiographic embolization was the primary treatment in both cases, with surgery for the first patient and later radiological drainage in the second. The hemorrhage was controlled in both cases despite the severe prognosis and high mortality in these cases.

Pancreaticoduodenal Artery Pseudoaneurysm Embolization

We report a case of successful transcatheter arterial embolization of a pancreaticoduodenal artery pseudoaneurysm (PSA) caused by erosion of the pancreatic pseudocyst content near pancreaticoduodenal arteries. A 55-year-old man was admitted to a local hospital for investigation of severe, stabbing epigastric pain confined to the upper abdomen. He had a history of previous alcohol abuse, chronic pancreatitis, and a duodenal ulcer. Upper gastrointestinal endoscopy revealed narrowing in the pyloric channel along with an ulcer located at the first and second portions of the duodenum with oozing beneath an adherent cloth and duodenal distortion. Computed tomography additionally revealed an enlarged head of the pancreas with numerous spot calcifications and round cystic formation inside, with a diameter of 30 × 25 mm. Following two surgical procedures for duodenal ulcers, selective angiography revealed a PSA located inside the pancreas head and high-grade stenosis > 90% of the celiac trunk and hepatic artery that rose separately from the aorta. Fiber coil embolization was used to occlude the PSA sac successfully. There was no complication after completion of the last embolic procedure. The patient was doing well after 26 months.

Two cases of pancreatic abscess associated with penetration to the gastrointestinal tract during treatment using endoscopic ultrasound-guided drainage

Of pancreatic pseudocysts, approximately 30% are complicated by abscess formation, perforation into the abdominal cavity, penetration to the gastrointestinal tract, or bleeding. We report two cases of pancreatic abscess complicating severe acute pancreatitis in which the abscess penetrated to the gastrointestinal tract during the course of treatment with endoscopic ultrasound (EUS)-guided pseudocyst drainage. In these cases, neither aggravation nor recurrence of the pancreatic abscess has been identified since the event occurred. The EUS-guided treatment was effective for improvement of severe inflammation of the pseudocyst as an initial treatment. However, drainage tube placement limitations pertained because the pseudocyst was present with multilocular infection. Penetrations eventually contributed to their resolution because the fistulas were used as wide drainage routes. It is important to understand the courses of these cases for preparation of therapeutic strategies to treat pancreatic pseudocyst/abscess.

Endovascular treatment of arterial bleeding in patients with pancreatitis

PURPOSE

To assess the technical and clinical success of endovascular treatment of arterial bleeding in pancreatitis.

MATERIALS AND METHODS

From 1992 to 2005, 28 patients with pancreatitis underwent endovascular treatment of associated arterial lesions. Fifteen patients were affected by acute pancreatitis and 13 by chronic pancreatitis. The diagnosis was obtained according to medical history and clinical and laboratory evidence of disease. Arterial involvement was diagnosed by non-invasive imaging and angiography. After treatment, all patients underwent CT scanning at a minimum of 15, 30 and 90 days. We evaluated the feasibility of embolization and patients' survival at 90 days.

RESULTS

Transcatheter embolization was feasible in 26/28 patients (93%). In 2 patients with acute pancreatitis, selective catheterization failed so we could not proceed with the angiographic approach. After treatment, there were 3/26 rebleeds (11.5%), all of whom died within the first week. At 90 days' follow-up, 21/26 patients (81%) were alive. Two of 26 patients (8%) suffered splenic complications. Among the 13 patients with acute pancreatitis, 8 (61.5%) were alive after 90 days. All 13 patients with chronic pancreatitis were alive after 90 days.

CONCLUSIONS

Comparing our results with the surgical literature, we found that embolization is less invasive and, at least, as successful as surgery. Thus, it should be considered the first choice in pancreatitis arterial complications.

Emergency endovascular repair of ruptured visceral artery aneurysms

Background

Visceral artery aneurysms although rare, have very high mortality if they rupture.

Case presentation

An interesting case of a bleeding inferior pancreaticduodenal artery aneurysm is reported in a young patient who presented with hypovolemic shock while being treated in the hospital after undergoing total knee replacement. Endovascular embolization was successfully employed to treat this patient, with early hospital discharge.

Conclusion

Prompt diagnosis and endovascular management of ruptured visceral aneuryms can decrease the associated mortality and morbidity.

[A pancreatic pseudocyst associated with three simultaneous hemorragic complications]

The onset of secondary hemorrhagic complications with the development of pancreatic pseudocysts is rare but has a high mortality rate. Management of the hemorrhagic complications of pancreatic pseudocysts is surgical despite the contribution of arterial embolization. We report the observation of a 59-year-old patient who had presented an episode of acute pancreatitis 1 month before consulting for abdominal pain associated with an episode of melena. The CT showed a pancreatic pseudocyst complicated by an intracystic tear, a splenic artery aneurysm in the Wirsung canal, and rupture of the spleen. These three lesions were treated simultaneously with left splenopancreatectomy starting with the splenic vessels. The simultaneous onset of three hemorrhagic complications of a pseudocyst is exceptional and has never been described to our knowledge.

Endovascular management of major arterial hemorrhage as a complication of inflammatory pancreatic disease

PURPOSE

Major arterial hemorrhage is an important complication of inflammatory pancreatic disease, with an overall mortality of 37%. The present study was undertaken to evaluate the experience of a tertiary referral center for pancreaticobiliary disease in the management of major arterial complications of pancreatitis with selective visceral angiography and transcatheter arterial embolization (TAE).

MATERIALS AND METHODS

A 6-year retrospective analysis of all patients undergoing visceral angiography for major bleeding as a complication of pancreatitis identified 35 patients (26 male, 9 female) with a mean age of 51.2 years (range, 11-73 y). Patient demographics, history, clinical presentation, angiographic findings, angiographic treatment, and follow-up outcomes were retrospectively noted. Technical success was defined as the devascularization of a focal lesion or reduction or cessation of blood flow to a target vascular bed or organ, and clinical success was defined as the resolution of the symptoms and signs that prompted the initial embolization.

RESULTS

Angiography identified the site of bleeding in 54.3% of patients (n=19) and angiographic intervention was performed in 77.1% of patients (n=27). Technical success was achieved in 81.5% of those 27 patients (n=22), with overall clinical success in 80.0% (n=28). Multiple angiograms were required in 12 patients, with four demonstrating bleeding from new sites. The mortality rate was 20% (7 of 35).

CONCLUSIONS

In major arterial hemorrhage resulting from pancreatic inflammatory disease, visceral angiography can identify the site of bleeding and hemostasis can be achieved. Repeat angiography is often required with bleeding from new sites. The mortality rate is comparable to that associated with surgery and reflects multisystem involvement in acute severe pancreatitis.

Endovascular Treatment of Pseudoaneurysm of the Common Hepatic Artery with Intra-aneurysmal Glue (N-Butyl 2-Cyanoacrylate) Embolization

A 40-year-old man, a chronic alcoholic, presented with acute epigastric pain. Selective celiac arteriography showed a pseudoaneurysm arising from the common hepatic artery. We hereby describe a technical innovation where complete pseudoaneurysm exclusion was seen after intra-aneurysmal N-butyl 2-cyanoacrylate (glue) injection with preservation of antegrade hepatic arterial flow and conclude that intra-aneurysmal liquid injection may have potential as a therapeutic option to reconstruct a defective vessel wall and thereby maintain the antegrade flow.

Pseudoaneurysms of the common hepatic artery following pancreaticoduodenectomy: successful emergency embolization

We report a rare case of two communicating pseudoaneurysms of the common hepatic artery 1 month postoperatively following pylorus-preserving pancreaticoduodenectomy due an abscess formation. We describe the superselective transcatheteral embolization technique with deployment of interlocking detachable coils and Histoacryl-Lipiodol in this case and discuss the recent literature. Despite the technical success by achieving hemodynamic stability with initial preservation of liver function, the patient died 23 days postembolization due to multiorgan failure.

Diagnosis and treatment of hemosuccus pancreaticus: development of endovascular management

OBJECTIVES

The purpose of this study was to analyze the diagnostic and therapeutic features of hemosuccus pancreaticus.

METHODS

We reviewed our experience with management of 17 patients admitted to surgery or gastroenterology units for hemosuccus pancreaticus between 1981 and 2005. We studied symptoms, contribution of established morphological examinations (upper digestive endoscopy, computed tomography, and selective digestive angiography), and treatment.

RESULTS

Fifteen men and two women with a mean age of 57 years presented hemosuccus pancreaticus. All the men had a history of chronic alcoholic pancreatitis. Thirteen patients (76.5%) presented overt digestive bleeding (5 melena, 2 hematochezia, 2 melena with hematochezia, and 4 hematemesis). The inaugural sign was anemia in 2 patients and epigastric pain another 2 patient. An upper digestive endoscopy was performed in 15 patients and visualized hemosuccus pancreaticus directly in 9 patients. Arteriography was performed in 16 patients (94.1%) and made the diagnosis in 14 (87.5%). Surgery was performed in 9 patients, after embolization in 2 patients. Embolization was performed in 9 patients and effective in 7 patients. Therapeutic abstention proved successful in 1 patient. There were no death and no recurrent bleeding.

CONCLUSIONS

Hemosuccus pancreaticus is a rare cause of digestive bleeding. Upper digestive endoscopy and angiography during active bleeding can provide the diagnosis. Most cases can be managed by angioembolization. However, in patients with recurrent bleeding or failed embolization, emergency surgery is required.

Management of Pancreaticoduodenal Artery Aneurysms: Results of Superselective Transcatheter Embolization

OBJECTIVE

The purpose of our study was to assess the efficacy of transcatheter arterial embolization for pancreaticoduodenal artery aneurysms.

CONCLUSION

We concluded that transcatheter arterial embolization is the initial and definitive therapeutic choice for pancreaticoduodenal artery aneurysms, with a possible option to perform surgery after embolization.

[Gastrointestinal bleeding--concepts of surgical therapy in the upper gastrointestinal tract]

Bleeding of the upper gastrointestinal tract is the main symptom of a variety of possible conditions and still results in considerable mortality. Endoscopy is the first diagnostic modality, enabling rapid therapeutic intervention. In case of intractable or relapsing bleeding, surgery is often inevitable. However, emergency operations result in significantly higher mortality rates. Therefore the option of early elective surgical intervention should be considered for patients at increased risk of relapsing bleeding. If bleeding is symptomatic due to a complex underlying condition such as hemosuccus pancreaticus or hemobilia, angiography is now recognized as the definitive investigation. Angiographic hemostasis can be achieved in most cases. Due to the underlying condition, surgical management still remains the mainstay in treating these patients. This paper reviews surgical strategy in handling upper gastrointestinal bleeding.

Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage

BACKGROUND

Pancreatic pseudocyst bleeding is an unusual entity of acute abdomen, usually occurring among alcoholics. A high mortality developed in patients with conservative treatment of hemorrhagic pancreatic pseudocyst. We report a 37-year-old male with a pseudoaneurysm in the tail of the pancreas presenting with sudden onset of abdominal pain and swelling. Emergency laparotomy after blood transfusion and fluid resuscitation was successfully performed.

METHODS

An abdominal radiography showed multiple calcifications in the epigastric area. Computed tomography of the abdomen showed a cystic lesion with a calcified wall in the tail of the pancreas and a large amount of ascites. After contrast enhancement, there was hemorrhage into the pancreatic pseudocyst with extravasation of contrast into the peritoneal cavity.

RESULTS

At operation, active bleeding was noted from a ruptured pseudocyst in the tail of the pancreas and ligation of the bleeding vessel was done.

CONCLUSIONS

Hemorrhage into the pancreatic pseudocyst associated with intraperitoneal bleeding is a potentially life threatening condition. Emergency surgical treatment should be carried out as soon as possible.

Transcatheter embolization of splenic artery pseudo-aneurysm rupturing into colon after post-operative pancreatitis

Splenic pseudoaneurysms following chronic pancreatitis can rarely become a source of life-threatening bleeding by rupturing into various regions or components, including pseudocysts, the abdominal cavity, the gastrointestinal tract, and the pancreatic duct. In such cases, prompt diagnosis and therapy are warranted. We report herein the case of a 52-year-old man in whom a splenic pseudoaneurysm ruptured into the colon via a fistula with an abscess cavity, causing massive bleeding, which was successfully managed by trans-catheter arterial embolization (TAE).

Vascular complications of pancreatitis

Vascular complications of pancreatitis are a major cause of morbidity and mortality. Arterial complications include haemorrhage from direct arterial erosion or pseudoaneurysm formation, and visceral ischaemia. Venous complications predominantly are related to splanchnic vein thrombosis. This review, with illustrative cases, describes the main manifestations of these complications and emphasizes the importance of early radiological diagnosis and intervention.

Thrombin injection of a pancreaticoduodenal artery pseudoaneurysm after failed attempts at transcatheter embolization

We describe a case of a pseudoaneurysm of the pancreaticoduodenal artery in a patient with history of cholecystectomy and chronic pancreatitis. Attempts at transcatheter coil embolotherapy failed because of vessel tortuosity. The lesion was then successfully treated by computed tomography-guided direct percutaneous injection of thrombin into the pseudoaneurysm. This technique may be a first line of treatment or a useful adjunct to transcatheter embolization technique.

Management and outcome of bleeding pseudoaneurysm associated with chronic pancreatitis

Background

A bleeding pseudoaneurysm in patients with chronic pancreatitis is a rare and potentially lethal complication. Optimal treatment of bleeding peripancreatic pseudoaneurysm remains controversial. This study reports on experience at Chang Gung Memorial Hospital (CGMH) in managing of bleeding pseudoaneurysms associated with chronic pancreatitis.

Methods

The medical records of 9 patients (8 males and 1 female; age range, 28 – 71 years; median, 36 years) with bleeding pseudoaneurysms associated with chronic pancreatitis treated at CGMH between Aug. 1992 and Sep. 2004 were retrospectively reviewed. Alcohol abuse (n = 7;78%) was the predominant predisposing factor. Diagnoses of bleeding pseudoaneurysms were based on angiographic (7/7), computed tomographic (4/7), ultrasound (2/5), and surgical (2/2) findings. Whether surgery or angiographic embolization was performed was primarily based on patient clinical condition. Median follow-up was 38 months (range, 4 – 87 months).

Results

Abdominal computed tomography revealed bleeding pseudoaneurysms in 4 of 7 patients (57%). Angiography determined correct diagnosis in 7 patients (7/7, 100%). The splenic artery was involved in 5 cases, the pancreaticoduodenal artery in 2, the gastroduodenal artery in 1, and the middle colic artery in 1. Initial treatment was emergency (n = 4) or elective (n = 3) surgery in 7 patients and arterial embolization in 2. Rebleeding was detected after initial treatment in 3 patients. Overall, 5 arterial embolizations and 9 surgical interventions were performed; the respective rates of success of these treatments were 20% (1/5) and 89% (8/9). Five patients developed pseudocysts before treatment (n = 3) or following intervention (n = 2). Pseudocyst formation was identified in 2 of the 3 rebleeding patients. Five patients underwent surgical treatment for associated pseudocysts and bleeding did not recur. One patient died from angiography-related complications. Overall mortality rate was 11% (1/9). Surgery-related mortality was 0%.

Conclusion

Angiography is valuable in localizing bleeding pseudoaneurysms. In this limited series, patients with bleeding pseudoaneurysms associated with chronic pancreatitis treated surgically seemingly obtained good outcomes.

Percutaneous thrombin injection to complete SMA pseudoaneurysm exclusion after failing of endograft placement

Visceral aneurysms are potentially life-threatening vascular lesions. Superior mesenteric artery (SMA) pseudoaneurysms are a rare but well-recognized complication of chronic pancreatitis. Open surgical repair of such an aneurysm, especially in patients after previous surgical treatment, might be dangerous and risky. Stent graft implantation makes SMA pseudoaneurysm exclusion possible and therefore avoids a major abdominal operation. Percutaneous direct thrombin injection is also one of the methods of treating aneurysms in this area. We report a first case of percutaneous ultrasound-guided thrombin injection to complete SMA pseudoaneurysm exclusion after an unsuccessful endograft placement. Six-month follow-up did not demonstrate any signs of aneurysm recurrence.

Systematic appraisal of the management of the major vascular complications of pancreatitis

BACKGROUND

This study is a systematic appraisal of the management of major vascular complications of pancreatitis conducted by collating individual patient-episode data from published literature.

METHODS

Searches identified 79 papers of which 62 provided detailed information on the clinical course of 214 patients. Principal outcomes were modes of presentation, results of diagnostic angiography, and embolization and overall outcome.

RESULTS

There were 160 "spontaneous" and 40 postoperative episodes of hemorrhage. Underlying pancreatic disease was chronic pancreatitis (40), pseudocyst (135), and acute pancreatitis in 39. Angiography was undertaken in 173 (81%) with embolization attempted in 115 and achieving hemostasis in 85 (75%). There were 40 (19%) deaths. Mortality was greater in patients undergoing surgery as first intervention compared with angiography first (P = .01, Fisher exact test).

CONCLUSION

This analysis of pooled data provides evidence of a central role for mesenteric angiography in the diagnosis of major vascular complications of pancreatitis and for angiographic embolization as a powerful tool for achieving hemostasis.

Endovascular management of pseudoaneurysms of the splenic artery: experience with six patients

The purpose of this paper was to describe our experience with the endovascular management of splenic artery pseudoaneurysms (SAPA). Seven patients with documented SAPA on CT and/or angiography were considered for endovascular treatment. The pseudoaneurysms were located in the main splenic artery (n = 4) or its branches (n = 3). In one patient in whom the pseudoaneurysm was located in a hilar branch, selective catheterization of splenic artery failed. Metallic coils (n = 1), gelfoam and hydrogel particles (n = 1), metallic coils and gelfoam (n = 2), metallic coil, gelfoam and acrylic glue (n = 2) were used as embolization material in the remaining six patients. These patients were followed for a mean period of 11.3 months. Transcatheter embolization was successful in five patients with no procedure-related complications. In one patient, embolization was incomplete and the patient underwent surgery, but died on the 10th postoperative day because of irreversible shock. Another patient, after successful embolization, underwent surgery for management of an associated pseudocyst. Endovascular treatment is a safe and effective method of management of SAPA.

CT and fluoroscopically guided percutaneous embolization treatment of a pseudoaneurysm associated with pancreatitis

A novel approach to embolization treatment with a cyanoacrylate solution for a bleeding pseudoaneurysm associated with pancreatitis is described in the setting of a critically ill patient. Computed tomography and a C-arm fluoroscopic unit were used to guide percutaneous placement of a needle and injection of the embolic material. This technique represents an alternative form of embolization when traditional angiographic techniques are not possible.

Complicaciones vasculares de la pancreatitis

Vascular complications of pancreatitis are infrequent but important clinical problems because of their higher mortality. Pseudocysts that appear in 5%-50% patients with pancreatitis can erode adjacent vessels with hemorrhage, venous thrombosis and pseudoaneurysms. Increase in pressure within pseudoaneurysm can give rise to its rupture, that is the most serious complication of pancreatitis. Intracystic and intraperitoneal or retroperitoneal hemorrhage are the other arterial complications that can occur in the natural history of pancreatitis. Most frequent venous complications are splenic thrombosis, splenoportal thrombosis, and mesenteric thrombosis.

Endovascular treatment of a giant superior mesenteric artery pseudoaneurysm using a nitinol stent-graft

A 68-year-old woman presenting with gastrointestinal bleeding (hematocrit 19.3%) and in a critical clinical condition (American Society of Anesthesiologists grade 4) from a giant superior mesenteric artery pseudoaneurysm (196.0 x 131.4 mm) underwent emergency endovascular treatment. The arterial tear supplying the pseudoaneurysm was excluded using a 5.0 mm diameter and 31 mm long monorail expanded polytetrafluoroethylene (ePTFE)-covered self-expanding nitinol stent. Within 6 days of the procedure, a gradual increase in hemoglobin levels and a prompt improvement in the clinical condition were observed. Multislice CT angiograms performed immediately, 5 days, 30 days and 3 months after the procedure confirmed the complete exclusion of the pseudoaneurysm.

Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis

BACKGROUND

Arterial pseudoaneurysm formation in pancreatitis is a rare complication. The optimal treatment modality is controversial. Operative treatment and interventional treatment, either alone or as a temporizing method with a later operation, are options.

METHODS

In this single-center, patient-based cohort study, we managed 35 patients (8 with necrotizing pancreatitis and 27 with chronic pancreatitis) with bleeding pseudoaneurysms treated over a period of 10.5 years with a median follow-up of 4.6 years. Angiography was performed depending on the patient's hemodynamic condition.

RESULTS

Angiography had a sensitivity of 96% for 26 patients. Angiographic embolization as primary treatment was performed in 16 patients (61% embolization rate); there were 2 rebleeding complications. No patients required intervention for embolization complications after discharge. Nineteen patients (54%) underwent an operation, 9 urgently without angiographic evaluation. The overall mortality rate for the 35 patients was 20% (19% for embolization, 21% after an operation). For necrotizing pancreatitis, an advantage of angiographic embolization was observed (mortality in 2/5 vs 2/3 after surgery). Ligation or repair of the bleeding vessel was complicated by higher rebleeding rates (6/13) than partial pancreatectomy (1/6).

CONCLUSIONS

Concerns that angiographic embolization is unable to provide definitive hemostasis in both acute and chronic pancreatitis are unfounded. In the operative treatment of chronic pancreatitis, partial pancreatectomy is superior to vessel ligation, depending on the patient's general condition and degree of pancreatic inflammation. We propose an algorithm for the management of arterial pseudoaneurysms in the setting of pancreatitis.

Use of recombinant activated factor VII for bleeding in pancreatitis: a case series

OBJECTIVES

To describe the effects of recombinant activated factor VII (rFVIIa) in the treatment of bleeding in a series of patients with acute or chronic pancreatitis.

METHODS

Twelve patients (age, 2.5-65 years) with pancreatitis and bleeding were treated with 18.5 to 120 microg/kg of rFVIIa. Eight patients also had sepsis/infection and/or disseminated intravascular coagulation (DIC). The effects of rFVIIa on bleeding, coagulation status, and transfusion requirements were noted.

RESULTS

Bleeding stopped in 4 patients, was markedly reduced in 4 patients, was reduced in 3 patients, and was remained unchanged in 1 patient. For most patients with pre- and post-rFVIIa data, coagulation parameters improved and transfusion requirements reduced. No thrombotic adverse events occurred. Seven patients died for reasons considered to be unrelated to rFVIIa treatment.

CONCLUSIONS

This case series indicates that rFVIIa may be an effective hemostatic treatment of patients with pancreatitis suffering from massive bleeding. There were no thromboembolic events in any patient, including those with sepsis or DIC.

Successful treatment of a ruptured infected aneurysm of the lumbar artery with transcatheter embolization

We report a patient who had an infected aneurysm of the lumbar artery caused by prolonged psoas abscess-forming spondylitis due to methicillin-resistant Staphylococcus aureus and who was treated successfully with transcatheter arterial embolization. This case suggests that an infected aneurysm can be treated successfully by transcatheter arterial embolization in emergent situations (active bleeding or septicemia) even if surgery is contraindicated.

Surgical management of peripancreatic arterial aneurysms

Peripancreatic artery aneurysms--gastroduodenal (GDA) and pancreaticoduodenal (PDA)--are highly unusual. We report 4 such aneurysms and have collated reports of true peripancreatic artery aneurysms based on an extensive review of the English literature. From this review, patient characteristics, clinical behavior, outcome and management strategies are assessed.

Haemorrhage from pancreatic pseudocysts presenting as upper gastrointestinal haemorrhage

Haemorrhage is a rare but frequently fatal complication of pancreatic pseudocysts. The high mortality associated with pancreatic haemorrhage makes prompt and aggressive management essential. Occasionally, haemorrhage may present atypically, leading to delay in its diagnosis and management. This report details a case of pancreatic haemorrhage presenting as an upper gastrointestinal bleed and discusses the subsequent management. When managing patients with pancreatic pseudocysts who present with the stigmata of upper gastrointestinal bleeding, the possibility that the bleeding originates from the pancreas must always be borne in mind.

Prevalence and treatment of bleeding complications in chronic pancreatitis

OBJECTIVES

As spontaneous major haemorrhage in patients with chronic pancreatitis is rare, limited data have been reported, and no evidence-based guidelines are currently available regarding the optimal treatment modality.

PATIENTS AND METHODS

We report our experience with 36 patients with severe bleeding complications from a series of 541 patients presenting with chronic pancreatitis (representing a prevalence of 6.7% of admitted patients), treated in one surgical department over a period of 9.5 years, with a median follow-up of 4.1 years.

RESULTS

Haemorrhage was indirectly related to chronic pancreatitis in eight patients (22.2%) with ulcer or variceal bleeding. Three patients (8.4%) demonstrated spleen infarction or rupture. The most common causes of major haemorrhage were pseudoaneurysms in 25 patients (69.4%). Nine of them were treated with primary embolization. Sixteen patients with pseudoaneurysms underwent surgery. The only mortalities (8.3%) observed were from bleeding-associated complications of pseudoaneurysms. Two patients died after surgery, and one after primary embolization. We observed a higher re-bleeding rate after surgery (25% vs 11% after embolization). The presence of haemorrhagic shock, and the amount of blood transfused, were significant determinants of hospital mortality. Patient age, pseudoaneurysm location, and treatment modality had no significant influence on mortality.

CONCLUSIONS

Any haemodynamically stable patient with haemorrhage due to arterial pseudoaneurysms should undergo angiography with embolization when technically possible. If there are no other pancreas-related indications for surgery, embolization remains the definitive treatment. If embolization is not available or has failed, surgery is indicated, although perioperative morbidity will be higher.

Aneurysm of the pancreaticoduodenal arteries with a celiac trunk lesion: current management

OBJECTIVE

We report a ruptured aneurysm of the pancreaticoduodenal arteries without acute or chronic pancreatitis but associated with a median arcuate ligament division that compressed the celiac trunk, an exceptional event, thus far described in only 11 patients. We also conducted a targeted review to seek information about clinical presentation, to hasten diagnosis and assist in therapeutic management.

METHODS

A 54-year-old man with retroperitoneal hemorrhage associated with an arcuate ligament division, documented on computed tomographic scans, underwent diagnostic arteriography and embolization to treat the bleeding aneurysm. In a second elective operation the causative arcuate ligament was sectioned to decompress the celiac artery, to prevent aneurysm recurrence.

RESULTS

Embolization stopped the aneurysmal bleeding, and arteriograms showed that surgical sectioning resolved the celiac trunk stenosis. At 1-year follow-up the patient had no signs of complications or recurrence of disease.

CONCLUSION

Ruptured aneurysm of the pancreaticoduodenal arteries associated with stenosis of the celiac trunk is a surgical emergency. Although a literature review disclosed no significant difference between outcomes after open surgery and radiologic arterial embolization, our experience in this case suggests immediate embolization during arteriography as the most effective treatment. Later, to prevent recurrence, the arcuate ligament should be surgically sectioned and the celiac artery stenosis treated.

Spontaneous intraperitoneal hemorrhage: imaging features

Spontaneous intraperitoneal bleeding can result from a vast array of etiologies. Fortunately, most are uncommon and currently available imaging modalities can be used to differentiate them in almost all cases. Meticulous imaging technique and careful observation of key imaging features are important for accurate characterization of the organ of origin of the spontaneous bleeding. CT is the single most important imaging technique in the detection and characterization of spontaneous intraperitoneal bleeding. Further development in multidetector technology, such as the introduction of new machines with 8 or 16 detectors, should improve the effectiveness of CT further. Sonography and MR imaging are complimentary to CT, especially in patients with pelvic abnormalities or equivocal CT findings.

Pseudoaneurysm of gastroduodenal artery following radical gastrectomy for gastric carcinoma patients

We report a rare case of a postoperative pseudoaneurysm of the gastroduodenal artery following radical gastrectomy. Surgical trauma to the gastroduodenal artery during regional lymphadenectomy was considered the cause of the postoperative pseudoaneurysm. The pseudoaneurysm was successfully managed by ligating the bleeding vessel. We should consider the possibility of pseudoaneurysm formation in a patient with gastrointestinal bleeding in the postoperative period following radical gastrectomy with regional lymph node and perivascular lymphatic dissection.

Clinical features and management of splenic artery pseudoaneurysm: case series and cumulative review of literature

INTRODUCTION

Splenic artery pseudoaneurysm is uncommon. We report our institution's recent 18-year experience with these aneurysms and review the literature.

METHODS

We reviewed the records for 37 patients with visceral artery pseudoaneurysm evaluated at our institution from 1980 to 1998. From this group we found only 10 patients (27%) with splenic artery pseudoaneurysm. We also reviewed 147 cases of splenic artery pseudoaneurysm reported in the English literature.

RESULTS

In this series of 10 patients, 5 were men. Mean age was 51.2 years (range, 35-78 years). Causes of aneurysm included chronic pancreatitis in 4 patients, trauma in 2 patients, iatrogenic cause in 1 patient, and unknown cause in 3. The most common symptom was bleeding in 7 patients and abdominal or flank pain in 5 patients; 2 patients had no symptoms. Aneurysm diameter was known for four pseudoaneurysms, and ranged from 0.3 to 3 cm (mean, 1.7 cm). Splenectomy and distal pancreatectomy were performed in 4 patients, splenectomy alone in 2 patients, endovascular transcatheter embolization in 2 patients, and simple ligation in 1 patient. One patient with a ruptured pseudoaneurysm died before any intervention could be performed; there were no postoperative deaths. Follow-up data were available for 7 patients, with a mean of 46.3 months (range, 4.5-120 months).

CONCLUSIONS

Splenic artery pseudoaneurysm is rare and usually is a complication of pancreatitis or trauma. Average aneurysm diameter in our series of 10 patients was smaller than previously reported (1.7 cm vs 5.0 cm). Although conservative management has produced excellent results in some reports, from our experience and the literature, we recommend repair of all splenic artery pseudoaneurysms.

Emergency complications of acute and chronic pancreatitis

Acute pancreatitis is a common disease with a relatively high morbidity and mortality. In contrast, chronic pancreatitis is a recurrent disease with multiple potential complications that occasionally require urgent intervention. This article focuses on the emergency complications of acute and chronic pancreatitis that require urgent intervention. Recent developments in the diagnosis and management of such complications are discussed.

Potentially fatal bleeding in acute pancreatitis: pathophysiology, prevention, and treatment

INTRODUCTION

Massive bleeding may complicate the course of either acute or chronic pancreatitis. Although the latter is more frequently involved when bleeding occurs in the acute form, a poorer prognosis is to be expected. Abscess, severe inflammation, regional necrosis, and pseudocysts may cause major vessel erosion, with or without pseudoaneurysm formation, whose eventual rupture may result in massive bleeding into the gastrointestinal tract, retroperitoneum, and peritoneal cavity.

AIMS

To define the most important pathophysiologic mechanisms and factors that might contribute to a better understanding, better prevention, and more efficient treatment of severe hemorrhage complicating acute necrotizing pancreatitis. Awareness of high-risk conditions occurring during the natural evolution of the disease (from extensive local severe enzymatic damage to late septic sequelae), avoidance of a too early and too aggressive approach to sterile pancreatic necrosis, and providing prompt and effective treatment of local septic complications, when they occur, are crucial steps for bleeding prevention.

METHODOLOGY

Forty-four cases of severe bleeding following acute pancreatitis that were reported during the last decade since 1992 (including the six cases reported here) are reviewed, analyzed, and summarized.

RESULTS

The overall mortality rate was 34.1%. Splenic artery, portal vein, spleen, and unspecified peripancreatic vessels were the most commonly involved sources of bleeding, with associated mortality rates of 33.3%, 50.0%, 30%, and 28.5%, respectively. Massive hemorrhage was more frequently associated with severe necrosis, with a mortality rate of 37.9%.

CONCLUSION

The increased use of diagnostic and interventional radiology, in association with prompt surgical treatment, appears to be the way to improve survival rates in cases of arterial bleeding. Venous bleeding due to lesion of major peripancreatic veins or diffuse bleeding represents a therapeutic challenge, and treatment of these conditions should be tailored to the individual case, as no general rule can be suggested. In extreme cases, open packing or salvage emergency pancreatectomy may represent the only chances for survival.

Embolisation of metachronous pseudoaneurysms complicating chronic pancreatitis

BACKGROUND

Pseudoaneurysm bleeding is a well-described complication of chronic pancreatitis. Reports of embolisation therapy for metachronous pseudoaneurysms in this condition are rare. We present such a patient and describe his management.

CASE OUTLINE

A 5 1-year-old man with chronic pancreatitis who presented with recurrent occult major gastrointestinal bleeding underwent angiography on two separate occasions, 2 years apart. Initial intervention revealed the origin of the coeliac axis to be occluded or absent, and a splenic artery (SA) aneurysm, feeding via the superior mesenteric artery, was embolised. Subsequent angiography after a major bleed showed a new pseudoaneurysm in the head of pancreas feeding from an aberrant hepatic artery, which was embolised. The second angiogram confirmed persistent occlusion of the SA aneurysm and 6 months follow-up showed no evidence of recurrence of the second aneurysm.

DISCUSSION

The resolution of these metachronous pseudoaneurysms by angiographic embolisation attests to the validity of this approach as potentially definitive and repeatable therapy.

Complications of acute pancreatitis: clinical and CT evaluation

Mortality of acute pancreatitis is dependent on the development of potentially lethal complications that can coexist and occur at any time following an acute attack. The nature and clinical relevance of these complications differ, contingent on the time of occurrence following a severe episode of pancreatitis. They can be divided into (1), early complications that manifest at the onset or within the first 2 to 3 days, (2) intermediate complications that occur predominantly during the second to fifth week, and (3) late complications that usually manifest months or years following the resolution of an acute attack. Early complications are systemic in nature with diverse clinical manifestations of the cardiovascular, pulmonary, renal, and/or metabolic systems. Intermediate complications are abdominal, pancreatic, and retroperitoneal, and are mostly septic in nature, associated with pancreatic or peripancreatic fat necrosis and pseudocysts. Late, life-threatening complications are mainly vascular or hemorrhagic in nature or involve the development of chronic pancreatic ascites. The early detection and objective evaluation of these complications by clinical and imaging methods leads to specific treatment options in the continuous attempt to decrease mortality rates in acute pancreatitis.

Haemosuccus pancreaticus: treatment by arterial embolization

AIM

Haemosuccus pancreaticus is bleeding into the pancreatic duct from a peripancreatic artery. This condition most commonly follows pseudoaneurysm formation secondary to acute or chronic pancreatitis. It is a rare disorder, challenging in both diagnosis and therapy. We present an eight-year experience of managing these patients using endovascular embolization as the primary therapy.

MATERIALS AND METHODS

We retrospectively reviewed the imaging, laboratory results and clinical notes of the five patients who presented to this institution between 1991-1999 with gastrointestinal bleeding subsequently found to be haemosuccus pancreaticus.

RESULTS

There were four men and one women aged 38-75 years. All had a history of gastrointestinal haemorrhage and had acute (n=1) or chronic pancreatitis with a complicating pseudoaneurysm. All underwent embolization as the primary therapy for the pseudoaneurysm. There was immediate technical success in all cases without major complication. No patient required operative surgery for the pseudoaneurysm. Follow-up ranged from 18 months to 7 years. One patient died four years after embolization due to hepatic failure but the other four remain well without further gastrointestinal bleeding.

CONCLUSION

Endovascular embolization is an effective and safe treatment for haemosuccus pancreaticus.

Hemorrhagic complications of pancreatitis: radiologic evaluation with emphasis on CT imaging

OBJECTIVE

To analyze and describe the incidence, pathophysiology, radiographic diagnosis and the initial management of hemorrhagic complications associated with pancreatitis.

MATERIAL AND METHODS

Among 1,910 patients diagnosed of having pancreatitis in the last 10 years, 26 developed hemorrhagic complications (1.3%). These complications were detected from 2 months to 8 years after one or several episodes of pancreatitis with a mean of 2.3 years. Radiographic studies were reviewed and clinical management and outcome were recorded.

RESULTS

Ten patients had CT evidence of pancreatic necrosis, 12 patients chronic pancreatitis, and 17 patients pancreatic pseudocysts. The cause of hemorrhage was bleeding pseudoaneurysm in 16 patients (61%), diffuse bleeding with pancreatic necrosis in 5 patients (19.5%) and hemorrhagic pseudocysts in 5 patients (19.5%). Intra-abdominal hemorrhage developed in 21 patients and gastro-intestinal bleeding in 5 patients. Arterial embolization was attempted in 12 patients and was successful in 9 patients (75%). Surgery was used in 16 patients and the overall mortality rate was 11%.

CONCLUSIONS

Hemorrhagic complications are rarely seen and are usually late sequelae of pancreatitis. They develop because of leaking or ruptured pseudoaneurysms, diffuse bleeding in pancreatic necrosis, and hemorrhagic pseudocysts. Early detection followed by angiography, embolization and/or surgery has decreased mortality rates.

Rupture of splenic artery pseudoaneurysm presenting with massive upper gastrointestinal bleed

Splenic artery pseudoaneurysms develop in as many as 10% of patients with acute pancreatitis. The diagnosis should be suspected in patients with pancreatitis who develop either upper gastrointestinal bleeding without an obvious cause or in whom a contrast-enhanced lesion is demonstrated within or adjacent to a suspected pseudocyst as determined by computed tomography scan.

Endovascular treatment of visceral artery aneurysms

PURPOSE

To review a 10-year experience with endovascular embolization of visceral artery aneurysms.

METHODS

Twenty-five patients (13 men; mean age 52.1 years, range 31-80) presented with VAAs of varying locations and etiologies: 10 splenic, 3 gastroduodenal, 2 pancreaticoduodenal, 3 hepatic, 3 superior mesenteric, 2 celiac, 1 left gastric, and 1 jejunoileal. Ten patients were asymptomatic; 7 aneurysms were ruptured. Transcatheter coil embolization was the treatment of choice in all patients.

RESULTS

Coil placement was initially (<7 days) successful in 23 (92%) patients. One superior mesenteric artery aneurysm remained perfused, and recurrent bleeding occurred 2 days after intervention in 1 case, but repeated embolization excluded the aneurysm. One patient with necrotizing pancreatitis died from sepsis 10 days after endovascular treatment and surgery (4% 30-day mortality). Long-term follow-up revealed excellent results after an average 48.7 months (range 14-75) with only 1 recurrence after 12 months.

CONCLUSIONS

Embolotherapy is the treatment of choice in visceral artery aneurysms, regardless of etiology, location, or clinical presentation.

Interventional radiology in inflammatory pancreatic disease

This article presents a review of the interventional radiological procedures in inflammatory pancreatic diseases including imaging guided biopsy, percutaneous aspiration and drainage, and transcatheter embolization of ruptured pseudoaneurysms.