Pancreatic pseudocyst bleeding associated with massive intraperitoneal hemorrhage

Atypical extensive pancreatic pseudocyst with hemorrhage in a hemodialysis patient

Pancreatic pseudocysts are a common complication of both acute and chronic pancreatitis. The complications of pancreatic pseudocysts include compression of abdominal great vessels, gastric or duodenal stenosis, cholestasis due to stenosis of common bile duct, infection, and hemorrhage into the cyst. Moreover, pancreatic pseudocysts most commonly occur around the pancreas; however, extension into the adjacent viscera including spleen, liver, transverse colon, anterior or posterior pararenal space, retroperitoneum and mediastinum does occur infrequently. Here, we report a rare case of atypical extensive pancreatic pseudocyst with hemorrhage in a hemodialysis patient.

Hemorrhagic pancreatic pseudocyst: A rare complication

Pancreatic pseudocysts are seen both in acute and chronic pancreatitis. Prevalence of pancreatic pseudocyst in chronic pancreatitis is 20% to 40% and is most commonly seen in alcoholic chronic pancreatitis. Intracystic hemorrhage from a pseudoaneurysm is a rare and potentially a lethal complication of pancreatic pseudocyst with an incidence of less than 10%. We herein present a case of a 42-year-old male with a past medical history of chronic alcoholic pancreatitis, stable pseudocyst in the tail of pancreas, alcohol abuse and seizures who presented with abdominal pain and acute anemia had this rare complication of hemorrhagic pseudocyst. The diagnostic modalities used to diagnose hemorrhagic pseudocyst are ultrasound with color doppler, CT with contrast, digital subtraction angiography and angiography. Angiographic embolization of the culprit artery is the preferred treatment of choice in the treatment of pseudoaneurysms. It is important for early recognition and treatment of this complication as the mortality can be as high as 40%.

Surgical Management of Pancreatic Pseudocysts

Open surgical intervention for treatment of simple pancreatic pseuodocyst (PP) has a high success rate and has been the historical gold standard. Open surgical intervention, however, confers significant morbidity and mortality, which has spurred the development of less invasive techniques. Laparoscopic approaches are feasible with the potential for lower complication rates and length of stay. The endoscopic approach has the appeal of potentially shorter hospitalization length of stays and does not require general anesthesia. Complicated PPs or those that arise in the setting of chronic pancreatitis warrant additional workup and special consideration.

The diagnostic challenge of the sequelae of acute pancreatitis on CT imaging: a pictorial essay

PURPOSE

The purpose of the study was to present a pictorial review of the long-term sequelae of acute pancreatitis on CT imaging as these findings can cause diagnostic confusion in the absence of a proper clinical history and/or prior CT imaging.

METHODS

We retrospectively identified 81 patients who had an episode of acute pancreatitis with diagnostic findings on CT and also underwent one or more follow-up CT scans at least 1 month beyond the acute episode. The residual findings on all follow-up CT scans were tabulated, including the time interval since the initial bout of acute pancreatitis.

RESULT

Residual inflammatory changes were present in 19.8% of cases, with a median time period lasting 86 days since the initial episode of acute pancreatitis. Residual fluid collections were seen in 27.2% and persisted for a median of 132 days. Three patients had residual solid-appearing inflammatory masses, which could be mistaken for neoplasms. Other long-term sequelae were also tabulated, including pancreatic ductal dilatation, pancreatic atrophy, new or increased pancreatic calcifications, biliary tract dilatation, central portal venous occlusion, and pseudoaneurysm formation. These residual findings and long-term complications are presented as a pictorial essay.

CONCLUSION

Recognizing the spectrum of residual findings of acute pancreatitis, some of which can be long term, is important in the correct interpretation of a pancreatic CT. These findings can mimic acute pancreatitis or a pancreatic/peripancreatic neoplasm and often cause diagnostic confusion, especially in the absence of prior CT imaging.

Endovascular intervention for management of pancreatitis-related bleeding: a retrospective analysis of thirty-seven patients at a single institution

PURPOSE

The aim of this study was to assess the outcome of endovascular intervention for pancreatitis-related hemorrhage at a single institution.

METHODS

From January 2000 to October 2012, thirty-seven patients underwent endovascular intervention for the management of pancreatitis-related hemorrhage. The underlying etiology of the disease, clinical symptoms and laboratory findings, abnormalities seen on computed tomography, and details regarding the endovascular procedures were assessed, as were the outcome of each procedure and procedure-related complications.

RESULTS

A total of 41 endovascular procedures were performed in 37 patients. The splenic artery (34.8%) was the most commonly treated artery, and pseudoaneurysm was the most commonly detected abnormality on digital subtraction angiography (78.3%). Transcatheter embolization was performed in the majority of patients (95.1%), while two patients were treated with stent-grafts. Successful hemostasis without rebleeding was achieved in 34 patients (91.9%). Two cases of rebleeding were successfully treated by reintervention. Focal splenic infarction, which developed in eight patients, was either asymptomatic or accompanied by mild, transient fever. Splenic abscess was the only major complication occurring in three patients. Two of these patients died from resulting sepsis, while the third recovered after antibiotic treatment.

CONCLUSION

Endovascular management is effective for achieving hemostasis in patients with pancreatitis-related bleeding and demonstrates low recurrence and mortality rates.

Pancreatic Pseudocyst with Splenic Artery Erosion, Retroperitoneal and Splenic Hematoma

The erosion of the peripancreatic vascular structures is a rare but life-endangering complication of pancreatic diseases. We report a female patient with a multicompartmentalized pancreatic pseudocyst that eroded the splenic artery resulting in a retroperitoneal and splenic hematoma with hemodynamic instability which required emergency laparotomy with splenectomy, partial cystectomy, ligation of the splenic artery at the level of the vascular erosion, cholecystectomy (lithiasis), and multiple drainage. The postoperative course was difficult (elevated level of platelets, pancreatic fistula) but eventually favourable, with no abdominal complaints and no recurrence at 2-year follow-up. The case shows that the pancreatic pseudocysts may present with acute hemorrhagic complications with life-endangering potential and significant postoperative morbidity.

Spontaneous intraperitoneal hemorrhage as the initial presentation of a gastrointestinal stromal tumor: a case report

BACKGROUND

Spontaneous hemoperitoneum is rare. The most common etiologies are gynecologic, splenic, and hepatic. Gastrointestinal stromal tumors (GISTs) are commonly associated with intraluminal bleeding, but rarely with spontaneous hemoperitoneum. We report a case of spontaneous hemoperitoneum caused by a gastric GIST.

CASE REPORT

A 54-year-old male presented with the acute onset of abdominal pain and a drop in hemoglobin. Subsequent evaluation, including a CT, MRI, and EUS, revealed a 1.2-cm mass along the greater curvature of the stomach and associated hemoperitoneum. The patient was taken electively to the operating room for laparoscopic removal of the mass. Pathology confirmed that it was a GIST.

CONCLUSION

GIST is a rare clinical entity that infrequently presents with spontaneous hemoperitoneum. Emergent treatment should be guided towards treating the spontaneous hemoperitoneum.