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

The Spanish Pancreatic Club's recommendations for the diagnosis and treatment of chronic pancreatitis: part 2 (treatment)

Chronic pancreatitis (CP) is a complex disease with a wide range of clinical manifestations. This range comprises from asymptomatic patients to patients with disabling symptoms or complications. The management of CP is frequently different between geographic areas and even medical centers. This is due to the paucity of high quality studies and clinical practice guidelines regarding its diagnosis and treatment. The aim of the Spanish Pancreatic Club was to give current evidence-based recommendations for the management of CP. Two coordinators chose a multidisciplinary panel of 24 experts on this disease. These experts were selected according to clinical and research experience in CP. A list of questions was made and two experts reviewed each question. A draft was later produced and discussed with the entire panel of experts in a face-to-face meeting. The level of evidence was based on the ratings given by the Oxford Centre for Evidence-Based Medicine. In the second part of the consensus, recommendations were given regarding the management of pain, pseudocysts, duodenal and biliary stenosis, pancreatic fistula and ascites, left portal hypertension, diabetes mellitus, exocrine pancreatic insufficiency, and nutritional support in CP.

A challenging case of epigastric pain: diagnosis and mini-invasive treatment of a large gastroduodenal artery pseudoaneurysm

The authors present a case of a gastroduodenal artery pseudoaneurysm in a patient with a medical history of pancreatic surgery. The lesion was found and evaluated by ultrasound, CT-angiography and then treated with trans-catheter embolisation. This mini-invasive approach led to a complete resolution of the lesion.

Successful arterial embolization of a giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis with literature review

We report a case of an uncommon giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis. It presented with a perfused volume of 17.3 cm(3) close to the branch-off of the right hepatic artery. Superselective transcatheter embolization including interlocking detachable coils and a mixture of Ethibloc and Lipiodol was our technique of choice. Following the procedure, the patient was in hemodynamically stable condition. At that time, he was free of any clinical symptoms and showed no further signs of bleeding or ischaemia. Additionally, we present an overview of the relevant literature.

Successful arterial embolization of a giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis with literature review

We report a case of an uncommon giant pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis. It presented with a perfused volume of 17.3 cm(3) close to the branch-off of the right hepatic artery. Superselective transcatheter embolization including interlocking detachable coils and a mixture of Ethibloc and Lipiodol was our technique of choice. Following the procedure, the patient was in hemodynamically stable condition. At that time, he was free of any clinical symptoms and showed no further signs of bleeding or ischaemia. Additionally, we present an overview of the relevant literature.

Hepatic artery pseudoaneurysm with extrahepatic biliary obstruction

Hepaticartery pseudoaneurysms are a rare complication of chronic pancreatitis. However, giant pseudoaneurysms (80 mm) and complicated biliary obstructions are extremely rare. This article reports a 75 year-old man with chronic pancreatitis that presented as upper abdominal pain and obstructive jaundice. Computed tomography revealed a hepatic artery pseudoaneurysm measuring 80 × 72 × 70 mm. We performed aneurysm resection and common hepatic artery bypass, using a great saphenous vein graft in the patient. The postoperative course was uneventful, and he was discharged on the 10th postoperative day. However, on the 135th postoperative day, he died of massive hemorrhage into the peritoneal cavity.

Fluid collections in and around the pancreas in acute pancreatitis

The advent of computed tomographic scan with its wide use in the evaluation of acute pancreatitis has opened up a new topic in pancreatology i.e. fluid collections. Fluid collections in and around the pancreas occur often in acute pancreatitis and were defined by the Atlanta Symposium on Acute Pancreatitis in 1992. Two decades since the Atlanta Conference additional experience has brought to light the inadequacy and poor understanding of the terms used by different specialists involved in the care of patients with acute pancreatitis when interpreting imaging modalities and the need for a uniformly used classification system. The deficiencies of the Atlanta definitions and advances in medicine have led to a proposed revision of the Atlanta classification promulgated by the Acute Pancreatitis Classification Working Group. The newly used terms "acute peripancreatic fluid collections," "pancreatic pseudocyst," "postnecrotic pancreatic/peripancreatic fluid collections," and "walled-off pancreatic necrosis" are to be clearly understood in the interpretation of imaging studies. The current treatment methods for fluid collections are diverse and depend on accurate interpretations of radiologic tests. Management options include conservative treatment, percutaneous catheter drainage, open and laparoscopic surgery, and endoscopic drainage. The choice of treatment depends on a correct diagnosis of the type of fluid collection. In this study we have attempted to clarify the management and clinical features of different types of fluid collections as they have been initially defined under the 1992 Atlanta Classification and revised by the Working Group's proposed categorization.

N-butyl cyanoacrylate embolization for pseudoaneurysms complicating pancreatitis or pancreatectomy

PURPOSE

To evaluate the clinical effectiveness and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for pseudoaneurysms complicating pancreatitis or pancreatectomy.

MATERIALS AND METHODS

Twelve procedures were performed in nine patients (seven men and two women; mean age, 60.6 years) for pseudoaneurysms that occurred secondary to pancreatitis or as a consequence of pancreatic juice leakage at the site of pancreatectomy. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1-1:4; in one patient with failed selective catheterization of the target vessel, the mixture ratio was 1:9. Technical and clinical success rates, recurrent bleeding, procedural complications, serum amylase level, and clinical outcome were determined for each procedure.

RESULTS

Embolization was technically successful in all procedures, with no recurrent bleeding documented from the initially treated territory. In three procedures, we encountered additional bleeding vessels at 11, 33, and 49 days after the procedures, which were successfully managed by a second embolization in each case. There were no major complications related to the procedures. As minor complications, in two procedures, the embolized material overflowed beyond the target vessels; however, no clinically significant ischemic events were observed in the embolized territories. Serum amylase did not increase compared with initial levels after any of the procedures. Seven patients were discharged after clinical improvement. Two patients died 2 and 3 weeks after the embolization as a result of multiple organ failure not associated with the procedure.

CONCLUSIONS

In this limited series, NBCA embolization was found to be feasible and effective for pseudoaneurysms as a complication of pancreatitis or pancreatectomy.

Pseudoaneurysm of the gastroduodenal artery secondary to chronic pancreatitis

Although pseudoaneurysms are a rare complication of chronic pancreatitis, they are potentially serious both because of the events they can lead to and the diagnostic challenges they may pose. Historically, they used to be treated surgically, through ligation and/or resection; it was not until the last decade that scarcely invasive percutaneous endovascular procedures were introduced. This article reports the case of a patient with chronic pancreatitis presenting with severe upper digestive hemorrhage caused by the rupture of a pseudoaneurysm of the gastroduodenal artery. The patient was successfully treated using selective embolization.

Unusual locations of pseudo aneurysms as a sequel of chronic pancreatitis

In patients with chronic pancreatitis, an actively bleeding pseudo aneurysm can be life threatening. Common sites of pseudoaneurysms are splenic, gastro-duodenal, superior & inferior pancreaticoduodenal arterial branches. Angioembolisation is an effective alternative to a complex and morbid operative management. Here we report 4 cases of unusual sites of pseudoaneurysms as a complication of pancreatitis, involving superior mesenteric and inferior phrenic arteries. Successful angioembolisation using glue and coil was achieved in 3 patients where as one underwent surgery. Technical success was 100% with the combination approach, though one patient died from multiorgan failure. This short case series reiterates the importance of vascular complications in pancreatitis at rare sites and also timely combined radiological and surgical approach for ensuring favorable outcome.

Walled-off pancreatic necrosis

Walled-off pancreatic necrosis (WOPN), formerly known as pancreatic abscess is a late complication of acute pancreatitis. It can be lethal, even though it is rare. This critical review provides an overview of the continually expanding knowledge about WOPN, by review of current data from references identified in Medline and PubMed, to September 2009, using key words, such as WOPN, infected pseudocyst, severe pancreatitis, pancreatic abscess, acute necrotizing pancreatitis (ANP), pancreas, inflammation and alcoholism. WOPN comprises a later and local complication of ANP, occurring more than 4 wk after the initial attack, usually following development of pseudocysts and other pancreatic fluid collections. The mortality rate associated with WOPN is generally less than that of infected pancreatic necrosis. Surgical intervention had been the mainstay of treatment for infected peripancreatic fluid collection and abscesses for decades. Increasingly, percutaneous catheter drainage and endoscopic retrograde cholangiopancreatography have been used, and encouraging results have recently been reported in the medical literature, rendering these techniques invaluable in the treatment of WOPN. Applying the recommended therapeutic strategy, which comprises early treatment with antibiotics combined with restricted surgical intervention, fewer patients with ANP undergo surgery and interventions are ideally performed later in the course of the disease, when necrosis has become well demarcated.

[Diagnostics of vascular diseases as a cause for acute abdomen]

Vascular pathologies are rare causes of an acute abdomen. If the cause is a vascular disease a rapid diagnosis is desired as vascular pathologies are associated with high mortality. A differentiation must be made between arterial and venous diseases. An occlusion of the superior mesenteric artery is the most common reason for acute mesenteric ischemia but intra-abdominal arterial bleeding is also of great importance. Venous pathologies include thrombotic occlusion of the portal vein, the mesenteric vein and the vena cava.Multi-detector computed tomography (MDCT) is predestined for the diagnostics of vascular diseases of the abdomen. Using multiphasic contrast protocols enables reliable imaging of the arterial and venous vessel tree and detection of disorders with high sensitivity and specificity. Although conventional angiography has been almost completely replaced by MDCT as a diagnostic tool, it is still of high importance for minimally invasive interventions, for example in the management of gastrointestinal bleeding.

Current management and novel insights in acute pancreatitis

Acute pancreatitis (AP) is a common and potentially lethal acute inflammatory process. Approximately 10-20% of patients develop a severe course and suffer systemic inflammatory response and/or pancreatic necrosis (PNec). To date, there is no single biomarker proven to perform better than clinical judgment in predicting severe AP. The available prognostic clinical scoring systems are used primarily for research purposes. Management of AP is limited to supportive care and treatment of complications when they develop. Patients with mild AP require regular ward admission, fluid administration, bowel rest and pain management. Patients with signs of severe AP should be identified early and admitted promptly to an intensive-care unit. Nutrition support via nasojejunal feedings should be initiated. Sterile PNec is managed conservatively. Infected PNec requires minimally invasive debridement via endoscopic or surgical approaches. The lack of scientific advancements in the management of AP reflects the limited understanding of the early pathogenetic mechanisms and our moderate-to-poor ability to predict severe course at the time of admission.

[Pseudoaneurysm of the left gastric artery]

We report the case of a 65-year-old man admitted for an upper-GI hemorrhage. A CT scan performed with vascular reconstructions demonstrated a pseudoaneurysm of the left gastric artery. Proximal vascular control of the celiac axis was obtained by balloon occlusion with a Fogarty balloon inserted retrograde via the femoral artery: the pseudoaneurysm was then successfully controlled with direct suture.

Gastric subserosal hematoma developing from focal pancreatitis: a case report

Pancreatitis complicated by gastric wall hemorrhagic is rarely reported. The imaging findings of focal pancreatitis with gastric wall hemorrhage can mimic a disease entity of gastric origin. We report a case of gastric subserosal hematoma developing in a patient with focal pancreatitis. The patient was initially scheduled to receive subtotal gastrectomy due to a presumed diagnosis of a disease entity of gastric origin. Computed tomography of the abdomen revealed focal pancreatitis that had eroded the gastric wall resulting in subserosal hemorrhage. The radiologist informed the surgeon of the possibility of focal pancreatitis complicated by gastric hemorrhage. The gastric subserosal hematoma was treated with percutaneous drainage and the patient recovered uneventfully.

Ruptured gastroduodenal artery pseudoaneurysm as the initial presentation of chronic pancreatitis

Gastroduodenal artery pseudoaneurysm is a rare but life threatening complication of pancreatitis. Diagnosis and management of it remain challenging. Surgical treatment was associated with a high mortality. Percutaneous transarterial embolization of bleeding artery has recently been advocated as a definitive therapy and can be attempted as the initial measure to control bleeding. We herein report a case of chronic pancreatitis presented with ruptured pseudoaneurysm of gastroduodenal artery which was successfully controlled with transarterial embolisation.

Imaging assessment of acute pancreatitis: a review

Acute pancreatitis is one of the more commonly encountered etiologies in the emergency setting. While in the majority of cases it is a self-limiting disease which responds rapidly to conservative management, in some cases acute pancreatitis may present with a more pronounced, sometimes dramatic, clinical picture and requires immediate medical care to avoid fatal complication. In this context, imaging plays a significant role because it enables identification of the development of the disease and local/systemic complications. The purpose of this article is to offer an overview of the disease and a spectrum of imaging findings in patients with acute pancreatitis, emphasizing the role of ultrasound, computed tomography, and magnetic resonance imaging according to the appropriate clinical context and advantages and limitations of each imaging modality are examined.

MDCT of acute mild (nonnecrotizing) pancreatitis: abdominal complications and fate of fluid collections

OBJECTIVE

The objective of our study was to describe the occurrence of local complications and the fate of fluid collections in milder forms of acute nonnecrotizing pancreatitis.

MATERIALS AND METHODS

Initial MDCT studies of 169 consecutive patients with mild acute pancreatitis and 203 follow-up CT examinations were reviewed. The fate of peripancreatic fluid collections was investigated, and the incidence and type of local complications were recorded and correlated to the CT grading system (A-E).

RESULTS

Complications developed in nine of 169 patients, for an incidence of 5.3%. All morbidity occurred in the subgroup of 73 patients with initial fluid collections, for an incidence of 12.3%. Follow-up CT examinations available in 51 of these 73 patients documented rapid fluid resolution in 35 cases (68.6%) and persistence of fluid more than 2 weeks from onset in seven asymptomatic patients (13.7%). Acute, life-threatening complications (hemorrhage, infection, perforation) occurred in five patients, for an incidence of 6.8% among the 73 patients with initial fluid collections, or 3.0% in the entire group of 169 patients. Five patients developed acute pseudocysts. Long-term follow-up studies discovered two patients with chronic pancreatitis and one with groove pancreatitis.

CONCLUSION

A small number of acute, life-threatening abdominal complications and chronic complications are expected to occur in patients with milder forms of acute nonnecrotizing pancreatitis presenting with fluid collections. In these patients, clinical monitoring and repeated imaging studies are recommended to document the resolution of fluid or the development of complications.

[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.

Hemorrhage in acute pancreatitis: should gastrointestinal bleeding be considered an organ failure?

OBJECTIVE

To define the magnitude, causes, risk factors, and consequences of hemorrhage in acute pancreatitis (AP).

METHODS

Consecutive patients with AP were studied for hemorrhagic complication and its impact on mortality. Patients with gastrointestinal (GI) hemorrhage or hemorrhage within the pancreatic bed were managed with transfusions, endotherapy, angiographic embolization, or surgery as appropriate.

RESULTS

Of 449 patients, 28 (6.2%) developed hemorrhage. The mean age of patients with hemorrhage was 39 +/- 14 years and 25 (89%) were men. Of the 28 patients, 16 had GI hemorrhage, and 12 had hemorrhage into the pancreatic bed. Median interval between the onset of AP and hemorrhage was 26.5 days. Pancreatic necrosis, sepsis, fluid collection, and organ failure were found to be risk factors for hemorrhage. Five patients had pseudoaneurysms; angiographic embolization was successful in 4 of them. The mortality rate in bleeders was higher than that in nonbleeders (28.6% vs 13%; P = 0.02). None of the patients died as a direct consequence of hemorrhage except 1 patient who died after surgery for failed embolization of bleeding pseudoaneurysm. Deaths were mainly caused by sepsis and multiorgan failure.

CONCLUSIONS

Hemorrhagic complications are usually late manifestations in the course of severe pancreatitis and per se have little bearing on mortality.

Acute parent artery dissection as a complication of mesenteric endovascular coil embolisation for pancreatic pseudoaneurysm

We wish to highlight arterial dissection as an unusual complication during endovascular coiling of a pancreatic pseudoaneurysm. Immediate recognition and prompt corrective measures prevented progression of this serious condition. In our patient, angioplasty prevented further propagation of the dissection and preserved coeliac artery patency.

Vascular complications of pancreatitis: imaging and intervention

The objective of this study was to highlight technical challenges and potential pitfalls of diagnostic imaging, intervention, and postintervention follow-up of vascular complications of pancreatitis. Diagnostic and interventional radiology imaging from patients with pancreatitis from 2002 to 2006 was reviewed. We conclude that biphasic CT is the diagnostic modality of choice. Catheter angiography may (still) be required to diagnose small pseudoaneurysms. Endovascular coiling is the treatment of choice for pseudoaneurysms. Close clinical follow-up is required, as patients may rebleed/develop aneurysms elsewhere.

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.

The role of nonenhanced magnetic resonance imaging in the early assessment of acute pancreatitis

BACKGROUND AND AIMS

Computed tomography (CT), especially contrast-enhanced CT (CECT), provides important information on the severity and prognosis of acute pancreatitis (AP). Magnetic resonance imaging (MRI) has become a useful tool as an alternative to CT in the assessment of AP. The primary aim of our study was to determine the diagnostic value of nonenhanced MRI (NEMRI) to assess severity and predict outcome in patients with AP from the third to fifth day after admission. We also correlated MRI findings with CT and biochemical parameters.

PATIENTS AND METHODS

The study included 101 patients (49 men, 52 women, median age 62 yr, range 20-82) with a diagnosis of AP admitted to our hospital between January 1, 2004 and June 31, 2005. The inclusion criteria consisted of a combination of clinical features, a typical case history, elevation of serum pancreatic enzymes, and diagnosis confirmed by imaging studies. Contrast-enhanced spiral CT exams were performed in all patients from the third to fifth day after admission, and Balthazar grade and CT severity index were calculated. All patients underwent NEMRI, and MR severity index (MRSI) was calculated. We also performed magnetic resonance cholangiopancreatography (MRCP) in all patients to detect bile duct lithiasis.

RESULTS

Significant correlation between CECT and NEMRI was found for Balthazar grade (P<0.001) and the assessment of pancreatic necrosis (P<0.001), as well as between the combined severity indices (rho=0.819, P<0.001). MRSI correlated with Ranson score (rho=0.656, P<0.01), C-reactive protein (CRP) levels 48 h after admission (rho=0.502, P<0.01), appearance of systemic complications (rho=0.576, P<0.01), and length of hospital stay (rho=0.484, P<0.01). Considering the Atlanta criteria as the gold standard and the Ranson score, no difference in sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the two methods was observed. Comparing the group of patients with presumed acute pancreatic hemorrhage with the group of patients with severe AP, we found a significantly higher APACHE II score on the first day (P<0.05), that the development of systemic complications was more frequent (P < 0.05), and that the hospital stay and ICU management of patients with MRI signs of pancreatic hemorrhage tended to be longer.

CONCLUSION

NEMRI is comparable to CECT in the early assessment of the severity of AP, and both methods are equally efficient in predicting local and systemic complications of AP. MRI has a potential advantage over CT in detecting bile duct lithiasis and pancreatic hemorrhage.

[Colonic necrosis following a pancreatic pseudocyst embolization]

A 43-year-old man with chronic alcohol pancreatitis was admitted in our intensive care unit for an haemorrhagic shock. An abdominal CT-scan performed on admission showed bleeding from a vessel in a pancreatic pseudocyst. Initial treatment included intravenous fluids, transfusion, mechanical ventilation and vasopressive support. Percutaneous arterial embolization (PAE) of a bleeding right superior colon artery was performed with an initial good result. Nevertheless after initial clinical improvement, hypotension refractory to fluid management occurred. An abdominal CT-scan disclosed pneumatosis in right colon. A right hemicolectomy was performed. Histologic analysis confirmed ischemic colitis. The patient recovered and was discharged from the intensive care unit. Colitis necrosis after PAE for pancreatic pseudoaneurysm had never been described before. It should be suspected when haemodynamic instability occurs following PAE.

Ruptured left gastric artery aneurysm: unique presentation with hemothorax and hemomediastinum

Although splanchnic artery aneurysms are uncommon and remain mostly asymptomatic, they are associated with a high mortality rate when they rupture. We discuss the case of a 66-year-old woman who had successful embolization of a left gastric artery aneurysm after presenting with acute chest pain and the unusual computed tomography findings of hemothorax and hemomediastinum. To our knowledge, only one other similar case has been published in the literature.

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.

Multi-section CT angiography compared with digital subtraction angiography in diagnosing major arterial hemorrhage in inflammatory pancreatic disease

PURPOSE

Major arterial hemorrhage is an uncommon but serious complication of pancreatitis with high morbidity and mortality. Digital subtraction angiography (DSA) has long been the gold standard for the detection of a visceral artery pseudoaneurysm or for the site of active bleeding in patients with pancreatitis. Multi-section CT angiography is a minimally invasive technique which can provide high-resolution and high-contrast images of the arterial lumen and wall, with a much lower risk of complication and morbidity compared to DSA. The aim of this study was to determine the accuracy of multi-section CT angiography for the diagnosis of arterial complications of inflammatory pancreatitic disease.

MATERIALS AND METHODS

A retrospective analysis of all patients undergoing visceral angiography for major bleeding as a complication of pancreatitis between 1998 and 2004 was performed. Twenty-nine studies in 25 patients (20 males, 5 females) with a mean age of 50.9 years (range 11-67 years) were identified where multi-section CT angiography was performed in the 24 h preceding the digital subtraction angiogram.

RESULTS

Digital subtraction angiography detected a pseudoaneurysm or contrast extravasation in 19 studies and no bleeding was demonstrated in 9 studies. CT angiography correctly identified the site and type of bleeding in 18 of the 19 positive studies. CT angiography detected extravasation of contrast in one study that was not demonstrated on digital subtraction angiography. The sensitivity and specificity for multi-section CT angiography for the detection of major arterial bleeding on a background of pancreatitis were 0.947 and 0.900, respectively.

CONCLUSION

Multi-section CT angiography is a sensitive and accurate technique for the detection of major arterial hemorrhage in inflammatory pancreatic disease and should be considered as the first investigation in the management of these patients.

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.

Multidetector CT of the pancreas

CT is the primary imaging modality of the pancreas. This article reviews the multidector CT technique and its current status in the diagnosis of various pancreatic diseases. Special emphasis is given to the impact of multidetector CT and postprocessing imaging techniques on the staging of pancreatic adenocarcinoma.

Factors influencing mortality in acute pancreatitis: can we alter them?

Severe acture pancreatitis (SAP), a multisystem disease, is characterized by multiple organ system failure and additionally by local pancreatic complications such as necrosis, abscess, or pseudocyst. The rate of mortality in SAP, which is about 20% of all cases of acute pancreatitis (AP), may be as high as 25%, as in infected pancreatic necrosis. The factors that influence mortality in different degrees are various. Etiology for the episode, age, sex, race, ethnicity, genetic makeup, severity on admission, and the extent and nature of pancreatic necrosis (sterile vs. infected) influence the mortality. Other factors include treatment modalities such as administration of prophylactic antibiotics, the mode of feeding (TPN vs. enteral), ERCP with sphincterotomy, and surgery in selected cases. Epidemiological studies indicate that the incidence of AP is increasing along with an increase in obesity, a bad prognostic factor. Many studies have indicated a worse prognosis in idiopathic AP compared to pancreatitis induced by alcoholism or biliary stone. The risk for SAP after ERCP is the subject of extensive study. AP after trauma, organ transplant, or coronary artery bypass surgery is rare but may be serious. Since Ranson reported early prognostic criteria, a number of attempts have been made to simplify or add new clinical or laboratory studies in the early assessment of severity. Obesity, hemoconcentration on admission, presence of pleural effusion, increased fasting blood sugar, as well as creatinine, elevated CRP in serum, and urinary trypsinogen levels are some of the well-documented factors in the literature. The role of appropriate prophylactic antibiotic therapy although still is highly controversial, in properly chosen cases appears to be beneficial and well accepted in clinical practice. Early enteral nutrition has gained much support and jejunal feeding bypassing the pancreatic stimulatory effect of it in the duodenum is desirable in selected cases. The limited role for endoscopic sphincterotomy in patients with demonstrated dilated CBD with impacted stone and evidence of impending cholangitis is well documented. Surgery in AP other than for removal of the gallbladder is often limited to infected pancreatic necrosis, pseudocysts, and pancreatic abscess and in some cases of traumatic pancreatitis with a ruptured duct system. The progress in the understanding of the role of cytokines will over us opportunities to use immunomodulatory therapies to improve the outcome in SAP.

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.

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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.