Diagnostic evaluation and aggressive surgical approach in bleeding pseudoaneurysms associated with pancreatic pseudocysts

[Complicated visceral artery aneurysms in chronic pancreatitis]

Visceral artery aneurysms are rare and occur only in 0.01-0.2% of people. According to various authors, incidence of aneurysm rupture is 10-20% with mortality rate of 20-70% depending on localization and dimensions. One of the causes of visceral artery aneurysms, in particular common hepatic artery aneurysm, is chronic pancreatitis. Incidence of this complication is 2-10%. The first clinical manifestation is often hemorrhagic shock following false aneurysm rupture and bleeding into abdominal cavity, gastrointestinal tract or retroperitoneal space. Common hepatic artery aneurysm is complicated by bleeding in 35% of cases, and mortality may be up to 75%. Treatment of visceral artery aneurysm following chronic pancreatitis and post-necrotic parapancreatic cyst includes several stages. Endovascular methods are the first stage of treatment. The second stage is elimination of the cause of visceral artery false aneurysm (surgery for chronic pancreatitis). We present 3 patients with visceral artery aneurysms and chronic pancreatitis.

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.

Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis

BACKGROUND

In patients with chronic pancreatitis, an actively bleeding pseudoaneurysm can be life-threatening. Angioembolization is an attractive alternative to often complex operative management, and its feasibility was assessed in a retrospective analysis.

METHODS

During 1993-2005, 33 patients (27 males, median age 51 years) with bleeding pancreatic pseudoaneurysms underwent urgent angiographic evaluation followed by angioembolization if possible. Angioembolization was performed in 23 patients, whereas 10 patients required hemostatic surgery, including 6 distal pancreatectomies and 3 vessel ligations.

RESULTS

Between 1993 and 2005 33 out of 745 patients (4.4%) admitted for chronic pancreatitis had bleeding pancreatic pseudoaneurysms. The proportion of bleeders out of the total number of hospital admissions for chronic pancreatitis was 33 out of 1,892 (1.7%). The overall success rate of angioembolization was 22 out of 33 (67%) including 3 patients requiring re-embolization for recurrent bleeding. The success rate was 16 out of 20 (80%) when the pseudocyst was in the head of the pancreas, and only 50% when the splenic artery was the source of bleeding. Four of the 5 cases with free bleeding into the peritoneal cavity required operative intervention. The overall mortality and morbidity rates were 2 out of 33 (6%) and 7 out of 33 (21%) respectively, with no significant differences between embolized and operated patients. Angioembolization was associated with a significantly lower need for total blood transfusions and length of hospital stay. During the years 2000-2005, the overall success rate of angioembolization was 95%.

CONCLUSIONS

All hemodynamically stable patients with chronic pancreatitis and bleeding pseudoaneurysms should undergo prompt initial angiographic evaluation and embolization if possible. Repeated angioembolization is feasible in patients with recurrent bleeding, whether initially embolized or operated. Patients with unsuccessful embolization should undergo emergency hemostatic surgery with ligation of the bleeding vessel in the head of the pancreas and distal resection in patients bleeding from the splenic artery or its branch. The combination of angioembolization and later endoscopic drainage of the pseudocyst via endoscopic retrograde cholangiopancreatography (ERCP) is effective in the majority of the cases of pseudoaneurysms in chronic pancreatitis.

Diagnosis of an aneurysm masquerading as a pancreatic-cyst lesion at EUS

BACKGROUND

EUS-guided FNA is commonly performed for evaluating pancreatic-cyst lesions. However, not all such lesions are true cystic neoplasms of the pancreas.

OBJECTIVE

Determine the frequency at which aneurysms mimicking cysts are encountered during EUS evaluation of the pancreas.

STUDY DESIGN

Observational study.

SETTING

Tertiary referral center.

PATIENTS

Consecutive patients found to have pancreatic cyst lesions at EUS.

INTERVENTIONS

Patients with a cyst lesion in the pancreas that was suspicious for an aneurysm at EUS underwent abdominal CT imaging for a definitive diagnosis.

MAIN OUTCOME MEASURES

To determine the frequency at which aneurysms are encountered during EUS while evaluating pancreatic-cyst lesions and to describe the EUS characteristics of an underlying aneurysm.

RESULTS

Four of 413 lesions (0.97%, 95% confidence interval 0.26%-2.5%) that appeared as pancreatic cysts at EUS were diagnosed to be aneurysms: 2 were splenic artery aneurysms, 1 was an aneurysm of the gastroduodenal artery, and another was an infrarenal aortic aneurysm. The aneurysms had a characteristic donut-like appearance at EUS: a thick outer wall with a central anechoic area.

LIMITATIONS

Observational study; small sample size.

CONCLUSIONS

Aneurysms can masquerade as pancreatic-cystic lesions. Awareness of this entity is important because an inadvertent FNA during EUS may potentially lead to serious complications.

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.

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.

Visceral Artery Aneurysms

Visceral artery aneurysms (VAA) frequently present as life-threatening emergencies. The purpose of this study was to review our experience with VAA treatment. Between 1988 and April 2002, 31 VAA were treated in 28 patients (14 males, 14 females) with average age of 55 +/- 15 years. The most common locations were the splenic artery (16) and the hepatic artery (7). Three patients underwent emergency surgery, 22 patients had elective open surgery, and 7 patients underwent endovascular treatment. In the surgical group the perioperative mortality rate was 3.6%. The perioperative morbidity rate was 7.1% (one case of respiratory distress manifested in the immediate postoperative period and one urgent case of bilious fistula). In the endovascular group none of the patients died; the perioperative morbidity rate was of 14.3% (one case of hepatic artery thrombosis after failure of gastroduodenal artery aneurysm embolization). Failure of the procedure was 42.9% (3 cases of aneurysm recanalization). In conclusion, we believe that an aggressive surgical approach is justified, even in the case of asymptomatic VAA, because of the low morbidity and mortality rates. Endovascular treatment should be reserved for selected cases.

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.

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.

Diagnosis and fine needle aspiration of pancreatic pseudocysts: the role of endoscopic ultrasound

Pseudocysts are localized collections of pancreatic fluid surrounded by nonepithelialized granulation tissue that occur following an insult to the pancreas. High image resolution and the ability sample in real-time by fine needle aspiration permit accurate distinction between various cystic lesions in the pancreas by endoscopic ultrasound (EUS). Other cyst characteristics and background pancreatic changes detectable at EUS assist in the diagnostic process. The use of Doppler flow ultrasound allows diagnosis of important pseudocyst complications such as pseudoaneurysms and varices. Endoscopic approaches to the drainage of symptomatic lesions previously relied on the use of cross-sectional imaging studies such as computed tomography scanning in combination with stent placement using a duodenoscope in the presence of an endoscopically visible cyst bulge. EUS facilitates this process allowing accurate imaging of the lesion prior to stent placement via the echoendoscope and overcomes many of the drawbacks and pitfalls of other endoscopic techniques.

Massive intraperitoneal hemorrhage from a pancreatic pseudocyst

Massive bleeding from a pancreatic pseudocyst is a rare condition that poses a diagnostic and therapeutic challenge. A 36-yr-old woman presented with acute pancreatitis due to gallstones. Twenty-two days later, she developed severe abdominal pain and hypotension. CT scan revealed hemorrhage into a pancreatic pseudocyst and a large amount of free blood in the peritoneal cavity. At laparotomy, 8 L of blood was evacuated from the peritoneal cavity and 14 units of blood were transfused. The gastroduodenal artery was found to be the cause of the bleeding and was undersewn. A pancreatic necrosectomy was performed and the cavity was packed. The packs were removed the following day. Postoperatively, pancreatic collections were aspirated under ultrasound guidance on three occasions. She was discharged 50 days after admission and had an open cholecystectomy 1 month later. She remains well 1 yr after surgery.

Massive gastrointestinal bleeding as the initial manifestation of pancreatic carcinoma

Pancreatic carcinoma is a rare cause of GI bleeding. We have studied eight patients in whom major digestive hemorrhage was the first sign of a subsequently proven pancreatic malignancy. Bleeding was characteristically severe and unremitting, including hematochezia (four), melena (three), and hematemesis (one). In seven cases, direct tumor invasion into a contiguous portion of the GI tract was present. Tumor erosion occurred into the third portion of the duodenum (three) descending (two), stomach (one), and transverse colon (one). In one patient, a metastatic bleeding lesion was present in the sigmoid colon. The four patients who required urgent laparotomy for control of major hemorrhage died during the initial hospitalization. Conventional diagnostic evaluation by endoscopic and roentgenographic techniques was commonly unsuccessful. Our retrospective analysis suggested that a more aggressive approach, including early angiography in unrelenting and undiagnosed bleeding, might have aided diagnosis and averted laparotomy in a population with dismal prospects for a surgical solution. Clinicians should be aware that pancreatic malignancy may present with a varying spectrum of GI bleeding ranging from occult to potentially exsanguinating hematemesis, hematochezia, or melena.