591 Abdominal Apoplexy – a Case of Spontaneous Haemoperitoneum from Pancreaticoduodenal Artery Bleed

Background

Inferior pancreaticoduodenal artery (IPDA) haemorrhages are extremely rare and often occur secondary to IPDA aneurysms. They can result in a spontaneous life-threatening bleed which requires urgent treatment via transcatheter arterial embolisation (TAE).

Case Summary

We report the case of an IPDA haemorrhage in a 52-year-old male who presented with a one-day history of severe worsening generalised abdominal pain. Although his initial blood pressure, heart rate and haemoglobin were within the normal range, he had a persistent metabolic acidosis with raised lactate. This prompted an urgent out-of-hours Computed Tomography (CT) scan. On return to the ward, he had a syncopal episode and was found to be in shock. An urgent venous blood gas revealed a substantial haemoglobin drop (133g/L to 88g/L) and review of his imaging identified intra-abdominal haemorrhage, confirmed by radiology to be an IPDA haemorrhage. The patient was managed according to the trust's major haemorrhage protocol and blue light transfer to a tertiary centre for embolisation by interventional radiology was arranged. He was transferred with ongoing resuscitation, and successfully underwent TAE of the IPDA. No aneurysm or other pathology was noted on angiography.

Conclusion

IPDA haemorrhages are uncommon. Physiological compensation may normalise initial observations and initial haemoglobin level may also be falsely reassuring. Therefore, it is important to monitor physiological indicators, such as pH and lactate, as real-time severity indicators to identify emergency pathology early.

Surgical consent during the COVID-19 pandemic

BACKGROUND AND AIMS

During the COVID-19 pandemic, surgical practice may deviate with operative and non-operative management considered. Appropriate discussion of options with patients is paramount to quality surgical care. Intercollegiate and EAES guidelines recommend discussing and documenting risk of COVID-19 exposure in the consent process for patients undergoing surgery.

MATERIALS AND METHODS

Closed-loop audit of consent forms for patients undergoing emergency and elective surgical procedures. Interventions implemented included education of wider surgical teams. Data was collected during a one-week period for each cycle and analysed using Chi-squared test.

RESULTS

In cycle 1, 6/17 (35.3%) case notes documented discussion of COVID-19 risk. Following intervention, compliance improved to 23/29 (79.3%) cases in cycle 2 and 33/45 (73.3%) cases in cycle 3.

CONCLUSION

Pre-intervention, our consenting practice was non-compliant. Our interventions led to significant and sustained improvements in practice. We recommend provision of wider surgical team education to facilitate good consenting practice.