Successful Treatment of Bleeding Pseudoaneurysms of Chronic Pancreatitis

A ruptured pseudoaneurysm is the most rapidly fatal complication encountered in patients with chronic pancreatitis, with a reported mortality rate of 12.5% in treated patients to >90% in those untreated. Although reportedly a rare complication of chronic pancreatitis, a pseudoaneurysm is encountered in 6–9.5% of patients with chronic pancreatitis and as many as 17% of all patients operated on for chronic pancreatitis. Timely diagnosis and treatment seems to result in markedly reduced mortality. Four patients with bleeding pseudoaneurysms associated with chronic pancreatitis and pseudocysts were encountered recently at Virginia Mason Medical Center. These patients' charts, as well as the English literature, were reviewed in detail. All of our cases occurred in alcoholic males. Pseudocysts with pancreatic ductal or pseudocyst rupture were seen in three cases. All had a history of crescendo-decrescendo pain episodes and had evidence of bleeding or were bleeding at presentation. Splenic vein occlusion was identified in 50% of the cases. A pseudoaneurysm was documented by angiography in all patients. Embolization was success fully attempted without complication in two patients. Three patients were ultimately treated with a pylorussparing (2) or standard (1) pancreaticoduodenectomy. These three are alive and doing well at 16, 26, and 52 months from the time of their procedure. A fourth patient was treated nonoperatively, because of severe comorbid disease and aberrant anatomy, with successful embolization of the pseudoaneurysm and biliary and pancreatic stenting. The pseudocyst resolved and he is asymptomatic 12 months after therapy. We advocate preoperative arteriography in all patients with suspected or known arterial pseudoaneurysm. Transcatheter embolization should be attempted in all symptomatic patients with pseudoaneurysms to prevent or treat bleeding episodes. Resection of the pseudocyst and pseudoaneurysm is optimal treatment, but interventional radiologic or gastroenterologic methods may allow for successful nonoperative management in selected patients.

[1]  T. Vargish,et al.  Massive gastrointestinal hemorrhage in pancreatitis secondary to visceral artery aneurysms. , 1992, The American surgeon.

[2]  A. W. Reid,et al.  Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis , 1992, The British journal of surgery.

[3]  A. Lonardo,et al.  Hemoductal pancreatitis secondary to gastroduodenal artery-ruptured pseudoaneurysm: a rare cause of hematemesis. , 1991, The American journal of gastroenterology.

[4]  N. Kimura,et al.  Successful transcatheter embolization of pseudoaneurysm associated with pancreatic pseudocyst. , 1991, The American journal of gastroenterology.

[5]  J. Kolars,et al.  Pancreatic pseudocysts: clinical and endoscopic experience. , 1989, The American journal of gastroenterology.

[6]  R. Kozarek,et al.  Endoscopic Placement of Pancreatic Stents and Drains in the Management of Pancreatitis , 1989, Annals of surgery.

[7]  T. Kiviluoto,et al.  Pseudocysts in chronic pancreatitis. Surgical results in 102 consecutive patients. , 1989, Archives of surgery.

[8]  L. Traverso,et al.  Pancreaticoduodenectomy. The importance of preserving hepatic blood flow to prevent biliary fistula. , 1989, The American surgeon.

[9]  C. Imrie,et al.  Importance of cause in the outcome of pancreatic pseudocysts. , 1988, American journal of surgery.

[10]  J. Tisnado,et al.  Splanchnic artery aneurysms and pseudoaneurysms: transcatheter embolization. , 1987, Radiology.

[11]  P. Freeny,et al.  Surgical significance of vascular changes in chronic pancreatitis. , 1987, Surgery, gynecology & obstetrics.

[12]  A. Warshaw,et al.  Massive arterial hemorrhage in patients with pancreatitis. Complementary roles of surgery and transcatheter occlusive techniques. , 1986, Archives of surgery.

[13]  C. Pellegrini.  The treatment of acute pancreatitis: a continuing challenge. , 1985, The New England journal of medicine.

[14]  H. Bruining,et al.  Haemorrhage from the pancreatic duct: A rare form of upper gastrointestinal bleeding , 1984, The British journal of surgery.

[15]  J. Terblanche,et al.  A new look at the arterial supply of the bile duct in man and its surgical implications , 1979, The British journal of surgery.

[16]  C. Frey.  Pancreatic Pseudocyst–Operative Strategy , 1978, Annals of surgery.

[17]  K. Tolman,et al.  Rupture of a splenic artery aneurysm into the pancreatic duct. , 1976, Gastroenterology.

[18]  Timothy A. Miller,et al.  Major arterial hemorrhage: a complication of pancreatic pseudocysts and chronic pancreatitis. , 1976, Archives of surgery.

[19]  A. Walt,et al.  The natural and unnatural history of pancreatic pseudocysts , 1975, The British journal of surgery.

[20]  N. Michels,et al.  Blood supply and anatomy of the upper abdominal organs, with a descriptive atlas , 1955 .