Three cases of massive bleeding from pancreatic pseudocysts

BackgroundIntracystic bleeding is an infrequent but potentially lethal complication of pancreatic pseudocyst. Early preoperative diagnosis is an important aspect of effective management.Case outlinesThree patients presented with bleeding into a pancreatic pseudocyst. One was managed by intracystic ligation and external drainage, one was managed with postoperative angiographic embolisation and the third patient underwent angiographic embolisation as definitive treatment.DiscussionMassive bleeding from a pseudoaneurysm associated with pseudocyst of the pancreas carries a high mortality and morbidity rate. A high index of suspicion for patients with suggestive clinical signs and symptoms plus careful evaluation on a thin-sliced contrast-enhanced CT scan with early and delayed films corroborated by selective angiography leads to better management.     

Rupture of a bleeding pancreatic pseudocyst into the stomach

A bleeding pancreatic pseudocyst following pancreatitis is a severe complication that can lead to massive gastrointestinal bleeding. Rupture of such a pseudocyst into the stomach is rare. We report herein a case of rupture of a bleeding pseudocyst into the stomach in a patient who was successfully treated with emergency surgery. A 60‐year‐old Japanese man with a history of chronic alcoholic pancreatitis with a pancreatic tail pseudocyst was referred to us because of hematemesis. The cavity of the pseudocyst, which was 3–cm in size and whose wall adhered to the stomach, was enhanced by dynamic bolus computed tomography (CT) in the late arterial phase. Splenic angiography revealed a bleeding pseudocyst in the splenic hilum. Embolization of the pseudocyst failed, because of arterial spasm. A distal pancreatectomy, splenectomy, and total gastrectomy were performed. The wall of the pseudocyst consisted of the pancreatic tail, granulation tissue, and the posterior wall of the stomach. The patient's postoperative course was uneventful. In the management of massive bleeding from a pseudocyst, early diagnosis with dynamic bolus CT and angiography is essential. A bleeding pseudocyst should be considered to be a lethal complication, but it can possibly be treated with a combination of angiographic embolization and surgery.     

Unusual presentation of a pancreatic pseudocyst

Summary Results and Conclusions Pancreatic pseudocysts may simulate renal cysts symptomatically and radiographically. Background Pancreatic disease can often mimic renal disease. This is especially true of pancreatic pseudocysts. Methods We report an interesting case of a pancreatic pseudocyst mimicking a renal cyst on a computed tomography (CT) scan. The clinical anatomy of retroperitoneal spaces and pathways followed by pancreatic secretions is examined. The literature on pancreatic diseases simulating renal disorders is reviewed.     

Massive gastric bleeding from pancreatic pseudocyst,caused by rupture of pseudoaneurysm

Massive bleeding into a pancreatic pseudocyst is an unusual but life-threatening clinical condition. In this report, we present a case of massive gastric hemorrhage from a pancreatic pseudocyst, caused by rupture of a pseudoaneurysm of the splenic artery. The patient was successfully managed by total gastrectomy with splenectomy and distal pancreatectomy. Of a total of 66 cases in our Japanese literature review, only 5 cases of gastric hemorrhage associated with pancreatic pseudocyst have been reported, including the case herein presented. Diagnosis and therapeutic strategy are discussed.     

Intracystic arteries in a chronic pancreatic pseudocyst

Background

An enlarging pancreatic pseudocyst can incorporate adjacent vessels into its wall, leading to pseudoaneurysm formation in the presence of proteolytic enzymes. Intact arteries running through the cyst cavity are very rare, however.

Case outline

A 54-year-old man with a chronic pancreatic pseudocyst (15 cm diameter) underwent internal drainage by means of cystjejunostomy Roux-en-Y. Two large pulsating arteries running through the cyst cavity were identified as the middle colic artery and one of its branches. Temporary clamping of the transcystic arteries revealed no signs of ischaemia in the transverse colon, so the vessels were ligated and the cystjejunostomy completed. The patient remains well one year later.

Discussion

Bleeding following internal drainage procedures carries a higher mortality rate than spontaneous bleeding in chronic pancreatic pseudocysts but is easier to prevent.This case highlights the importance of thorough exploration of the pseudocyst to identify any vessels in its cavity or wall.     

Two cases of hemosuccus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization

Hemosuccus pancreaticus is a rare complication of chronic pancreatitis. We report two cases of hemosuccus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization (TAE). The first patient was a 47-year-old man with alcoholic chronic pancreatitis. He presented with upper abdominal pain and hematemesis. Upper GI endoscopy failed to detect the source of bleeding, but computed tomography (CT) showed a hypervascular area about 3?cm in diameter in a pseudocyst at the pancreatic tail. Angiography revealed a pseudoaneurysm in the caudal pancreatic artery. Hematemesis was considered to be due to rupture of the pseudoaneurysm. TAE of the splenic artery was performed selectively, and this successfully stopped the bleeding. The second patient was a 52-year-old man with alcoholic chronic pancreatitis. He presented with hematemesis. Upper GI endoscopy detected bleeding from the papilla of Vater. CT showed hemorrhage in a pseudocyst at the pancreatic body. Angiography revealed angiogenesis around the pseudocyst. Hematemesis was considered to result from rupture of the pseudoaneurysm. TAE of the dorsal pancreatic artery and posterior superior pancreaticoduodenal artery was performed and hemostasis was achieved. We conclude that TAE is a minimally invasive and highly effective treatment for hemosuccus pancreaticus.     

Management of pancreatic pseudocyst

The natural course, complications, and management of 37 patients with pancreatic pseudocyst treated at our institution were reviewed. The lesions were classified into three groups, cysts secondary to acute pancreatitis, to chronic pancreatitis, and to trauma. Spontaneous resolution or cyst diminution was observed in 75% of the patients with acute pancreatitis and trauma, but in only 33% of those with chronic pancreatitis. The interval until resolution or diminution in chronic pancreatitis was shorter than that in pseudocyst of other etiologies, but the incidence of complications in patients with chronic pancreatitis was not significantly higher than that among patients with other etiologies. Multiple complications were found only among the patients with chronic pancreatitis. Surgical management was performed in 25% of the patients with acute pancreatitis and trauma and 66% of the patients with chronic pancreatitis. The postoperative mortality rate was 10%. Reoperation was necessary in 6 of 7 patients who had undergone external drainage, including 3 patients treated with ultrasonography-guided percutaneous catheter drainage (US-PCD). These results suggest that it is necessary to closely monitor patients with chronic pancreatitis and/or external drainage, and in these patients it may become necessary to reoperate. US-PCD was useful as an emergency procedure in pseudocyst patients whose general condition was poor, despite the disadvantages of the piercing of adjacent organs by the catheter, infection, and pseudocyst recurrence.     

Late complication in patients undergoing pancreatic resection with intraoperative radiation therapy: gastrointestinal bleeding with occlusion of the portal system

BACKGROUND: There are few reports of late complications in patients who have undergone pancreatic resection with intraoperative radiation therapy (IORT), because carcinoma of the pancreas (PCa) and the bile duct (BCa) have a poor prognosis. The purpose of the present paper was to review gastrointestinal (GI) bleeding occurring with occlusion of the portal system (PVs) as a complication of IORT in patients surviving long term without recurrence. PATIENTS: From 1990 to 1999, 45 patients underwent surgical resection of the pancreas with IORT. Eleven of these patients survived >3 years without recurrence, and occlusion of PVs was recognized in five patients at follow-up examination. Three of these five patients received repeated blood transfusions for GI bleeding. RESULTS: One patient had BCa and two had PCa, and pancreatoduodenectomy was carried out. The delivered radiation doses of IORT were 30 Gy (two patients) and 35 Gy (one patient). The postoperative periods to initial GI bleeding were 36, 26 and 9 months, respectively. In all cases, angiography revealed occlusion of PVs and the collateral circulation. The bleeding points were esophageal varix (case 1), remnant stomach varix (case 2) and a jejunal ulcer (case 3), and blood transfusions were carried out totaling 44, 60 and 16 units, respectively. The GI bleeding disappeared spontaneously in case 1, developed sporadically in case 2 and was stopped by metallic stent insertion in PVs in case 3. CONCLUSION: During long-term follow up after pancreatectomy with IORT, it is necessary to monitor patients for GI bleeding. A clinical trial on optimum doses, long-term safety and benefit of IORT is necessary.     

Fungal pleural effusion secondary to a rare cause of pancreatic pseudocyst

We report a case of fungal pleural effusion secondary to presumed valproate induced pancreatitis with pseudocyst and stricture formation. A child with dyskinetic cerebral palsy who had been on sodium valproate for several years was transferred for drainage of a left sided pleural effusion. Pleural fluid culture consistently grew Candida glabrata although the patient was treated with broad‐spectrum antibiotic and antifungal therapy. Clinical deterioration ensued with abdominal discomfort, feed intolerance, and re‐accumulation of the effusion. Investigations revealed a large pancreatic pseudocyst compressing the stomach and impairing pancreatic function. Subsequent therapeutic evacuation of pancreatic fluid demonstrated C. glabrata. This case underscores that pleural disease may be secondary to abdominal pathology, and always to consider rare side‐effects of medication in the face of a puzzling clinical picture. Pediatr Pulmonol. 2009; 44:616–618. © 2009 Wiley‐Liss, Inc.     

Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm

Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues.With disease progression,patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss.Among them,a pseudoaneurysm,mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas,is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs.At present,no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation.The role of arterial embolization,the timing of surgical intervention and even surgical procedures are still controversial.In this review,we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleedersand to evaluate the associated complications such as pseudocyst formation,followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient’s condition.With advances and improvements in endoscopic devices and techniques,therapeutic endoscopy for pancreatic pseudocysts is technically feasible,safe and effective.Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition,for those in whom arterial embolization of the bleeding pseudoaneurysm fails,and when endoscopic management of the pseudocyst is unsuccessful.If a bleeding pseudoaneurysm is located over the tail of the pancreas,resection is a preferential procedure,whereas if the lesion is situated over the head or body of the pancreas,relatively conservative surgical procedures are recommended.     

Epidemiology of acute upper gastrointestinal bleeding

Acute upper gastrointestinal bleeding is an important emergency situation. Population-based epidemiology data are important to get insight in the actual healthcare problem. There are only few recent epidemiological surveys regarding acute upper gastrointestinal bleeding. Several surveys focusing on peptic ulcer disease showed a significant decrease in admission and mortality of peptic ulcer disease. Several more recent epidemiological surveys show a decrease in incidence of all cause upper gastrointestinal bleeding. The incidence of peptic ulcer bleeding remained stable. Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, responsible for about 50% of all cases, followed by oesophagitis and erosive disease. Variceal bleeding is the cause of bleeding in cirrhotic patients in 50-60%. Rebleeding in upper gastrointestinal bleeding occurs in 7-16%, despite endoscopic therapy. Rebleeding is especially high in variceal bleeding and peptic ulcer bleeding. Mortality ranges between 3 and 14% and did not change in the past 10 years. Mortality is increasing with increasing age and is significantly higher in patients who are already admitted in hospital for co-morbidity. Risk factors for peptic ulcer bleeding are NSAIDs use and H. pylori infection. In patients at risk for gastrointestinal bleeding and using NSAIDs, a protective drug was only used in 10%. COX-2 selective inhibitors do cause less gastroduodenal ulcers compared to non-selective NSAIDs, however, more cardiovascular adverse events are reported. H. pylori infection is found in about 50% of peptic ulcer bleeding patients. H. pylori should be tested for in all ulcer patients and eradication should be given.     

Hemorrhagic pseudocyst and pseudocyst with pseudoaneurysm successfully treated by pancreatectomy: report of three cases

Hemorrhagic pseudoaneurysm of pancreatic pseudocyst is one of the serious complications of acute pancreatitis. We successfully treated three patients who had hemorrhagic pseudocyst and pseudocyst with pseudoaneurysm by pancreatectomy. Case 1 was 43-year-old Japanese man who had had several episodes of acute pancreatitis and was diagnosed with hemorrhagic pseudoaneurysm of the splenic artery in a pseudocyst in the pancreatic tail, shown on computed tomography (CT) and angiography. Transarterial embolization (TAE) yielded hemostasis of the pseudoaneurysm, but rebleeding occurred 2 weeks after the TAE. Distal pancreatectomy and splenectomy was successfully performed. Case 2 was a 64-year-old Japanese man who presented to us with several attacks of acute pancreatitis. Imagings showed bleeding pseudoaneurysm of the transverse pancreatic artery in a pseudocyst in the pancreatic body. Because of marked stenosis in the proximal portion of the transverse pancreatic artery, TAE was unsuccessful. Distal pancreatectomy and splenectomy was performed successfully. Case 3 was a 40-year-old Japanese woman who had a history of abdominal trauma. Imagings showed bleeding pseudoaneurysm of the splenic artery in a posttraumatic pseudocyst in the pancreas. TAE of the pseudoaneurysm was unsuccessful because of the proximity of the pseudoaneurysm and the splenic artery. Distal pancreatectomy and splenectomy was successfully performed and her postoperative outcome was satisfactory. Whenever interventional radiology (IVR) is not indicated or has failed, aggressive and immediate surgical intervention should be considered for early and definitive recovery in these patients.     

New mechanical puncture videoechoendoscope: one-step transmural drainage of a pseudocyst

A new mechanical puncture video echoendoscope (GF-UMD-240P 270 degrees image field parallel to the endoscope axis) has been used for puncture and drainage of a symptomatic pancreatic pseudocyst. It is equipped with a 2.8 mm working channel and an elevator allowing single step drainage with passage of a 7F nasocystic catheter.     

Modified packing technique for control of presacral pelvic bleeding

A modification of pelvic packing to control presacral bleeding is described. This method makes removal of the packing less uncomfortable and usually does not require anesthesia.     

内镜治疗在急性非静脉曲张上消化道出血中的应用

急性非静脉曲张上消化道出血是临床常见的急危重症。内镜技术在急性非静脉曲张上消化道出血的治疗中有重要价值。近年此领域有了持续的新进展。本文即就内镜治疗对急性非静脉曲张上消化道出血的适宜治疗患者、治疗时机以及治疗方法和策略等方面给予简述。     

Gastrointestinal bleeding 30 years after a complicated cholecystectomy

Gastrointestinal bleeding from small-bowel varices is a rare and difficult to treat complication of portal hypertension. We describe the case of a 79-year-old female patient with recurrent severe hemorrhage from smallbowel varices 30 years after a complicated cholecystectomy. When double balloon enteroscopy was unsuccessful to reach the site of bleeding, a rendezvous approach was favored with intraoperative endoscopy. Active bleeding from varices within a biliodigestive anastomosis was found and controlled ...