Duodenal "diverticulization" for massive haemorrhage from pancreatic pseudocyst.

A case of massive haemorrhage into the gastrointestinal tract from a pancreatic pseudocyst is presented. The pseudocyst was a complication of acute pancreatitis, and control of the haemorrhage by operation was difficult because of the friability of the cyst wall. The surgical procedure called duodenal diverticulization is described and was found to be a useful adjunct to suture ligation for bleeding which was almost uncontrollable and when death of the patient seemed inevitable.     

JODENAL “DIVERTICULIZATION” FOR MASSIVE HAEMORRHAGE FROM PANCREATIC PSEUDOCYST

A case of massive haemorrhage into the gastrointestinal tract from a pancreatic pseudocyst is presented. The pseudocyst was a complication of acute pancreatitis, and control of the haemorrhage by operation was difficult because of the friability of the cyst wall. The surgical procedure called duodenal diverticulization is described and was found to be a useful adjunct to suture ligation for bleeding which was almost uncontrollable and when death of the patient seemed inevitable.     

Large intestine bleeding caused by the lienal artery pseudoaneurysm rupture complicating a pancreatic pseudocyst

Bleeding pseudoaneurysm of a peripancreatic artery is a rare cause of gastrointestinal haemorrhage. Arterial pseudoaneurysm develops as a result of partial enzymatic damage of arterial wall in acute or chronic pancreatitis. The authors report the case of a 60-years old man with bleeding into the lienal flexure of the colon due to the erosion of the pseudoaneurysm of a branch of splenic artery into the pancreatic pseudocyst in the tail region of the pancreas communicating with the colon. The diagnosis was established by CT-scan and angiography. The patient underwent surgery with the ligation of the bleeding vessel and the resection of the part of the colon.     

Hemorrhage-induced rupture of the pancreatic pseudocyst]

Hemorrhage from pseudocyst may be the most serious complication of chronic pancreatitis: the mortality from such hemorrhage approaches 80%. The bleeding arises from a major artery--the artery is eroded by the basic process of autodigestion, and the pseudocyst is converted into a pseudoaneurysm. The wall of the pseudoaneurysm is subjected to arterial pressure and may perforate into the peritoneal cavity, an adjacent segment of the gastrointestinal tract, or the pancreatic ductal system. Clinical signs and indications of complicated pseudocyst are sudden abdominal pain, hypotension, sudden increase in abdominal tenderness, decrease of hematocrit and sudden disappearance of the mass. Sonography, CT and angiography accurately define the bleeding lesion and greatly aid in planning operative strategy. Surgery, angiographic embolisation, or a combination of both may be employed. Transcystic arterial ligation and internal drainage of the pseudocyst or distal pancreatectomy are the operative procedures of choice and give the best results.     

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. Received: November 15, 1999 / Accepted: April 6, 2000     

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 3cm 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.     

A case of hemosuccus pancreaticus associated with chronic pancreatitis

The term "hemosuccus pancreaticus" was coined by Sandblom in 1970, to describe a syndrome manifested by massive gastrointestinal hemorrhage through the pancreatic duct and the ampulla of water. A case of hemosuccus pancreaticus which had no hematemesis and melena is reported in comparison with two previously experienced cases. A 68-year-old alcoholic man was referred to Eiju General Hospital for poor appetite and occasional colicky pain in left epigastrium. Abdominal angiography and computed tomography revealed an aneurysm at the tail of the pancreas and hemosuccus pancreaticus caused by true aneurysm was strongly suspected. Laparotomy revealed chronic pancreatitis and a pancreatic pseudocyst at the tail of the pancreas that was considered to be the cause of the pain. Resection of pancreatic tail and splenectomy was performed without complication. Histopathological diagnosis of the resected pancreas was chronic pancreatitis. He has complained no abdominal pain and melena for 6 months after operation.     

Major gastrointestinal hemorrhage associated with pancreatic pseudocyst

Although the pancreas is not a frequent source of major gastrointestinal hemorrhage, bleeding in patients with pancreatitis is not an uncommon complication. In patients with bleeding who are known to have pancreatitis or a pseudocyst, this organ must be considered a possible site of hemorrhage.It is recommended that celiac axis and superior mesenteric artery angiography be performed prior to barium contrast studies.If bleeding is originating from a pancreatic pseudocyst, aggressive surgical intervention should be undertaken. Three cases are described in which prompt operation was successful.Intracystic suture-ligation of the bleeding vessel together with cystogastrostomy was performed in two cases. One case of bleeding from a pseudocyst in the head of the pancreas and involving the gastroduodenal artery was treated by excision of the cyst and head of the pancreas.     

Mucinous cystadenoma of the pancreas associated with acute pancreatitis and concurrent pancreatic pseudocyst

We report an unusual occurrence of a recurrent pancreatic pseudocyst caused by an underlying mucinous cystadenoma of the distal pancreas. A 54-year old female was admitted for acute pancreatitis. Her only risk factors included the use of hydrochlorothiazide and two or three glasses of wine daily. Abdominal computed tomography (CT) done a week after onset of her symptoms showed a 5-cm cystic lesion in the tail of the pancreas suspected to be a pseudocyst. Her symptoms subsequently resolved. One month later, she had another episode of pancreatitis and an abdominal CT showed an 11 x 16 cm pseudocyst along with the previously mentioned cystic lesion. Approximately 6 weeks after her initial presentation, she was taken to the operating room for an exploratory laparotomy and cyst gastrostomy for a symptomatic pseudocyst. An intraoperative frozen section of the cyst wall showed a fibrous wall with acute and chronic inflammation without an epithelial lining. Six weeks after her cyst gastrostomy, she returned with abdominal pain, early satiety, and anorexia. Abdominal CT showed reaccumulation of fluid within the pseudocyst and endoscopic retrograde cholangiopancreatography (ERCP) revealed a normal caliber pancreatic duct with an abrupt cutoff at the distal duct. She underwent exploratory laparotomy with drainage of 3 L of fluid from the pancreatic pseudocyst. After gaining access to the lesser sac, a 6-cm cystic lesion was identified in the tail of the pancreas. She underwent a distal pancreatectomy and splenectomy. The intraoperative and final pathology confirmed the presence of a benign mucinous cystadenoma. The patient had an uneventful recovery, began to tolerate oral intake, and was discharged 7 days after surgery. The differentiation between a pancreatic pseudocyst and benign cystic neoplasms of the pancreas is crucial to determine treatment options. Cystic neoplasms of the pancreas, whether mucinous or serous, have the potential to harbor malignancy, and resection is recommended.     

Hemosuccus pancreaticus caused by a primary splenic artery aneurysm as a rare cause of gastrointestinal bleeding: report of a case

Hemosuccus pancreaticus is a rare complication of chronic pancreatitis. It is defined as hemorrhage from the papilla of Vater via the pancreatic duct. A 77-year-old man presented with a history of intermittent episodes of hematemesis and abdominal pain. Upper gastrointestinal endoscopy showed no obvious bleeding point, but clots were seen in the stomach and duodenum. Computed tomography (CT) showed a splenic artery aneurysm, and we diagnosed hemosuccus pancreaticus caused by rupture of the aneurysm into the main pancreatic duct. We performed distal pancreatectomy, during which we found the splenic artery aneurysm with thrombus in the pancreatic tail. Angiography of the resected specimen showed the splenic artery aneurysm and the communication with the main pancreatic duct. Microscopic examination revealed a true aneurysm of the splenic artery. Interventional radiology is commonly performed for diagnosis and treatment, but arterial embolization has a high recurrence rate. Thus, surgery is still required for hemosuccus pancreaticus.     

A rare pancreatic pseudoaneurysm in patient with acute pancreatitis and multiple myeloma

The authors report the case of a 78-year old patient affected by multiple myeloma who develops acute pancreatitis and pseudoaneurysmal dilatation of the inferior pancreaticoduodenal artery causing erosion of the second portion of the duodenal wall and hematemesis. The authors focus first on the supposed etiological relationship between multiple myeloma and acute pancreatitis, and they assume that the therapeutic treatment for the bone marrow disease (bortezomib) may have triggered the pancreatic inflammatory response. They then analyze the pathogenesis of the vascular complication which seems to be related to the lytic action of pancreatic enzymes on the vessel wall which results in the formation of a pseudoaneurysm first and a pseudocyst then. The vascular complication was diagnosed by computed tomography (CT) thus avoiding selective angiography which was considered too invasive for the patient. The careful and conservative treatment of the complication has allowed for full healing of the cephalopancreatic region, in addition to avoiding surgery or embolization treatment of the pseudoaneurysm which is accompanied by a mortality rate as high as 50%.     

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.     

Improved Outcomes in Postoperative and Pancreatitis-related Visceral Pseudoaneurysms

Pseudoaneurysm (PSA) of the visceral arterial tree is an uncommon but highly lethal complication of pancreatic surgery and pancreatitis. Surgical and angiographic interventions are used in treatment; however, optimal therapy remains unclear. We hypothesized that the natural history of PSA is different in these discrete clinical settings. From 1995–2005, 37 patients with PSA were treated: 13 after pancreatic surgery and 24 in the setting of pancreatitis. Postoperative patients most frequently presented with bleeding (92%), either from the gastrointestinal (GI) tract or a surgical drain. In this group, the diagnosis was most commonly made by angiography (77%), and 62% had a pancreatic fistula. In patients with pancreatitis, abdominal pain was the only presenting symptom in 62%, and GI bleeding was present in 29%. Eighty-seven percent had an associated pseudocyst or fluid collection. Interventional radiologic therapy successfully arrested hemorrhage in all 35 patients in whom it was employed. There were four false negative angiograms, and two patients required repeated interventions for rebleeding. The overall mortality was 14%. Pseudoaneurysms present differently in these two clinical settings, but transcatheter intervention is the first treatment of choice in clinically stable patients. Early recognition and prompt angiographic occlusion leads to improved outcomes. This study was presented as a poster of distinction at the 2006 annual meeting of the American Hepato-Pancreatico-Biliary Association, Miami Beach, FL, March 9–12, 2006.     

胰腺假性囊肿合并出血的诊断与治疗

目的探讨胰腺假性囊肿合并出血的诊断治疗方法.方法回顾性分析6例胰腺假性囊肿合并出血的临床资料.临床表现为腹腔内出血和消化道出血两种类型,症状根据出血部位和出血量而不同;CT和血管造影能清楚显示出血部位.结果本组非手术治疗1例,手术治疗2例,介入栓塞治疗2例,手术结合介入栓塞治疗1例;1例死亡,5例治愈.结论胰腺假性囊肿并出血发病凶险、处理棘手,CT和选择性血管造影是首选检查方法,手术和血管栓塞应合理选择和综合应用.     

Seltene Ursache einer rezidivierenden, nekrotisierenden Pankreatitis

BACKGROUND: Necrotising pancreatitis may develop as a consequence of pancreatic duct obstruction by stones, tumors or in the presence of a pancreas divisum. Alcohol and nicotine are regarded as risk factors for the disease becoming chronic. PATIENT AND COURSE OF THE DISEASE: A 63-year-old female patient with suspected cystadenocarcinoma of the pancreas tail, which was resolved as a pancreatic pseudocyst, was treated for recurrent pancreatitis for 2 years. A tumor in the pancreas head was only detected on a follow-up CT after resection of a complicating liver abscess. In retrospect, progressive pancreatic duct anomalies were visible on previous scans. Partial duodenopancreatectomy confirmed the presence of a pancreas head carcinoma. CONCLUSION: Continuous critical re-evaluation of all potential causes of pancreatitis including rare conditions, such as a tumor, is required particularly if pancreatitis recurs over a long period. Re-evaluation of studies over time and of findings apart from the actual main focus of the complication, in this case pancreatitis of the pancreas tail, may help to detect the underlying disease instead of just treating the consequences.     

Gastrointestinal hemorrhage from pseudoaneurysms in pancreatic pseudocysts

Gastrointestinal hemorrhage secondary to hemosuccus pancreaticus is a rare condition that poses a significant diagnostic and therapeutic challenge. It is reported to occur most commonly in the setting of acute or chronic pancreatitis with rupture of pseudoaneurysms of the spleen or hepatic artery into the pancreatic duct. In this report three such cases have been reported. Abdominal ultrasound and CT scanning can noninvasively define pancreatic pseudocysts with a high degree of accuracy. Real-time ultrasonography may document a pulsatile pseudoaneurysm. Radionuclide arterial scanning, by demonstrating pooling of blood in the area of a pseudocyst, can point to the source of bleeding in patients with pancreatitis and gastrointestinal hemorrhage. Selective celiac angiography, however, is the only diagnostic test that can definitively outline a pseudoaneurysm and demonstrate its rupture into a pseudocyst or into the pancreatic duct. Pancreatic resection including excision of the pseudoaneurysm and pseudocyst (when present) is the treatment of choice. In cases where resection is not possible, ligation of the artery proximal and distal to the pseudoaneurysm and drainage of the pseudocyst into the gastrointestinal tract is an acceptable alternative procedure. Although intraarterial catheter embolization of the bleeding vessel can be a lifesaving procedure in these very sick patients, subsequent resection of the lesion is warranted as the definitive treatment.     

Splenic arterial hemorrhage in pancreatitis: Report of three cases

Gastrointestinal hemorrhage is a rare complication of pancreatitis and can involve any of the peripancreatic vessels. The three cases reported herein illustrate the involvement of the splenic artery in diverse forms of pancreatitis: chronic pancreatitis, a pancreatic pseudocyst, and necrotizing pancreatitis. Bleeding was controlled in all cases by a bipolar ligation of the bleeding vessel at surgery.     

Evidence for a central role for selective mesenteric angiography in the management of the major vascular complications of pancreatitis

BACKGROUND: Although mesenteric angiography and embolization are established radiologic procedures, the evidence-base to aid decision making regarding selection of these procedures in the emergent situation in patients with hemorrhagic complications of pancreatitis is limited. METHODS: A retrospective analysis of 19 patients with hemorrhagic complications of pancreatic inflammatory disease (acute pancreatitis, chronic pancreatitis, and pseudocyst) referred over a 4-year period and identified at the point of mesenteric angiography in order to determine the influence of interventional radiologic maneuvers on outcome. RESULTS: Mesenteric angiography localized bleeding in 15 (79%), with 11 (58%) embolizations undertaken. There was one (9%) procedure-related complication and 3 (27%) rebleeds. Of 11 patients undergoing embolization, 8 (73%) required no further intervention for bleeding and 8 (73%) survived. CONCLUSIONS: Mesenteric angiography is valuable in localizing bleeding in patients with major vascular complications of pancreatic inflammatory disease. Angiographic embolization can achieve definitive hemostasis and stabilize a critically ill patient to permit disease reappraisal.     

重症急性胰腺炎合并出血的影像诊断与介入治疗

目的 探讨影像诊断及介入治疗在重症急性胰腺炎患者并发出血时的应用价值。方法 回顾性分析本单位1999年3月至2005年9月间收治的32例重症急性胰腺炎并发出血患者的影像诊断及介入治疗的临床资料。结果 32例患者中以消化道出血为主者8例，以腹腔出血为主者21例，以假性囊肿内出血为主者3例。26例患者通过血管造影证实为假性动脉瘤破裂出血，其中23例行超选择性栓塞以控制出血，8例行多次栓塞治疗，3例栓塞失败后给予垂体后叶素灌注控制出血。另有3例患者经磁共振血管造影检查证实为胰源性门脉高压导致的静脉破裂出血，其中1例通过介入断流和放置支架控制出血。3例患者未找到出血血管，行手术治疗。32例患者中治愈2l例，死亡11例，无1例发生血栓形成及脏器缺血坏死等严重并发症。结论 重症急性胰腺炎并发出血时应尽早行血管造影，同时结合增强CT、磁共振血管造影及消化道内镜迅速明确出血部位及原因，介入治疗可作为控制出血的首选治疗措施，必要时行手术治疗。     

Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis

Spontaneous haemorrhage associated with chronic pancreatitis in 17 patients was related to a pseudocyst in 15 (88 per cent) patients and to pancreatic lithiasis (one patient) or to infarction-rupture of the spleen (one patient). Bleeding was massive in six patients and intermittent in 11. It resulted from erosion of the gastroduodenal or the splenic artery in four patients. Bleeding into the pancreatic duct occurred in four patients and erosion of the duodenum by a bleeding pseudocyst in five. Haemorrhage was confined to a pseudocyst in six patients and was intraperitoneal in two. Of the 15 patients with bleeding pseudocysts, ten underwent primary pancreatic resection (eight proximal and two distal pancreatectomies) with no mortality but four had early complications. Four of the five patients who underwent transcystic ligation of bleeding vessels and pseudocyst drainage had postoperative complications: one died from sepsis and liver failure and three underwent reoperation for severe postoperative bleeding. Of these, two had proximal pancreatic resection with one death. The third patient had further suture ligation and external drainage. The overall postoperative mortality rate was 12 per cent and following emergency surgery 33 per cent. Favourable results were achieved in two-thirds of patients when the primary operative strategy could be directed towards the control of bleeding and removal of the affected pancreatic segment. Primary pancreatic resection, although technically demanding in the presence of haemorrhage, is recommended whenever possible for the treatment of bleeding pancreatic pseudocysts and pseudoaneurysms associated with chronic pancreatitis.