Pancreatitis: Preventing catastrophic haemorrhage

Abstract

Pancreatitis represents nearly 3% of acute admissions to general surgery in United Kingdom hospitals and has a mortality of around 1%-7% which increases to around 10%-18% in patients with severe pancreatitis. Patients at greatest risk were those identified to have infected pancreatic necrosis and/or organ failure. This review seeks to highlight the potential vascular complications associated with pancreatitis that despite being relatively uncommon are associated with mortality in the region of 34%-52%. We examine the current evidence base to determine the most appropriate method by which to image and treat pseudo-aneurysms that arise as the result of acute and chronic inflammation of pancreas. We identify how early recognition of the presence of a pseudo-aneurysm can facilitate expedited care in an expert centre of a complex pathology that may require angiographic, percutaneous, endoscopic or surgical intervention to prevent catastrophic haemorrhage.

Endovascular Management of Pancreatitis-Related Hemorrhage: Single-Center Experience

“…The pathogenesis of arterial involvement is multifactorial and is due to destruction of vessel wall by the proteolytic enzymes released secondary to pancreatic inflammation and necrosis, and the combined effect of ischemic necrosis and proteolytic destruction of vessel wall in abscesses and pseudocysts. [1][2][3][4][5][6][7] Noninvasive evaluation of pancreatitis-related bleeding is usually performed with CT angiography. Convention angiography is performed when CT angiography is positive, or when the bleeding persists despite a negative CT angiography.…”

“…1,2 The most common vessels involved in pancreatitis-related pseudoaneurysm are the splenic artery in 30 to 50%, the gastroduodenal artery (GDA) in 20 to 25%, pancreaticoduodenal vessels in 20 to 25%, and mesenteric, colic, and hepatic vessels in the remaining patients. 3 Mortality due to arterial hemorrhage in pancreatitis can be as high as 34%. [4][5][6][7] Mortality following surgical management of arterial hemorrhage varies from 20 to 50% with a rebleeding rate as high as 25%.…”

Review of Current Evidence in Acute Pancreatitis

“…Intramural hematomas in the absence of bleeding or other complications are managed conservatively. Otherwise, embolization may be opted as a safe and minimally invasive approach, reserving surgery for selected cases only [105,106].…”

Pediatric Pancreaticobiliary Intervention

“…Pancreatic pseudoaneurysms or uncontained bleeding are usually suspected with signs of hemorrhagic shock, including decreased serum hemoglobin, hypotension, tachycardia, or even gastrointestinal bleeding if there has been involvement of enteric arteries. 24 If the patient is unstable, resuscitative measures and emergent catheter angiography and embolization should be performed. If the clinical picture permits time for noninvasive imaging, CT angiography should be performed as sites of bleeding can be complex and multifocal.…”