© Borgis - New Medicine 2/2008, s. 45-47
*Eryk Chrapowicki, Marek Kruk, Grzegorz Krasowski, Andrzej Płoński
A case of recurrent bleeding from the upper gastrointestinal tract in the course of acute pancreatitis
Department of General Surgery, Wolski Gostyńska Memorial Hospital, Warsaw
We present a rare case of coincidence of severe and life-threatening complications of pancreatitis: abscess and bleeding due to rupture of pseudoaneurysm. CT angiography is usually recommended to establish the diagnosis. Aspiration or surgery with drainage of the abscess are the common methods of treatment. Endovascular embolisation of the feeding artery seems to be the method of choice, but surgery is reserved for patients with haemodynamic instability and haemorrhagic shock or with recurrent bleeding.
The acute pancreatitis morbidity rate is estimated at 240/1 million habitants, i.e. about 9 000 patients per year. According to the Atlanta classification, severe and benign forms of pancreatitis may be distinguished. In the severe form, which concerns about 15% of patients, many systemic and local complications may occur. Both abscess and, leading to pseudoaneurysm formation, vascular erosion are generally known local complications of severe pancreatitis. Each of them is associated with a high death risk (12% and 57%, respectively). Among many publications regarding diagnostics and treatment conducted in similar cases that we have found while reviewing world-wide literature, we did not come across an article describing coincidence of both above-mentioned complications. Thus, we believe that diagnostics and treatment procedures may be very difficult to establish.
A sixty-three-year-old male patient, with long-term alcohol abuse and a history of alcohol-induced chronic pancreatitis, was admitted to the internal ward due to exacerbation of epigastric pain. A physical examination of his abdomen did not reveal any abnormal findings; no peritoneal symptoms were found. BP 130/80, HR 88. Except for high levels of serum amylase (948), with normal range not exceeding 250, all the other biochemical blood parameters were in the normal ranges.
A computer tomography scan of the abdomen revealed a pseudocyst (83x94x93 mm size) which was localized in the head of the pancreas, moulding to the duodenum, and abutting the distal part of the stomach.
Conservative treatment was initiated: intraintestinal (enteral) nutrition, analgesics and relaxants were applied and endoscopic drainage of the pseudocyst was planned.
On the 20th day of hospitalization the patient presented symptoms of bleeding from the upper gastrointestinal tract in the form of blood vomiting, melaena and blood pressure decrease. He was given some fluids i.v., omeprasol, a group-compatible transfusion, three units of erythrocytic mass, and 2 units of plasma, and it enabled stabilization of his state to be achieved. An emergency gastroscopy revealed massive duodenal ulceration covered with a clot, which included about 1/3 of the duodenal circumference. The patient was classified for surgical treatment; he was transferred to the surgical ward, and the Whipple operation was planned.
Due to poor nutritional status, confirmed by laboratory test results, parenteral nutrition was instituted.
On the 3rd day after the patient´s transfer, he had massive bleeding into the gastrointestinal lumen. He underwent an emergency operation.
After performing a gastrostomy and duodenotomy, the operating surgeons found out that the pancreatic abscess had perforated into the duodenal lumen. A bleeding vessel was visible in the abscess cavity and it was underpinned with nonabsorbable sutures. In regard of ischaemic lesions observed in the initial 1/3 of the duodenal wall, the pylorus and the duodenal stump were sutured, and necrotic tissues were removed after checking the patency of the biliary tracts and localization of the papilla of Vater. Precolic gastroduodenostomy with Brown´s fistula was subsequently carried out. A jejunostomy was performed in order to conduct parenteral alimentation in the postoperative period. The abscess cavity was drained using a Petzer´s drain placed in the area of the duodenal chimney (edge) as well as in rectovesical excavation.
The patient stayed in the intensive care ward for 8 days. When his state was better, he was moved to the general surgery ward. From day 11 after the operation enteral alimentation was introduced and intensive physical rehabilitation was carried out. Oral alimentation was introduced on day 15. Further hospitalization proceeded with no complications. The patient was discharged from the hospital on day 25. Control CT scan of his abdominal cavity was planned after 1 month.
Eight days after discharge, the patient was once again admitted to the surgical ward due to symptoms of bleeding from the upper gastrointestinal tract which initially were stopped using conservative therapy. Gastroscopy performed on the next day revealed the sources of bleeding and, thus, a CT examination was carried out, which revealed the existence of an anomalous cistern of clotted blood, which was probably a residue of aneurysm of the gastro-duodenal artery, located between the pancreas and the duodenum.
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