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262 RUPTURED ARTERY OR PSEUDOANEURYSM: A CAUSE OF SEVERE BLEEDING IN PANCREATITIS S Cho, P Kortan, G Kandel, N Marcon, G May Major vessel erosion with or without pseudoaneurysm formation, and its rupture leads to massive bleeding and may complicate the course of pancreatitis.
Division of Gastroenterology and Therapeutic Endoscopy, St Michael's Hospital, University of Toronto, Toronto, Ontario
CASE REPORTS: We report three patients who presented to our institution in a period of three months with massive bleeding due to ruptured artery or pseudoaneurysm on background of recent episode of acute pancreatitis. Two patients had known pseudocysts and had undergone endoscopic and percutaneous drainage respectively. All three patients were in hemorrhagic shock on presentation, and upper endoscopies only revealed large amounts of clots in the lumen and failed to locate the source of bleeding. Mesenteric angiograms demonstrated pseudoaneurysms of gastroduodenal and splenic arteries respectively in the two patients with known pseudocysts, which were managed successfully with angiographic embolizations. These patients remain well at 6-months follow-up. The third patient had active extravasation of contrast from the bifurcation of distal splenic artery and required two angiographic embolizations to stop the bleeding. He died from non-gastrointestinal septic complication.
Although the arterial complications of pancreatitis are traditionally considered rare, the bleeding associated is often massive and is the most rapidly fatal complication of pancreatitis. In order to prevent delayed diagnosis and reduce mortality, the most important factor in detecting bleeding from ruptured artery or pseudoaneurysm is considering the diagnosis early to guide appropriate investigation and treatment. Endoscopy has limited role in its treatment but is indicated initially to exclude more common causes of bleeding such as erosive gastritis, peptic ulcers, and esophageal and gastric varices. Mesenteric angiography is the investigation of choice and offers the concurrent treatment option in the form of transcatheter arterial embolization with selective catheterization of the feeding vessel and its occlusion with coils or other thrombogenic agents. The time gained by successful embolization should be used to carefully reevaluate these critically ill patients to see if definitive operative intervention of pseudocysts or intraabdominal sepsis is indicated and feasible.