Complicated acute pancreatitis: The worst-case scenario

R Subhash, VA Iyoob, N Bonny 
 Department of Surgical Gastroenterology, Government Medical College, Trivandrum, Kerala, India

Correspondence Address:
R Subhash
Department of Surgical Gastroenterology, Government Medical College, Trivandrum, Kerala
India

Full Text

Pseudoaneurysms can arise as a complication of both acute and chronic pancreatitis. They are mainly described in peripancreatic arteries like splenic artery and gastroduodenal artery. However, pseudoaneurysm of the abdominal aorta secondary to acute pancreatitis is extremely rare with only very few cases reported so far in the literature. [1],[2],[3][,4] Here we discuss a case of infrarenal abdominal aortic pseudoaneurysm associated with acute alcoholic pancreatitis.

A 51-year-old male patient with history of chronic alcoholism was referred from a peripheral hospital with features of acute severe pancreatitis. Patient was managed conservatively, and he responded well to the treatment. He was discharged after three weeks of inpatient care. After three months the patient was readmitted with severe abdominal pain. On examination, he had abdominal tenderness with few intraparietal abscesses in the anterior abdominal wall and over the flanks. A contrast-enhanced computed tomography (CECT) of the abdomen revealed multiple small collections of fluid in the retroperitoneum, communicating with the abdominal wall abscesses through tissue planes. Ultrasonography (USG)-guided incision and drainage of abdominal wall abscesses extruded pus, which was sent for microbiological examination. Antibiotics were started accordingly, and patient showed a good response. He was discharged after a week with the advice of close follow-up. Patient was then lost to follow-up for one year, when he again presented with intractable back pain with mild abdominal discomfort. Examination of the abdomen showed evidence of healed abdominal wall fistulas with a pulsatile swelling in the umbilical region. Initial ultrasonogram of the abdomen and subsequent CECT with CT angiogram revealed a huge pseudoaneurysm of the infrarenal aorta with few retroperitoneal fluid collections [Figure 1],[Figure 2] and [Figure 3]. The patient was immediately transferred to the vascular surgery department, where while planning for extra-anatomic bypass graft repair, he developed massive hematemesis (probably due to aortoenteric fistula) and died the next day.{Figure 1}{Figure 2}{Figure 3}

Bleeding from pseudoaneurysm is a serious and life-threatening complication of pancreatitis. Pseudoaneurysms occur in 3.5-10% cases of pancreatitis. The majority of them arise in the splenic artery (42%) followed by the gastroduodenal artery (22%) and small pancreatic branches of these vessels. [2] The condition manifests when there are rupture or pressure symptoms of pseudoaneurysm. Symptoms depend upon the site and severity of bleeding. Generally, pseudoaneurysms present as upper abdominal pain, melena, hematemesis, jaundice and anemia. Diagnosis requires thorough medical history and physical examination with a high index of suspicion. Confirmation is done with a good-quality CECT with CT angiogram of the abdomen which can demonstrate the pancreatic pathology along with pseudoaneurysm. Visceral angiography may also be required especially when intervention is planned. The ideal treatment of peripancreatic pseudoaneurysm is selective transarterial embolization. However, there is no consensus in the management of abdominal aortic pseudoaneurysm associated with pancreatitis because of its rarity. There are different modalities described in the available literature, like open surgery and repair with prosthetic graft or cryopreserved allograft, [3] extra-anatomic bypass grafting and endovascular exclusion of pseudoaneurysm. [4] Acute hemorrhage from pseudoaneurysm is potentially life-threatening with mortality ranging from 12-50% even with aggressive treatment.

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