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Complete remission of pancreatic pseudoaneurysm rupture with arterial embolization in a patient with poor risk for surgery: a case report.

Chu KE, Sun CK, Wu CC, Yang KC - Case Rep Gastroenterol (2012)

Bottom Line: Pancreatic pseudoaneurysm is a rare vascular complication of chronic pancreatitis resulting from erosion of the pancreatic or peripancreatic artery into a pseudocyst that is identified as a pulsating vascular malformation which may lead to lethal complications if left untreated.The results observed in our patient suggest that pancreatic pseudoaneurysm may be successfully managed with angiography only and that not all cases require surgical intervention.This is particularly relevant in critically ill patients in whom surgical intervention would be unfeasible.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology, Department of Internal Medicine, Taipei, Taiwan.

ABSTRACT
Pancreatic pseudoaneurysm is a rare vascular complication of chronic pancreatitis resulting from erosion of the pancreatic or peripancreatic artery into a pseudocyst that is identified as a pulsating vascular malformation which may lead to lethal complications if left untreated. Many publications in the literature consider angiography as the first step in the management of pancreatic pseudoaneurysm to stabilize the patient's critical condition; it should be followed by surgical intervention as the definite treatment. We report a rare case of pancreatic pseudoaneurysm rupture with hemodynamic embarrassment in a critical patient with multiple comorbid conditions and poor risk for surgery who responded dramatically to angiographic management as a single therapeutic modality without further surgical intervention. The results observed in our patient suggest that pancreatic pseudoaneurysm may be successfully managed with angiography only and that not all cases require surgical intervention. This is particularly relevant in critically ill patients in whom surgical intervention would be unfeasible.

No MeSH data available.


Related in: MedlinePlus

Extravasation of the contrast medium was completely arrested after arterial embolization.
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Figure 3: Extravasation of the contrast medium was completely arrested after arterial embolization.

Mentions: The patient was hospitalized with a diagnosis of chronic pancreatitis with pseudocyst formation, pneumonia with parapneumonic pleural effusion, septicemia, chronic renal failure and recent brain stroke. Four days after hospitalization, a follow-up transabdominal ultrasound revealed a rapidly enlarging pseudocyst in the tail of the pancreas which reached 10 cm in size. Endoscopic retrograde cholangiopancreatography was undertaken. Multiple actively bleeding duodenal ulcers were noted. Extravasation of the contrast medium over the body portion of the main pancreatic duct was demonstrated and a communication between the pseudocysts and the main pancreatic duct was suspected. A 5 Fr, 12 cm-long Zimmon pancreatic stent was inserted into the main pancreatic duct after endoscopic sphincterotomy. The patient was placed on treatment with proton pump inhibitors for the duodenal ulcer bleeding. He showed a relatively acceptable clinical course with regression of the pancreatic pseudocysts in two subsequent transabdominal ultrasound follow-ups. On the 25th day of hospitalization, the patient presented a sudden, sharp left hemiabdominal pain associated with general pallor, diaphoresis, tachycardia and abdominal distension, and systolic arterial pressure dropped to 70 mm Hg. The pseudocyst located in the pancreatic tail which decreased in size after main pancreatic duct stenting showed turbulent blood flow as visualized by color Doppler imaging (Toshiba Xario SSA-660A), establishing the tentative diagnosis of pancreatic pseudoaneurysm with probable rupture according the patient's clinical settings. Emergent contrast-enhanced computed tomography of the abdomen was undertaken and showed hyperdense hemorrhagic content in the pseudocyst (fig. 1). Sudden rupture of a pancreatic pseudoaneurysm with active bleeding was highly suspected, and surgeons were immediately called to evaluate the possibility of surgical hemostasis in this poor-risk and rapidly deteriorating patient with hemodynamic embarrassment. However, the surgeons considered that surgical intervention would not be advisable in this shocked patient with multiple severe systemic illness and very poor general performance. An emergent celiac angiogram was performed and a giant aneurysm supplied by the splenic artery was disclosed (fig. 2). The splenic angiogram showed profuse extravasation of the contrast medium from the aneurysm into the peritoneal cavity. Arterial embolization with insertion of metallic coils into the aneurysm was undertaken and the patient was sent back to the wards with relative stable hemodynamics. His clinical course was acceptable with progressive recovery after the transarterial embolization. On the 42nd day of hospitalization a follow-up transabdominal ultrasound still showed a 6.8 cm pseudocyst in the tail of the pancreas, however no turbulent blood flow could be detected by color Doppler imaging this time, probably denoting a satisfactory effect of the embolization (fig. 3). The patient was finally dismissed in a stable condition and still follows regular visits to the outpatient clinic 2 years after the successful life-saving embolization.


Complete remission of pancreatic pseudoaneurysm rupture with arterial embolization in a patient with poor risk for surgery: a case report.

Chu KE, Sun CK, Wu CC, Yang KC - Case Rep Gastroenterol (2012)

Extravasation of the contrast medium was completely arrested after arterial embolization.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC3369412&req=5

Figure 3: Extravasation of the contrast medium was completely arrested after arterial embolization.
Mentions: The patient was hospitalized with a diagnosis of chronic pancreatitis with pseudocyst formation, pneumonia with parapneumonic pleural effusion, septicemia, chronic renal failure and recent brain stroke. Four days after hospitalization, a follow-up transabdominal ultrasound revealed a rapidly enlarging pseudocyst in the tail of the pancreas which reached 10 cm in size. Endoscopic retrograde cholangiopancreatography was undertaken. Multiple actively bleeding duodenal ulcers were noted. Extravasation of the contrast medium over the body portion of the main pancreatic duct was demonstrated and a communication between the pseudocysts and the main pancreatic duct was suspected. A 5 Fr, 12 cm-long Zimmon pancreatic stent was inserted into the main pancreatic duct after endoscopic sphincterotomy. The patient was placed on treatment with proton pump inhibitors for the duodenal ulcer bleeding. He showed a relatively acceptable clinical course with regression of the pancreatic pseudocysts in two subsequent transabdominal ultrasound follow-ups. On the 25th day of hospitalization, the patient presented a sudden, sharp left hemiabdominal pain associated with general pallor, diaphoresis, tachycardia and abdominal distension, and systolic arterial pressure dropped to 70 mm Hg. The pseudocyst located in the pancreatic tail which decreased in size after main pancreatic duct stenting showed turbulent blood flow as visualized by color Doppler imaging (Toshiba Xario SSA-660A), establishing the tentative diagnosis of pancreatic pseudoaneurysm with probable rupture according the patient's clinical settings. Emergent contrast-enhanced computed tomography of the abdomen was undertaken and showed hyperdense hemorrhagic content in the pseudocyst (fig. 1). Sudden rupture of a pancreatic pseudoaneurysm with active bleeding was highly suspected, and surgeons were immediately called to evaluate the possibility of surgical hemostasis in this poor-risk and rapidly deteriorating patient with hemodynamic embarrassment. However, the surgeons considered that surgical intervention would not be advisable in this shocked patient with multiple severe systemic illness and very poor general performance. An emergent celiac angiogram was performed and a giant aneurysm supplied by the splenic artery was disclosed (fig. 2). The splenic angiogram showed profuse extravasation of the contrast medium from the aneurysm into the peritoneal cavity. Arterial embolization with insertion of metallic coils into the aneurysm was undertaken and the patient was sent back to the wards with relative stable hemodynamics. His clinical course was acceptable with progressive recovery after the transarterial embolization. On the 42nd day of hospitalization a follow-up transabdominal ultrasound still showed a 6.8 cm pseudocyst in the tail of the pancreas, however no turbulent blood flow could be detected by color Doppler imaging this time, probably denoting a satisfactory effect of the embolization (fig. 3). The patient was finally dismissed in a stable condition and still follows regular visits to the outpatient clinic 2 years after the successful life-saving embolization.

Bottom Line: Pancreatic pseudoaneurysm is a rare vascular complication of chronic pancreatitis resulting from erosion of the pancreatic or peripancreatic artery into a pseudocyst that is identified as a pulsating vascular malformation which may lead to lethal complications if left untreated.The results observed in our patient suggest that pancreatic pseudoaneurysm may be successfully managed with angiography only and that not all cases require surgical intervention.This is particularly relevant in critically ill patients in whom surgical intervention would be unfeasible.

View Article: PubMed Central - PubMed

Affiliation: Division of Gastroenterology, Department of Internal Medicine, Taipei, Taiwan.

ABSTRACT
Pancreatic pseudoaneurysm is a rare vascular complication of chronic pancreatitis resulting from erosion of the pancreatic or peripancreatic artery into a pseudocyst that is identified as a pulsating vascular malformation which may lead to lethal complications if left untreated. Many publications in the literature consider angiography as the first step in the management of pancreatic pseudoaneurysm to stabilize the patient's critical condition; it should be followed by surgical intervention as the definite treatment. We report a rare case of pancreatic pseudoaneurysm rupture with hemodynamic embarrassment in a critical patient with multiple comorbid conditions and poor risk for surgery who responded dramatically to angiographic management as a single therapeutic modality without further surgical intervention. The results observed in our patient suggest that pancreatic pseudoaneurysm may be successfully managed with angiography only and that not all cases require surgical intervention. This is particularly relevant in critically ill patients in whom surgical intervention would be unfeasible.

No MeSH data available.


Related in: MedlinePlus