Life-threatening wirsungorrhagia

Abstract

A 51-YEAR-OLD MAN with a medical history of alcoholic chronic pancreatitis and appendectomy was admitted to the emergency department with epigastric pain, melena, and rectorragia. The hemoglobin level was 4.3 g/dL without leukocytosis. The patient described a recent history of recurrent episodes of loss of consciousness and intermittent epigastric and periumbilical pain. Upper endoscopy revealed an active bleeding through the major papilla. Computed tomography of the abdominal revealed an hemorrhagic 42-mm cystic lesion in the pancreatic head with a dilated the Wirsung duct filled with hyperdense material (Fig 1, A and B). A celiac-mesenteric angiogram revealed a bleeding pseudoaneurysm of the anterior pancreaticoduodenal arcade directly communicating with a pancreatic pseudocyst. The celiac artery did not fill because of compression by the active median arcuate ligament (Fig 2, A and B). Liver arterial flow was maintained via retrograde flow through the pancreaticoduodenal arcades and the gastroduodenal artery. Embolization was deemed as not technically feasible because of the difficulty of selectively cannulating the feeding vessels of the pseudoaneurysm. During exploratory laparotomy, revascularization of the celiac territory with section of the median arcuate ligament was followed by a pancreaticoduodenectomy. Digestive reconstruction was performed by pancreaticogastrostomy, hepaticoojejeunostomy, and gastrojejunostomy. The postoperative course was uneventful. During