Patient with Severe Pancreatitis and Recurrent GI Bleeding Controlled by Splenic Artery Embolization

Abstract

Hemorrhage is uncommon but serious complication of pancreatitis. It may develop by different mechanisms, involve different vascular structures, and require different therapeutic approaches. We present a patient with severe pancreatitis who developed recurrent bleeding by several different mechanisms eventually controlled by a single therapeutic intervention. A 37 year old man with recurrent acute alcoholic pancreatitis was admitted with hematemesis. An EGD revealed bleeding gastric varices and sclerotherapy was performed with good hemostasis. Serial abdominal CT scans (incl. CT angiogram) showed pancreatic phlegmon, rapidly growing pancreatic pseudocyst, splenic artery pseudoaneurim, peripancreatic hematoma, and thrombosed splenic vein. Shortly after that the patient had another episode of hematemesis. The repeat EGD did not show bleeding gastric varices but a fresh blood leaking from the duodenal wall. An angiogram was done which confirmed splenic vein thrombosis and demonstrated a leakage of the splenic artery peseudoaneurism into the retroperitoneal space and into the pancreatic pseudocyst which had eroded into the duodenal wall. Embolization with polyvinyl alcohol particles was performed with complete occlusion of the splenic artery pseudoaneurism and cessation of bleeding. No side effects of treatment were observed. On further 5 months follow up the patient has not had further episodes of bleeding. The follow up abdominal CT scans showed gradual resolution of pancreatitis, pancreatic pseudocyst, and splenic artery pseudoaneurism after its occlusion. GI bleeding by different mechanisms was observed in this patient with severe pancreatitis: bleeding gastric varices secondary to left-sided portal hypertension due to splenic vein thrombosis; and splenic artery pseudoaneurism complicated by rupture into retroperitoneal space and into pancreatic pseudocyst which eroded into the duodenum. The bleeding was controlled with an angiographic embolization of the splenic artery. Mesenteric angiography is not only the gold standard for localization of bleeding pseudoaneurisms but, if combined with embolization, it achieves control of bleeding in 75%. In addition, even though splenectomy is a treatment of choice for symptomatic patients with splenic vein thrombosis, the percutaneous splenic artery embolization, is an good alternative for a “non-surgical splenectomy”.