Pseudoaneurysm bleed in chronic pancreatitis: beware of multiple feeding vessels-a case report

Abstract

Gastroduodenal artery (GDA) pseudoaneurysm is a rare but potentially fatal complication in chronic pancreatitis. Managing GI bleed in chronic pseudocyst due to ruptured pseudoaneurysm having multiple feeding vessels and that too in a background of portal hypertension is a challenging task. A 43 year old male patient with chronic calcific pancreatitis presented to our department with 10 days history of malena and drop in hemoglobin. He under micro coil embolization of GDA 12 days before in another hospital for ruptured GDA pseudoaneurysm with upper GI bleed. Upper GI endoscopy revealed grade II-III esophageal varices with portal hypertensive gastropathy with blood in 2nd part of duodenum. CECT scan revealed features of chronic calcific pancreatitis with pseudocyst and GDA pseudoaneurysm with intracystic bleed. Patient again underwent coil embolization in our hospital. However, the patient again developed GI bleed. Patient was taken for emergency laparotomy and found to have bleed from splenic artery as well as GDA pseudoaneurysm into the pseudocyst. Transcystic pseudoaneurysm ligation with ligation of intracystic bleeding vessels and lateral pancreaticojejunostomy was done. Postoperatively patient recovered well. Rupture of pseudoaneurysm in chronic pancreatitis is associated with almost 100% mortality if untreated. Though radiological intervention should be the primary modality of treatment, low threshold for surgery should be kept, considering multiple feeding vessels to the pseudocyst pseudoaneurysm, which may be missed in angiography