S1517 Evaluating Obscure GI Bleeding in Pancreatitis

Abstract

INTRODUCTION: Pancreatic pseudoaneurysm is a rare complication of pancreatitis and occurs in as many as 10% of cases and has a mortality rate ranging from 11-50%. In pancreatitis, pancreatic enzymes cause a necrotizing arteritis of surrounding vessels. Weakened arterial vessel architecture can result in bleeding into a pseudocyst causing rupture and subsequent massive bleeding into the gut lumen or peritoneal cavity. Herein we describe a case involving pancreatitis with pseudocyst complicated by a splenic artery pseudoaneurysm presenting with abdominal pain, anemia, and GI bleeding. CASE DESCRIPTION/METHODS: A 50 year old woman was transferred to our hospital system with acutely worsening abdominal pain and anemia. Her medical history was significant for morbid obesity and recent pancreatitis complicated by necrotizing pancreatitis with large pseudocyst and a right sided pleural effusion. On admission, vitals revealed BP 148/74, HR 79 bpm, RR 20 resp/min, T 36.6 °C, SpO2 100% on room air. Labs revealed WBC 6.58g k/uL, hgb 6.9 g/dL, plts 47, t bili 1.4, alk phos 107, ALT 18, AST 13. CT redemonstrated a moderately sized acute necrotic collection of the pancreas head and neck with no clearly defined wall enclosing the area. A repeat CT scan in 2 weeks was ordered to ensure maturity of the walled off necrosis prior to EUS guided drainage. Shortly after admission the patient developed hematemesis and maroon colored stools. EGD was positive only for moderate edema, erythema, and friability of the entire duodenum, however, a fistula between the pancreatic collection and the stomach/duodenum was not excluded. Ongoing hematemesis prompted an emergent CTA which was notable for a 1.4 cm distal splenic artery pseudoaneurysm (Figure 1). IR performed a successful coil embolization of the splenic artery (Figure 2 A-B). The patient tolerated the procedure well with no complications. DISCUSSION: There is significant mortality associated with rupture of a splenic artery pseudoaneurysm. A high index of suspicion for ruptured splenic artery pseudoaneurysm resulting in GI bleeding through fistulation is required in patients with acute and/or chronic pancreatitis who experience worsening abdominal pain, anemia, and/or overt GI bleed. Early identification and intervention of these pseudoaneurysms is paramount and can be emergently managed with arterial embolization or surgery to prevent life threatening complications.Figure 1.: CT angiogram showing a splenic artery pseudoaneurysm near tail of pancreas.Figure 2.: IR embolization. A) Pseudoaneurysm of the distal splenic artery. B) Successful microcoil embolization of a splenic artery across a pseudoaneurysm with no evidence of active extravasation after embolization with stasis of flow in the splenic artery.