Massive gastrointestinal bleed-ing is a serious complicationof acute pancreatitis. It

needs urgent evaluation of its causeand definitive therapy. Aneurysm for-mation from vessels adjacent to thepancreas should be suspected. Uppergastrointestinal endoscopy, ultra-sonography and computed tomogra-phy help in the diagnosis, but preciselocalization of the bleeding site isonly possible with angiography.Bleeding from a large vessel should be

controlled by angiographic emboliza-tion. If this fails, definitive surgicaltherapy entails resection of theaneurysm to prevent rebleeding. The death rate is high but can be reduced with prompt and propermanagement.We present 2 cases of post-trau-

matic pancreatitis with aneurysm formation from the splenic artery. Onepatient had massive gastrointestinal he-morrhage and the second had bleed-ing into an associated pseudocyst.

CASE REPORTS

Case 1

A 30-year-old man presented witha history of blunt abdominal trauma45 days earlier. Two days after thetrauma he experienced acute pain inthe epigastrium with radiation to theback. He was treated with antibioticsand intravenous fluids at a medical in-stitution and was discharged when thepain subsided. Four days later the pain

Case ReportÉtude de cas

POST-TRAUMATIC PANCREATITIS WITH ASSOCIATEDANEURYSM OF THE SPLENIC ARTERY: REPORT OF 2 CASESAND REVIEW OF THE LITERATURE

Vivek Tandon, MS;* Raju Shanna, MD;† Girish K. Pande, MB BS, MS, PhD*

From the *Department of Gastrointestinal Surgery and Liver Transplantation and the †Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India

Accepted for publication May 1, 1998.

Correspondence to: Dr. Girish K. Pande, Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, Ansari Nagar, New Delhi110029, India; fax 91-11-6862663, gkpande@medinst.ernet.in

© 1999 Canadian Medical Association (text and abstract/résumé)

In patients with acute pancreatitis, profuse gastrointestinal bleeding is associated with a high death rate.The cause of such bleeding must be evaluated and the bleeding controlled urgently. Aneurysm formationis usually the cause of the bleeding. Angiography is needed to make a definitive diagnosis and the bleedingsite should be controlled by angiographic embolization if possible. If this fails, aneurysm resection is neces-sary. Two patients are described. Both had aneurysms of the splenic artery, presenting as massive gastroin-testinal bleeding in one patient and bleeding into an associated pseudocyst in the other. They required sur-gical repair, which was successful in both cases.

Chez les patients victimes d’une pancréatite aiguë, il y a un lien entre le saignement gastro-intestinal abon-dant et un taux de mortalité élevé. Il faut évaluer la cause du saignement et le contrôler de toute urgence.Le saignement est habituellement causé par un anévrisme. Il faut procéder à une angiographie pour poserun diagnostic certain et contrôler le site du saignement par embolisation angiographique si possible. En casd’échec, il faut réséquer l’anévrisme. On décrit le cas de deux patients. Tous deux avaient un anévrisme del’artère splénique qui a causé un saignement gastro-intestinal massif dans un cas et un saignement dans unpseudokyste connexe dans l’autre. Il a fallu réparer les anévrismes en procédant à une intervention chirurgi-cale qui a réussi dans les deux cas.

CJS, Vol. 42, No. 3, June 1999 215

recurred. Ultrasonography revealed apseudocyst measuring 8.7 × 3 cm inthe body of the pancreas. He was read-mitted and was recovering when he ex-perienced recurrent melena. Uppergastrointestinal endoscopy revealed ev-idence of erosive mucosal disease,which was treated with antacids andblood transfusions. However, the me-lena persisted, and he had recurrenthematemesis, 4 to 5 episodes daily and50 mL in each episode. This contin-ued for 10 days by which time he hadreceived 32 units of blood. He was re-ferred to the All India Institute ofMedical Sciences.On admission, he did not give any

history of jaundice or fever during hisillness. His vital signs were stable. Hewas pale, afebrile and anicteric. On ab-dominal examination, an ill-definedtender mass was noted occupying theepigastrium and left hypochondrium.Liver and spleen were not palpableand there was no ascites. Laboratoryinvestigations gave the following re-sults: hemoglobin level 98 g/L, totalserum bilirubin level 25.6 µmol/L,

serum aspartate aminotransferase level57 U/L, serum alanine aminotrans-ferase level 50 U/L, serum alkalinephosphatase level 218 U/L (normal80 to 280 U/L), total serum proteinlevel 81 g/L, serum albumin level 25g/L. CT at the time of admissionshowed acute pancreatitis with a cystin the body of the pancreas contain-ing blood. The spleen was enlargedand contained multiple infarcts. Up-per gastrointestinal endoscopy re-vealed extrinsic compression on theposterior wall of the stomach with asmall opening in the centre, leakingblood. A natural cystogastrostomywas suspected.The patient remained hemodynam-

ically stable. He had no bleeding for 3days. On the fourth day he had 2episodes of hematochezia associatedwith a fall in the hemoglobin levelfrom 122 g/L to 92 g/L. Celiac an-giography revealed a wide-mouthedaneurysm of the proximal splenicartery (Fig. 1). Since the patient con-tinued to bleed, laparotomy was done.There was evidence of pancreatitis

with fat necrosis. A large pseudo -aneurysm arising from the proximalsplenic artery was densely adherent tothe stomach and communicated withits lumen. The aneurysm was ligatedproximally and distally; splenectomyand resection of the adherent segmentof transverse colon were done. Anileostomy and mucous fistula werefashioned, and a feeding jejunostomywas added. His postoperative recoverywas uncomplicated and he was dis-charged on the 10th postoperativeday. After 3 months he was readmit-ted and intestinal continuity wasreestablished by an end-to-side colo-colic anastomosis. At last follow-up 4months later, he was well.

Case 2

A 35-year-old man sustained bluntabdominal trauma as a result of whichhe had pain in the left upper quadrantand lumbar region with radiation tothe back, which lasted for 4 days.Three months later he had severe ab-dominal pain with fever and coffee-brown vomitus associated with the ap-pearance of a lump in the left upperabdomen. Ultrasonography revealed apseudocyst in the body of pancreas.Upper gastrointestinal endoscopy wasnormal.He presented to All India Instute of

Medical Sciences. His vitals were stablebut he looked pale and ill. His upper ab-domen was distended and a nontenderlump, measuring 8 × 7 cm, was palpa-ble in the epigastrium and lefthypochondrium. Results of laboratoryinvestigations were as follows: hemo-globin level 63 g/L, leukocyte count12.5 × 109/L, serum urea nitrogen level8.9 mmol/L urea, total serum biliru-bin level 13.7 µmol/L, serum alkalinephosphatase 248 U/L (normal 80 to280 U/L), serum aspartate aminotrans-ferase level 53 U/L, serum alanineaminotransferase level 56 U/L, total

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FIG. 1. Case 1. Selective celiac angiogram shows an aneurysm arising from the mid-portion of thesplenic artery (arrow).

serum protein level 59 g/L, serum al-bumin level 27 g/L. Ultrasonographyrevealed a large pseudocyst in the bodyof the pancreas, within which was an-other cystic lesion. Doppler scanningsuggested that the cystic lesion was ananeurysm arising from the proximalsplenic artery. CT confirmed the find-ings and gave evidence that suggestedbleeding from the aneurysm into thepseudocyst (Fig. 2). Angiography (Fig.3) showed a pseudoaneurysm arisingfrom the proximal splenic artery. Em-bolization was attempted but failed be-cause the splenic artery could not becatheterized. Emergency laparotomy,done because of continued bleeding,revealed a large pseudocyst in the lessersac of peritoneum full of clots. Evacua-tion of the clots revealed an aneurysmfrom the proximal splenic artery thathad ruptured and was bleeding. Theaneurysm was excised after proximaland distal ligation of the splenic artery.The splenic artery distal to theaneurysm was thrombosed. The cystwas drained into a Roux loop of je-junum and a feeding jejunostomy es-tablished. Postoperatively, he did welland was discharged on the sixth post-operative day.

DISCUSSION

Severe hemorrhage, though rare, isa serious complication of pancreatitis.The reported incidence varies from1.7% to 2.5% in large series.1,2 Hemor-rhage may occur into the retroperi-toneum, the peritoneal cavity or thegastrointestinal tract. Eckhauser andassociates3 reported an incidence of7.5% in a series of 250 patients,whereas Marks and colleagues,1 intheir series of 529 patients with pan-creatitis, reported an incidence of 4%.Most commonly gastrointestinal he-morrhage is related to peptic ulcer dis-ease, gastritis or varices due to portalhypertension.4,5 Less often, bleeding

may occur from erosion of gastroin-testinal mucosa contiguous with an in-flamed pancreas or from damagedpancreatic and peripancreatic vessels,with or without formation ofaneurysms. Paxton and Payne6 de-tected numerous areas of hemorrhagic

ulceration in the mucosa of the stom-ach, small bowel and colon at autopsyin cases of fatal pancreatitis. This formof bleeding, although rare, is docu-mented more often with the wide-spread use of endoscopy. The pre-ferred mode of treatment is a cysto -

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FIG. 3. Case 2. Selective celiac angiogram shows an aneurysm (arrow) arising from the proximalsplenic artery.

FIG. 2. Case 2. Computed tomography scan demonstrates a pseudocyst containing an aneurysm (arrow)arising from the proximal splenic artery with evidence of active bleeding.

gastrostomy, including the inflamedarea of the stomach, as this not onlydrains the cyst but also removes thebleeding source from the stomach.7 Incases of gastrointestinal bleeding orig-inating from damaged pancreatic andperipancreatic vessels, the pathophysi-ological process involved is poorly un-derstood. The peripancreatic vesselsmay become damaged from the in-flammation or because of the digestiveeffect of elastase or other pancreaticenzymes.8 Weakening of the vesselwall with formation of a trueaneurysm occurs in 10% to 21% pa-tients with pancreatitis.9,10 Occasion-ally, a damaged vessel or an aneurysmmay develop a communication with apseudocyst. The splenic artery is in-volved most commonly althoughother branches of the celiac axis, suchas the gastroduodenal or pancreatico-duodenal artery, may also be in-volved.11–14 However, bleeding derivedfrom the middle colic, gastroepiploic,gastric, hepatic and superior mesen-teric arteries has also been re-ported.5,15–18 The blood gains access tothe gastrointestinal tract through thepancreatic duct, common bile duct orby direct rupture into the lumen ofthe bowel. The damaged vessel oraneurysm may communicate with thepancreatic duct or bile duct either di-rectly or by means of a pseudocyst.Direct communication with the lu-

men of the gastrointestinal tract is un-common, although there are reportsof rupture into the stomach, duode-num, colon and even esophagus.14,18–20

Schrocchi and Anderson21 reported 19cases of pseudocyst erosion into adja-cent viscera and found single organerosion to be twice as common as rup-ture into multiple organs. The com-monest site of rupture was the stom-ach followed by the duodenum.21

The bleeding is usually massive andthe patients present with recurrent he-matemesis and melena, requiring mul-

tiple blood transfusions.4 Early en-doscopy helps to rule out the morecommon causes of gastritis, peptic ul-cer and portal hypertension and occa-sionally, as in our patient, may identifythe site of rupture. Ultrasonographyand CT may suggest a bleedingpseudoaneurysm in 70% to 80% cases;however, the pseudoaneurysm itself isidentified in less than 10% of cases.22

The presence of a homogeneous areaof enhancement contiguous with anartery on CT and the presence of asimilar anechoic mass on sonogramshave been mentioned as strongly sug-gestive of a pseudoaneurysm.23,24

Doppler ultrasonography has beenused successfully in the diagnosis ofsplenic artery aneurysms, and the pat-terns vary depending on the amountof clot in the pseudoaneurysm.24 SpiralCT scans have been found to correlatewell with angiography in the detectionof visceral vessel aneurysms.25,26 Thiswas also seen in both cases describedhere. However, angiography is the investigation of choice since it identi-fies the site of bleeding in nearly 100%of cases.4,5,28

Surgical options in these patientsinclude draining the cyst, with trans -cystic ligation of the bleeding vessel orresection of the cyst or pseudo -aneurysm. The former has a 40% to80% rate of rebleeding and the deathrate associated with the procedure isless than 20%.22,27,28 Resection carries amuch higher death rate of 15% to50%, but the reported incidence of re-current bleeding is less than 15%.22,27,28

Thus, it is more useful to carry out adefinitive procedure in the form of re-section, but the decision to proceedneeds to be balanced with the fact thatthese patients are often too sick to tol-erate an extensive surgical procedure.If facilities are available, angiographywith embolization is the treatment ofchoice. It carries no significant mor-bidity and mortality and may be cura-

tive. Surgery should be reserved forhemodynamically unstable patients inwhom embolization has failed.22,27,28

However, of the 2 cases reported here,embolization was unsuccessful in 1,and surgery was preferred in the otherbecause it would help to control thebleeding and provide a feeding je-junostomy, which was required be-cause the patient had ongoing acutepancreatitis.

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