Kosin Med J.  2020 Jun;35(1):52-57. 10.7180/kmj.2020.35.1.52.

A Case of unexpected Fatal Hemoperitoneum in Non-severe Acute Pancreatitis

• Choi SJ
• Yoon EL
• Lee JH
• Kim KY
• Choi SI
• Choi Wc

• KMID: 2503729
• DOI: http://doi.org/10.7180/kmj.2020.35.1.52

Abstract

Acute pancreatitis (AP) severity is determined by associated organ failure (OF). However, enzymatic erosion of peripancreatic vessels can lead to life-threatening hemoperitoneum in clinically non-severe AP without OF. We herein report a case of unexpected hemoperitoneum which developed in a patient with clinically resolving AP without OF. A 36-year-old woman with alcohol use disorder presented with resolving epigastric pain and sustained abdominal distension of 2 weeks’ duration. Ranson’s score on admission was 1 and Computed tomography (CT) revealed non-necrotic AP with peripancreatic fluid collection. She showed sudden hypotension with an abrupt decrease in serum hemoglobin within 24 hours after admission. She was suspected to have an acute hemoperitoneum associated with venous bleeding from AP based on repeated CT. Venous bleeding from the splenic branch was ligated during surgery. The possibility of bleeding at the pancreatic bed should be considered even if the pancreatitis is not severe.

Keyword

Alcoholic; Hemoperitoneum; Pancreatitis; Surgery

Figure

• 

  Fig. 1 Liver dynamic computed tomography (CT) scan of patient taken within 4 hours of admission. (A) There are multiple cystic lesions in pancreas presumed to be small pseudocysts in portal phase. (B) Peripancreatic fluid collection is notable at the pancreas head in portal phase (arrow). (C) There is active leakage of contrast media from the mesenteric vessel at duodenojejunal junction in delayed phase (arrow).

• 

  Fig. 2 Abdominal pelvis CT scan of patient taken after 29 hours of first CT scan immediately after clinical hypotensive event. (A) There is evidence of hemoperitoneum in left upper quadrant in non-contrast enhanced image (arrow) without active leakage of contrast media in arterial phase. (B) Newly developed hemoperitoneum is notable in pelvic cavity in non-contrast enhanced image (arrow).

Reference

1. Scott Tenner WMS. Acute pancreatitis. Mark Feldman LSF, Brandt Lawrence J, editors. Sleisenger and Fordtran’s Gastrointestinal and liver disease:Pathophysiology/Diagnosis/Management. 10th ed. Saunders: Elsevier;2016. p. 969–93.

2. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013; 62:102–11.

3. Vege SS, Gardner TB, Chari ST, Munukuti P, Pearson RK, Clain JE, et al. Low mortality and high morbidity in severe acute pancreatitis without organ failure: a case for revising the Atlanta classification to include “moderately severe acute pancreatitis”. Am J Gastroenterol. 2009; 104:710–5.

4. Flati G, Andrén-Sandberg A, La Pinta M, Porowska B, Carboni M. Potentially fatal bleeding in acute pancreatitis: pathophysiology, prevention, and treatment. Pancreas. 2003; 26:8–14.

5. Andersson E, Ansari D, Andersson R. Major haemorrhagic complications of acute pancreatitis. Br J Surg. 2010; 97:1379–84.

6. Sharma PK, Madan K, Garg PK. Hemorrhage in acute pancreatitis: should gastrointestinal bleeding be considered an organ failure? Pancreas. 2008; 36:141–5.

7. Querido S, Carvalho I, Moleiro F, Povoa P. Fatal acute necrohaemorrhagic pancreatitis with massive intraperitoneal and retroperitoneal bleeding: a rare cause of exsanguination. BMJ Case Rep. 2016.