Ann Hepatobiliary Pancreat Surg.  2020 Aug;24(3):292-300. 10.14701/ahbps.2020.24.3.292.

Hemorrhage complicating the course of severe acute pancreatitis

• Gupta V
• Krishna P
• Kochhar R
• Yadav TD
• Bargav V
• Bhalla A
• Kalra N
• Wig JD

• KMID: 2505341
• DOI: http://doi.org/10.14701/ahbps.2020.24.3.292

Abstract

Backgrounds/Aims
The course of severe acute pancreatitis (SAP) complicated by hemorrhage is associated with poor outcome.
Methods
Twenty-four (13%) out of 183 cases of SAP had hemorrhagic complications- 12 intraabdominal & 12 intraluminal, 13 had major & 11 had minor and 16 had de-novo & 8 post-surgical bleeding. The mean duration of pancreatitis prior to bleeding was 27±27.2 days. Results: Predictors of haemorrhage on univariate analysis were delayed admission (0.037), more than one organ failure (p=0.008), presence of venous thrombosis (p=0.033), infective necrosis (0.001) and systemic sepsis – bacterial (0.037) & fungal (p=0.032). On multivariate analysis infected necrosis (OR=11.82) and presence of fungal sepsis (OR=3.73) were the significant factors. Patients presenting with more than one organ failure and bacterial sepsis had borderline significance on multivariate analysis. Need for surgery (50% vs.12.6%), intensive care stay (7.4±7.9 vs. 5.4±5.2 days) and mortality (41.7% vs. 10.7%) were significantly higher in patients who suffered haemorrhage. Seven of the 13 with major bleeding had pseudoaneurysms-4 were embolized, 4 needed surgery including 1 embolization failure. Seven with intraabdominal bleeding required surgical intervention,2 had successful embolization and 3 had expectant management. CT severity index and surgical intervention, were significantly associated with intraabdominal bleeding. Organ failure, presence of pseudoaneurysm and surgical intervention were associated with major bleeding.
Conclusions
Hemorrhage in SAP was associated with increased morbidity and mortality. Infected necrosis accentuated the degradation of the vessel wall, which predispose to hemorrhage. Luminal bleeding may be indicative of erosion into the adjacent viscera by the pseudoaneurysm.

Keyword

Haemorrhage; Pancreatitis; Bleeding; Complication; Acute; Abdominal; Pseudoaneurysm

Figure

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  Fig. 1 Algorithm for management of patients experiencing haemorrhage during the course of acute pancreatitis. #Irrespective of the bleed being major or minor; UGIE, upper gastrointestinal endoscopy; LGIE, lower gastrointestinal endoscopy; CT angio, computed tomogram angiography; ET, endoscopic therapy; AE, angioembolization; DSA, digital substraction angiography.

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  Fig. 2 Classification and localization of the bleeding associated with severe acute pancreatitis. #2 eroded in duodenum and one into colon. *Exact source could not be localized. Values in parenthesis indicate number of patients in each category. PC, pancreatic collection; HV, hollow viscus; Pseudoaneu, Pseudoaneurysm.

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