SUCCESSFUL TREATMENT OF BLEEDING PSEUDOANEURYSMS OF CHRONIC-PANCREATITIS

A ruptured pseudoaneurysm is the most rapidly fatal complication encountered in patients with chronic pancreatitis, with a reported mortality rate of 12.5% in treated patients to >90% in those untreated. Although reportedly a rare complication of chronic pancreatitis, a pseudoaneurysm is encountered in 6-9.5% of patients with chronic pancreatitis and as many as 17% of all patients operated on for chronic pancreatitis. Timely diagnosis and treatment seems to result in markedly reduced mortality. Four patients with bleeding pseudoaneurysms associated with chronic pancreatitis and pseudocysts were encountered recently at Virginia Mason Medical Center. These patients' charts, as well as the English literature, were reviewed in detail. All of our cases occurred in alcoholic males. Pseudocysts with pancreatic ductal or pseudocyst rupture were seen in three cases. All had a history of crescendo-decrescendo pain episodes and had evidence of bleeding or were bleeding at presentation. Splenic vein occlusion was identified in 50% of the cases. A pseudoaneurysm was documented by angiography in all patients. Embolization was successfully attempted without complication in two patients. Three patients were ultimately treated with a pylorus-sparing (2) or standard (1) pancreaticoduodenectomy. These three are alive and doing well at 16, 26, and 52 months from the time of their procedure. A fourth patient was treated nonoperatively, because of severe comorbid disease and aberrant anatomy, with successful embolization of the pseudoaneurysm and biliary and pancreatic stenting. The pseudocyst resolved and he is asymptomatic 12 months after therapy. We advocate preoperative arteriography in all patients with suspected or known arterial pseudoaneurysm. Transcatheter embolization should be attempted in all symptomatic patients with pseudoaneurysms to prevent or treat bleeding episodes. Resection of the pseudocyst and pseudoaneurysm is optimal treatment, but interventional radiologic or gastroenterologic methods may allow for successful nonoperative management in selected patients.