Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm

Abstract

Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues. With disease progression, patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss. Among them, a pseudoaneurysm, mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas, is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs. At present, no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation. The role of arterial embolization, the timing of surgical intervention and even surgical procedures are still controversial. In this review, we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleeders and to evaluate the associated complications such as pseudocyst formation, followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient’s condition. With advances and improvements in endoscopic devices and techniques, therapeutic endoscopy for pancreatic pseudocysts is technically feasible, safe and effective. Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition, for those in whom arterial embolization of the bleeding pseudoaneurysm fails, and when endoscopic management of the pseudocyst is unsuccessful. If a bleeding pseudoaneurysm is located over the tail of the pancreas, resection is a preferential procedure, whereas if the lesion is situated over the head or body of the pancreas, relatively conservative surgical procedures are recommended.

Keywords: Chronic pancreatitis, Pseudocyst, Pseudoaneurysm bleeding, Arterial embolization, Endoscopy, Surgery

Core tip: Chronic pancreatitis complicated with a bleeding pseudoaneurysm is a life-threatening condition. Therapeutic strategies for this rare disease remain controversial. In this review, surgical treatment as a first-line therapy is associated with a high mortality rate in emergency situations. Dynamic abdominal computed tomography and angiography should be performed as the initial management strategy to localize the bleeder, followed by embolization to control the bleeding to achieve early stabilization of the patient’s condition. Surgical intervention should be performed for patients who are unable to undergo or who fail arterial embolization for pseudoaneurysm bleeding, or when endoscopic management of the pseudocyst is unsuccessful.