What is the most common cause of massive bleeding in chronic pancreatitis, specifically: pseudoaneurysm, arteriovenous (AV) fistula, mycotic aneurysm, or fibromuscular dysplasia?

From the Guidelines

The most common cause of massive bleeding in chronic pancreatitis is pseudoaneurysm (option a). Pseudoaneurysms develop when pancreatic enzymes leak and erode into adjacent arterial walls, weakening them and creating a blood-filled sac that communicates with the arterial lumen. In chronic pancreatitis, this typically affects the splenic artery, gastroduodenal artery, or pancreaticoduodenal arteries. The persistent inflammation and enzymatic activity in chronic pancreatitis gradually damages these vessel walls, leading to pseudoaneurysm formation. When these pseudoaneurysms rupture, they can cause life-threatening hemorrhage into the pancreatic duct (hemosuccus pancreaticus), gastrointestinal tract, peritoneal cavity, or retroperitoneum. Management typically involves urgent angiography with embolization or surgical intervention. While arteriovenous fistulas, mycotic aneurysms, and fibromuscular dysplasia can occur in the pancreatic region, they are much less common causes of massive bleeding in the specific context of chronic pancreatitis. According to the ESPEN guideline on clinical nutrition in acute and chronic pancreatitis 1, chronic pancreatitis represents a chronic inflammation of the pancreatic gland with development of fibrosis, which can lead to various complications, including abdominal pain, malnutrition, and increased risk of osteoporosis and fractures. However, the guideline does not specifically address the cause of massive bleeding in chronic pancreatitis, but it highlights the importance of considering patients with chronic pancreatitis at risk for various complications.

Some key points to consider in the management of massive bleeding in chronic pancreatitis include:

• Urgent angiography with embolization or surgical intervention to control the bleeding
• Management of underlying chronic pancreatitis to prevent further complications
• Nutritional support to prevent malnutrition and related complications, as recommended by the ESPEN guideline 1
• Consideration of preventive measures for osteoporosis and increased fracture risk in patients with chronic pancreatitis, as suggested by the ESPEN guideline 1.

It is essential to prioritize the management of massive bleeding in chronic pancreatitis, as it can be life-threatening, and consider the underlying disease process and potential complications to provide comprehensive care.

From the Research

Causes of Massive Bleeding in Chronic Pancreatitis

The most common cause of massive bleeding in chronic pancreatitis is:

• Pseudoaneurysm, as reported in several studies 2, 3, 4, 5, 6

Characteristics of Pseudoaneurysms

• Pseudoaneurysms are a rare complication of chronic pancreatitis with a severe prognosis and high mortality 3
• Conversion of a pancreatic pseudocyst into a pseudoaneurysm is a potentially lethal complication because, when rupture occurs, there is a high mortality rate 3
• The most common causes of major haemorrhage were pseudoaneurysms in 25 patients (69.4%) 5

Treatment of Pseudoaneurysms

• Endovascular trans-catheter embolization for the treatment of pancreatic pseudoaneurysms is a safe, effective and repeatable procedure with high success rates 3
• Any haemodynamically stable patient with haemorrhage due to arterial pseudoaneurysms should undergo angiography with embolization when technically possible 5
• Angiography and selective coil embolization is a safe and effective way to arrest the hemorrhage 6