From the Guidelines
Pancreatic diseases that can cause intra-abdominal hemorrhage include acute pancreatitis, chronic pancreatitis, pancreatic pseudocysts, pancreatic trauma, and pancreatic cancer, with acute pancreatitis being the most common cause, particularly severe necrotizing pancreatitis. These conditions can lead to hemorrhage through various mechanisms, including enzymatic vessel erosion, pseudoaneurysm formation, direct vascular trauma, or tumor invasion.
Causes of Intra-abdominal Hemorrhage
- Acute pancreatitis: severe necrotizing pancreatitis can lead to erosion of pancreatic enzymes into blood vessels
- Chronic pancreatitis: can cause pseudoaneurysms of peripancreatic arteries that may rupture
- Pancreatic pseudocysts: can become complicated by hemorrhage when they erode into adjacent blood vessels
- Pancreatic trauma: whether blunt or penetrating, can directly damage pancreatic tissue and nearby blood vessels
- Pancreatic cancer: especially advanced cases, may invade surrounding vascular structures leading to bleeding
Management
Management typically involves:
- Immediate resuscitation
- Identification of the bleeding source through CT angiography or other imaging
- Interventions such as angiographic embolization or surgery depending on the patient's hemodynamic stability and the specific underlying cause, as recommended by recent guidelines 1. The use of contrast-enhanced CT-scan is the fastest and most comprehensive technique for evaluating duodeno-pancreatic injuries, with a sensitivity and specificity of 86% and 88%, respectively, in diagnosing blunt hollow viscus injury 1. In pancreatic trauma, contrast-enhanced CT-scan has high specificity (90–95%) but low sensitivity (52–54%) for ductal involvement, and a repeat CT-scan with curved multi-planar reconstruction and specific pancreatic phase can help in diagnosing pancreatic ductal injuries 1. Non-operative management (NOM) may be considered in selected patients with pancreatic trauma, particularly those with minor or moderate injuries, and can be successful in up to 89% of cases, with a lower morbidity and mortality rate compared to operative management 1. However, the decision to pursue NOM or operative management should be made on a case-by-case basis, taking into account the patient's hemodynamic stability, the severity of the injury, and the presence of other abdominal injuries requiring surgery 1.
From the Research
Pancreatic Diseases Causing Intra-Abdominal Hemorrhage
- Acute pancreatitis (AP) can cause intra-abdominal hemorrhage, particularly in cases of severe acute pancreatitis (SAP) 2, 3, 4, 5
- Chronic pancreatitis can also lead to intra-abdominal hemorrhage, often due to pseudoaneurysm formation or diffuse bleeding 3, 4, 6, 5
- Pancreatic neoplasms, such as pancreatic cancer, can cause intra-abdominal hemorrhage, particularly if they lead to portal or splenic vein occlusion 6, 5
- Arteriovenous malformations (AVMs) can also cause intra-abdominal hemorrhage in patients with pancreatic diseases 6
- Post-pancreatectomy hemorrhage is another potential cause of intra-abdominal hemorrhage 5
Mechanisms of Hemorrhage
- Vessel wall erosion and rupture of pseudoaneurysms (PSAs) are common mechanisms of intra-abdominal hemorrhage in pancreatic diseases 2, 3, 4
- Diffuse bleeding in pancreatic necrosis can also lead to intra-abdominal hemorrhage 3, 4
- Hemorrhagic pseudocysts can cause intra-abdominal hemorrhage, particularly in patients with chronic pancreatitis 4
Diagnosis and Treatment
- Digital subtraction angiography (DSA) and computed tomography (CT) imaging are useful diagnostic tools for detecting intra-abdominal hemorrhage in pancreatic diseases 2, 4, 5
- Transcatheter arterial embolization (TAE) is a common treatment for intra-abdominal hemorrhage in pancreatic diseases, with a high success rate and low recurrence 5
- Surgery, such as laparotomy, may be necessary in some cases, particularly if TAE is unsuccessful or if there are complications 3, 5