What type of pancreatitis is associated with intrabdominal hemorrhage (bleeding)?

From the Guidelines

Hemorrhagic pancreatitis is the type of pancreatitis most strongly associated with intrabdominal bleeding. This severe form of acute pancreatitis involves bleeding within and around the pancreas, which can extend into the surrounding abdominal cavity. The bleeding occurs due to erosion of blood vessels by activated pancreatic enzymes that digest vascular walls, particularly when necrosis is present. According to the 2019 WSES guidelines for the management of severe acute pancreatitis 1, acute on-going bleeding when endovascular approach is unsuccessful is an indication for surgical intervention. Patients with hemorrhagic pancreatitis typically present with severe abdominal pain, hypotension, and may develop Grey Turner's sign (flank ecchymosis) or Cullen's sign (periumbilical ecchymosis) as blood tracks through tissue planes. Management includes aggressive fluid resuscitation, blood product transfusion as needed, correction of coagulopathy, and consideration of interventional radiology for embolization of bleeding vessels in unstable patients. Key considerations in management include:

• Aggressive fluid resuscitation to maintain blood pressure and perfusion of vital organs
• Blood product transfusion as needed to replace lost blood volume and correct coagulopathy
• Correction of coagulopathy to prevent further bleeding
• Consideration of interventional radiology for embolization of bleeding vessels in unstable patients
• Surgical intervention may be necessary in cases of ongoing bleeding or other complications such as abdominal compartment syndrome or bowel ischemia, as indicated by the 2019 WSES guidelines 1. The mortality rate for hemorrhagic pancreatitis is significantly higher than non-hemorrhagic forms, often exceeding 40%, making prompt recognition and treatment essential. Alcohol abuse and gallstones are common underlying causes that trigger the initial inflammatory cascade leading to this severe complication.

From the Research

Type of Pancreatitis Associated with Intrabdominal Bleeding

• Hemorrhagic pancreatitis is a type of pancreatitis associated with intrabdominal bleeding, as reported in a study published in 1979 2.
• The study found that death due to hemorrhagic pancreatitis occurs an average of 10 days after the onset of symptoms or within 7 days of hospitalization.
• Another study published in 2001 found that hemorrhagic complications of pancreatitis, including intra-abdominal hemorrhage, are rare but can be fatal 3.
• The cause of hemorrhage in pancreatitis can be due to bleeding pseudoaneurysm, diffuse bleeding with pancreatic necrosis, or hemorrhagic pseudocysts 3.

Characteristics of Hemorrhagic Pancreatitis

• Hemorrhagic pancreatitis is characterized by translocation of large volumes of albumin-rich fluid from the intravascular compartment to the retroperitoneum and pleural and abdominal cavities 2.
• This can lead to hemoconcentration, hypotension, tachycardia, tachypnea, ascites, abdominal distress, respiratory insufficiency, and renal failure 2.
• A study published in 2010 found that major haemorrhagic complications of acute pancreatitis are rare, but clinically important, and can be fatal 4.
• The study also found that sentinel bleeding can occur before major postoperative bleeding, and that intra-abdominal haemorrhage presenting more than 1 week after disease onset is a highly fatal complication 4.

Management and Outcome of Hemorrhagic Pancreatitis

• Early recognition and management of hemorrhagic pancreatitis are crucial to improve survival rates 2, 3, 5.
• Diagnostic and therapeutic lavage, as well as resection of the necrotic pancreas, may be necessary in some cases 2.
• A study published in 2003 found that awareness of high-risk conditions, avoidance of early and aggressive approach to sterile pancreatic necrosis, and prompt treatment of local septic complications can help prevent bleeding 5.
• The study also found that the increased use of diagnostic and interventional radiology, in association with prompt surgical treatment, can improve survival rates in cases of arterial bleeding 5.