Three weeks after a pancreaticoduodenectomy, a patient presents with massive clot‑filled hematemesis—what is the most likely cause and how should it be emergently managed?

Post-Whipple Massive Hematemesis at 3 Weeks: Pseudoaneurysm Until Proven Otherwise

The most likely cause is a ruptured pseudoaneurysm of the gastroduodenal artery stump or hepatic artery branches, and emergency management requires immediate angiography with endovascular embolization as the first-line intervention. 1, 2, 3

Most Likely Etiology

Pseudoaneurysm formation occurs in approximately 3% of post-pancreaticoduodenectomy patients and carries up to 50% mortality when rupture occurs. 2, 3 The timing at 3 weeks post-operatively is classic for this complication.

Common Pseudoaneurysm Locations (in order of frequency):

• Gastroduodenal artery stump (41%) - the most common site 3
• Hepatic artery branches (right, proper, or common hepatic artery) (30%) 3
• Right gastric artery (7%) 3
• Peripancreatic arteries (15%) 3

Key Risk Factors Present:

• Pancreatic fistula - documented in 44% of pseudoaneurysm cases, creates local inflammatory environment that erodes vessel walls 3
• Intra-abdominal collections or infection - promote vessel wall breakdown 2
• Sentinel bleeding - occurs in 77.8% of cases before massive hemorrhage 3

Emergency Management Protocol

Immediate Resuscitation (First Priority):

Aggressive hemodynamic stabilization must precede diagnostic attempts, focusing on restoring organ perfusion rather than normalizing blood pressure initially. 4

• Secure large-bore IV access immediately 5
• Initiate massive transfusion protocol with 1:1 ratio of packed red blood cells to fresh frozen plasma 6, 5
• Target fibrinogen >1.5 g/L and platelet count >75 × 10⁹/L - levels below these thresholds significantly increase bleeding risk 4, 6, 5
• Active warming of patient and all blood products to 37°C is mandatory 6
• Administer tranexamic acid 1g IV over 10 minutes, followed by 1g over 8 hours - proven mortality benefit in massive hemorrhage 6, 5

Diagnostic and Therapeutic Approach:

Angiography is both diagnostic and therapeutic, and has become the standard of care over surgical exploration. 3

First-Line: Emergency Angiography with Embolization

• Proceed directly to angiography rather than endoscopy - endoscopy has limited utility for post-surgical arterial bleeding 3, 7
• Angiography achieves hemostasis in 78.2% of cases 3
• CT angiography can be performed if patient is stable enough - helps localize unusual bleeding sources 7

Embolization Technique Selection:

Endovascular trapping of the hepatic artery (embolization proximal and distal to the GDA stump) is superior to selective embolization. 8

• Trapping technique has 0% rebleeding rate versus 100% rebleeding with selective embolization 8
• Selective embolization of GDA stump alone leads to recurrent bleeding requiring repeat intervention 8
• For hepatic artery pseudoaneurysms, consider stent graft placement - preserves hepatic arterial flow while excluding pseudoaneurysm 1

Complications of Embolization to Anticipate:

Hepatic ischemia occurs but is usually manageable conservatively. 3, 8

• Liver abscesses or infarction develop in approximately 38% after hepatic artery embolization 3
• Subsegmental infarction (more common with trapping technique) versus multisegmental infarction (more common with selective embolization) 8
• Hepatic failure is rare but can occur 3
• Conservative management with antibiotics and supportive care is usually successful 8

Surgical Exploration (Last Resort):

Emergency laparotomy should only be performed when endovascular options have failed or are unavailable. 4

• Direct surgical exploration without localization carries extremely high mortality 4
• Required in approximately 22% of cases when angiography fails 3
• Two patients in the literature died from sudden massive hemorrhage before any intervention could be attempted 3

Post-Hemostasis Critical Care

All patients require ICU admission with intensive monitoring after achieving hemostasis. 4, 6

• Frequent coagulation monitoring (platelet count, fibrinogen, PT, aPTT) 6, 5
• Monitor for rebleeding through drain assessment and serial hemoglobin 4
• Aggressive correction of acidosis, hypothermia, and coagulopathy once bleeding controlled 4, 6
• Initiate venous thromboprophylaxis as soon as bleeding controlled - patients rapidly develop prothrombotic state 4, 6, 5

Critical Pitfalls to Avoid

• Do not attempt endoscopy as primary diagnostic modality - wastes time and rarely identifies arterial bleeding source in post-Whipple patients 3
• Do not proceed to laparotomy without attempting angiography first - unless patient is in extremis or angiography unavailable 4, 3
• Do not use selective embolization techniques - high rebleeding rate necessitates repeat intervention 8
• Do not delay tranexamic acid administration - must be given within 3 hours of bleeding onset for maximum benefit 6, 5
• Do not overlook pancreatic fistula as underlying cause - present in 44% of cases and requires definitive management 3