Surinder Singh Rana*, Vishal Sharma, Ravi Sharma, Deepak K Bhasin
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Received April 22nd, 2014- Accepted April 25th, 2014
Endosonography; Pancreatitis, Acute Necrotizing / complications
A 32 year old male patient diagnosed as alcohol related acute necrotising pancreatitis (ANP) 2 months ago, now presented with abdominal pain and early satiety. Contrast enhanced computerized tomography (CECT) showed 12 cm walled off pancreatic necrosis (WOPN) (Figure 1). Endoscopic ultrasound (EUS) revealed large WOPN and power doppler revealed vascularity in collection with pulsatile flow suggestive of blood leaking into collection (Figure 2). However, no abnormal vessel or pseudoaneurysm could be identified. CT angiography (CTA) also showed normal major abdominal arteries (Figure 3). Since patient was symptomatic, after informed consent EUS guided transmural drainage was attempted. Now there was no vascularity in collection and procedure was successfully accomplished. A 7 Fr nasocystic drain (NCD) was inserted and it drained purulent material. Patient had marked symptomatic relief but 6 hours later had severe pain and hematemesis with blood coming through NCD also. CTA revealed blood in WOPN but no abnormal bleeding vessel was identified (Figure 4). Digital subtraction angiography (DSA) also did not reveal any abnormal or bleeding vessel. The patient was managed with blood transfusion and NCD was kept patent by intermittent flushing. The bleeding subsided and the effluent from NCD cleared in 48 hours. The NCD was replaced with 10 Fr pigtail stents and CT abdomen done 3 weeks later revealed resolution of WOPN (Figure 5). The patient has been asymptomatic over a follow up period of 13 months.
Gastrointestinal bleeding is rare but potentially lethal complication of acute pancreatitis as well as of transmural drainage of pancreatic collections [1, 2, 3]. CTA is the most common procedure used to detect pseudoaneurysms but it can miss them if they are small or bleeding is intermittent and slow because of compression by collection [4, 5]. In these situations, EUS can help in detecting this potentially catastrophic complication of pancreatitis.
The authors have no potential conflict of interest.