Case Presentation:
A 49 year old woman presented to the Emergency Department with abdominal pain and vomiting. No pertinent information was found in her past history or review of systems. Vital signs and the rest of her physical examination was normal except for right upper quadrant tenderness. Laboratory data showed a white blood cell count of 15,500 cells/µL, a total billirubin of 1.3 mg/dL, an alkaline phosphatase of 158 U/L, an aspartate aminotransferase of 923 U/L, an alanine aminotransferase of 801 U/L, and a lipase of 3250 U/L. Right upper quadrant ultrasound revealed gallbladder sludge. The patient was admitted and treated for gallstone pancreatitis. The morning after presentation she was found without a pulse or spontaneous breathing. After one dose of epinephrine her pulse returned. She was transferred to the intensive care unit where studies showed an acidosis, acute anemia and a new coagulopathy. Increased abdominal girth was noted and an ultrasound showed intra‐abdominal hemorrhage. An abdominal computerized tomography scan showed extravasation of contrast from an unclear site but no evidence of pancreatic necrosis. Interventional Radiology found active bleeding from the gastroduodenal artery (GDA) with no pseudoaneurysms. GDA cannulation was unsuccessful but resulted in dissection of the GDA which stopped the bleeding. She continued to be coagulopathic and developed abdominal compartment syndrome. A laparotomy was performed and ischemic bowel was seen. The patient’s family withdrew support and she expired 14 hours after her arrest.
Discussion:
Fatal gastrointestinal bleeding is a rare but recognized complication of acute pancreatitis with an incidence of 1.2 to 14.5%. 60% of cases result from necrotizing pancreatitis and rupture of pseudoaneurysms. Bleeding associated with pancreatic necrosis has been associated with 38% mortality. Three reviews reported on 68 patients with hemorrhage and pancreatitis. These patients had: a median age of 69, risk factors for bleeding present, prior evidence or complications of pancreatitis, onset of bleeding from day nine onwards and a mortality rate of 3‐21%. Diagnosis requires CT scan or angiography and treatment options include ligation, repair of the vessel, distal pancretectomy and transcatheter arterial embolization.
Conclusions:
This middle aged female had acute pancreatitis and developed a massive intra‐abdominal hemorrhage due to GDA erosion one day following admission. The patient had no known risk factors for bleeding and no evidence of prior pancreatitis, pancreatic necrosis or complications from pancreatitis. Any patient with pancreatitis who has signs of bleeding, should be urgently evaluated for hemorrhagic complications associated with pancreatitis. Early diagnosis and treatment may prevent a fatal outcome.