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Pancreatic pseudocyst causing hemobilia and massive gastrointestinal hemorrhage
Pancreatic Pseudocyst Causing Hemobilia and Massive Gastrointestinal Hemorrhage W. EDWARD DALTON, MD, ~ Richmond, Virginia HYUNG MO LEE, MD, Richmond. Virginia G. MELVILLE WILLIAMS, MD,* Richmond. Virginia DAVID M. HUME, MD, Richmond, Virginia Hemorrhage into pancreatic pseudocysts with subsequent rupture into s t o m ~ h or bowel is a rare but acknowledged cause of massive gastrointestinal bleeding [1]. It has also occasionally been reported after cystenterostomy or cystgastrostomy [2]. Hemorrhage into a pancreatic pseudocyst causing hemobilia and presenting as massive upper gastrointestinal hemorrhage is extremely rare, there being only one such case reported in the world literature [3]. The following is a report of a second c;~se.
Case Report The patient (I J , MCV 50-808-3a), a sixty-one year old man, was admitted to the MCV emergency room with massive upper gastrointestinal bleeding manifested by hematemesis and melena. He complained of severe abdominal pain. Six months earlier he had had an abdominal aortic aneurysmectomy at this hospital. There was a histor), of chronic alcoholism, but no previous history of intestinal bleeding or symptoms of peptic ulcer, He had not consumed alcohol for more than a year. fJlood pressure on admission was 80/60 mm Hg, and pulse was 110 per minute. The patient was a thin man in acute distress. The skin and mucus membranes were pale, the lungs were clear, and there were no stigmas of liver disease. Tachycardia was present, but the heart sounds and rhythm were normal. His abdomen was not distended, but he had voluntary guarding and tenderness with rebound in the right upper quadrant. The bowel sounds were active and there were no abdominal masses. Aortic pulsations could not be felt, but the peripheral pulses were weak but equal bilaterally. He had gross blood per rectum, and a nasogastrie tube drained large amounts of bright blood. Hemoglobin was 6.2 mg per cent, white blood cell count 12,600 per mm:*, blood urea nitrogen 28 mg per cent and amylase 60 Somogyi units. Chest and abdominal roentgenograms were not remarkable. The patient received four units of whole blood, 500 ml of plasma, and 3,000 ml of lactate solution. His blood pressure rose to 120/70 mm l~g and urine output was good. Gastrointestinal bleeding and abdominal pain conFrom the Department of ~urEery, Medical College of Virginia, Richmond. Virginia, = Present address: The Johns Hopkin~ Hospital, Baltimore. Maryland.
106
tinued and an.caortoenteric fistula was strongly suspected, AI.adominal laparotomy wa:~ begun ninety minutes after arrival in the emergency room. Upon opening the peritoneal cavity no free blood was found, and the liver appeared normal. A small pseudocyst was noted in the he;ld of the pancreas. Blood filled the entire gastrointestinal tract. Careful exploration of the aortic Dacron® graft revealed no enteric fistula. At this point it w;is thought that the pancreatic pseudocyst might be the source of bleeding for it had not been present at surgery six months earlier. "l"ne pseudocyst measured 2.5 cm in diameter and pushet~.the first portion of the duodenum forward. (Figure ~1,) A longitudinal duodenotomy was made, and the duodenal mucosa appeared normal. No bleeding point could be seen although bright blood was found in the duodenum. A gastrotomy was performed to inspect the gastric mucosa and the gastroesophageal junction. Both appeared normal, and there was no bleeding from above, although blood was found in the stomach. Attention was again turned to the duodenum, and after careful inspection a small clot was noted to extrude from the ampulla of Vater, indicating that hemorrhage might have occurred into the pseudocyst and reached the duodenum via the pancreatic ducts. The ampullary clot was removed and bright blood followed. An opening was made into the pseudocyst through the back wall of the duodenum, and the source of the bleeding became evident. Two pulsatile streams came from the superior pancreaticoduodenal artery. Suture ligatures promptly stopped the bleeding. Inspection of the cyst cavity showed an erosion at the posteroinferior wall into the common bile duet. The common bile duct was opened and probed to ensure patency. The gallbladder was removed and found to be full of blood. A T tube cholangio ogram was normal (the cyst cavity was temporarily packed to prevent the dye from pooling there). The back wall of the duodenum was anastomosed to the pseudo. cyst, and the duodenotomy and ga.~trotomy were closed. The patient's postoperative course was benign. Serum bilirubin was 8.0 nag on the first day after surgery and fell to normal limits by the fourth day. The serum amylase and glucose vahies remained normal. A T tube cholangiogram obtained on the eleventh postoperative day did not demonstrate the cyst cavity. (Figure 2.) The T tube was removed, and the patient was discharged on the twelfth day. A five month follow-up study reveals no further bleeding and no recurrence of abdominal pain.
The Amer|can Journal of Surgery
Pancreatic Pseudocyst
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Figure 1
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Schematic drawing of operative findings.
Comments T r a u m a [2l and iatrogenic injuries [4] are the most common causes of hemobilia. Nontraumatic hemobilia only rarely presents as massive hemorrhage in the upper gastrointestinal tract. Aneurysms of tile hepatic artery or its major branches account for almost all cases of massive bleeding into the intestinal tract via the biliarv system [5,6]. There are numerous causes of occult bleeding, ~mlong which acute cholecystitis [7], carcinoma of the liver and extrahepadc biliary system [8], and ascaroidcs liver abscesses [9] are most common. Glass and Newstedt [3] reported a case of massive hcmobitia and complete biliary obstruction due to pancreatic cal,culi, treated successfully by pancreaticodu,~denectomy. Examination of thL~ specimen revealed flint the head of the pancreas was replaced by a large pseudocyst filled with old blood. The case report here i~; similar with respect to the massive intestinal hem<~rrhage and the location of the pseudocyst. We were ,flHe to avoid extirpativc surgery by locating and con:rolling the hemorrhagc and performing cystoduodem~stomy. The patient'~ previous aortic surgery led us h~ make an incorrect preoperative di;,gnosis. The classic triad of symptoms of h c m o b i l i a ~ r i g h t upper quadrant abdominal pain, jaundice, and intestinal hcm,)rrhage [ l O ] ~ w e r e present in this patient, although Ihe jaundice was not discovered at the initial exammation. The life-threatening nature of the hemorrhage hi this c a s e d i d n o t allow us time for detailed pre~perative studies. Selective angiography [11] and radioactive scanning [121 have been said to be heipfttl in making a preoperative diagnosis of hemobilia.
Summary A case of massive bleeding of the gastrointestinal u'act associated with hemobilia caused by hemorrhage into a pancreatic pseudocyst anti erosion inlo the corn-
Vol. 120, July ]970
Figure 2. T tube cholangiogram obtained on eleventh postoperative day.
mort bile duct is Ycporled. It was treated successfully by ligation of the bleeding vessel and cystoduodcnostomy.
References 1. Cogbilt CL: Hemorrhage in pane: , ic pseudocysts. Re, view of literature and report o :wo cases. Ann Surg 167: ] 12. 1968. 2. Hillis W: Surgical m a n a g e m e n t of pseudocysts of the pancreas. Amer J Surg 105: 651. 1963. 3. Glass RL. Newstedt JR: Hemobilta: an unusual com. plication of chronic pancreatitis. MisSouri ~ "d 61: 853, 1964. 4. Robin B, Vuyre P: Les hemobities post-operato ; dan la chirurgie des voies biliares extra.hepat.~, les. J Chit (Pari~J 91 : 273, 1966, 5. MacKay AG, Page HG: Hematemests associated with hemobilia. Report of a case due to an intrahepatic~ artery aneurysrn, with survival. New Eng J Med 260: 468. 1959. 6. Grove WJ: Biliary tract hem~rrhage as ~ cause of hema + temesis. Arch SurE, 83: 83, 196J. 7. Koch H: Ursachen kryptoginer inteslenalblutungen I. Die hamobilie. Bruns Beitr K/In Chir 211; 246. 1965. 8. Patel J, Robin B: Hemobilie et hemocllolecyste atgu par cancer de la vesicule. La Presse Med 76: 577. 1968. 9. Ton That TunE, Nguyen Duong Quane, Neo Dinh Mac: Les hemobiles tropicales, Bul Mere Sac Chit Paris 55: 302. 1965. ]0. Bradl~am G: Hemobilia. J S Carolina Med Ass 62: 137, 1966. ] 1 . Gundersen AE. Green RM: Traumatic hemobtlia: ac. curate preoperative diagnosis by hepatic artery an. giogram. Surgery 62: 862. ] 9 6 7 . 12, Graft R J: Considerations in tile t r e a t m e n t of t r a u m a t i c hemobilia. Amer J Surg ] 0 5 : 662. 19163.
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Case Report The patient (I J , MCV 50-808-3a), a sixty-one year old man, was admitted to the MCV emergency room with massive upper gastrointestinal bleeding manifested by hematemesis and melena. He complained of severe abdominal pain. Six months earlier he had had an abdominal aortic aneurysmectomy at this hospital. There was a histor), of chronic alcoholism, but no previous history of intestinal bleeding or symptoms of peptic ulcer, He had not consumed alcohol for more than a year. fJlood pressure on admission was 80/60 mm Hg, and pulse was 110 per minute. The patient was a thin man in acute distress. The skin and mucus membranes were pale, the lungs were clear, and there were no stigmas of liver disease. Tachycardia was present, but the heart sounds and rhythm were normal. His abdomen was not distended, but he had voluntary guarding and tenderness with rebound in the right upper quadrant. The bowel sounds were active and there were no abdominal masses. Aortic pulsations could not be felt, but the peripheral pulses were weak but equal bilaterally. He had gross blood per rectum, and a nasogastrie tube drained large amounts of bright blood. Hemoglobin was 6.2 mg per cent, white blood cell count 12,600 per mm:*, blood urea nitrogen 28 mg per cent and amylase 60 Somogyi units. Chest and abdominal roentgenograms were not remarkable. The patient received four units of whole blood, 500 ml of plasma, and 3,000 ml of lactate solution. His blood pressure rose to 120/70 mm l~g and urine output was good. Gastrointestinal bleeding and abdominal pain conFrom the Department of ~urEery, Medical College of Virginia, Richmond. Virginia, = Present address: The Johns Hopkin~ Hospital, Baltimore. Maryland.
106
tinued and an.caortoenteric fistula was strongly suspected, AI.adominal laparotomy wa:~ begun ninety minutes after arrival in the emergency room. Upon opening the peritoneal cavity no free blood was found, and the liver appeared normal. A small pseudocyst was noted in the he;ld of the pancreas. Blood filled the entire gastrointestinal tract. Careful exploration of the aortic Dacron® graft revealed no enteric fistula. At this point it w;is thought that the pancreatic pseudocyst might be the source of bleeding for it had not been present at surgery six months earlier. "l"ne pseudocyst measured 2.5 cm in diameter and pushet~.the first portion of the duodenum forward. (Figure ~1,) A longitudinal duodenotomy was made, and the duodenal mucosa appeared normal. No bleeding point could be seen although bright blood was found in the duodenum. A gastrotomy was performed to inspect the gastric mucosa and the gastroesophageal junction. Both appeared normal, and there was no bleeding from above, although blood was found in the stomach. Attention was again turned to the duodenum, and after careful inspection a small clot was noted to extrude from the ampulla of Vater, indicating that hemorrhage might have occurred into the pseudocyst and reached the duodenum via the pancreatic ducts. The ampullary clot was removed and bright blood followed. An opening was made into the pseudocyst through the back wall of the duodenum, and the source of the bleeding became evident. Two pulsatile streams came from the superior pancreaticoduodenal artery. Suture ligatures promptly stopped the bleeding. Inspection of the cyst cavity showed an erosion at the posteroinferior wall into the common bile duet. The common bile duct was opened and probed to ensure patency. The gallbladder was removed and found to be full of blood. A T tube cholangio ogram was normal (the cyst cavity was temporarily packed to prevent the dye from pooling there). The back wall of the duodenum was anastomosed to the pseudo. cyst, and the duodenotomy and ga.~trotomy were closed. The patient's postoperative course was benign. Serum bilirubin was 8.0 nag on the first day after surgery and fell to normal limits by the fourth day. The serum amylase and glucose vahies remained normal. A T tube cholangiogram obtained on the eleventh postoperative day did not demonstrate the cyst cavity. (Figure 2.) The T tube was removed, and the patient was discharged on the twelfth day. A five month follow-up study reveals no further bleeding and no recurrence of abdominal pain.
The Amer|can Journal of Surgery
Pancreatic Pseudocyst
Choledocho t "t ...,.J,... FiSIuI0 " <'.~
\
Figure 1
/
/~ ............
........... " ./
t t l t"
! '
i
Schematic drawing of operative findings.
Comments T r a u m a [2l and iatrogenic injuries [4] are the most common causes of hemobilia. Nontraumatic hemobilia only rarely presents as massive hemorrhage in the upper gastrointestinal tract. Aneurysms of tile hepatic artery or its major branches account for almost all cases of massive bleeding into the intestinal tract via the biliarv system [5,6]. There are numerous causes of occult bleeding, ~mlong which acute cholecystitis [7], carcinoma of the liver and extrahepadc biliary system [8], and ascaroidcs liver abscesses [9] are most common. Glass and Newstedt [3] reported a case of massive hcmobitia and complete biliary obstruction due to pancreatic cal,culi, treated successfully by pancreaticodu,~denectomy. Examination of thL~ specimen revealed flint the head of the pancreas was replaced by a large pseudocyst filled with old blood. The case report here i~; similar with respect to the massive intestinal hem<~rrhage and the location of the pseudocyst. We were ,flHe to avoid extirpativc surgery by locating and con:rolling the hemorrhagc and performing cystoduodem~stomy. The patient'~ previous aortic surgery led us h~ make an incorrect preoperative di;,gnosis. The classic triad of symptoms of h c m o b i l i a ~ r i g h t upper quadrant abdominal pain, jaundice, and intestinal hcm,)rrhage [ l O ] ~ w e r e present in this patient, although Ihe jaundice was not discovered at the initial exammation. The life-threatening nature of the hemorrhage hi this c a s e d i d n o t allow us time for detailed pre~perative studies. Selective angiography [11] and radioactive scanning [121 have been said to be heipfttl in making a preoperative diagnosis of hemobilia.
Summary A case of massive bleeding of the gastrointestinal u'act associated with hemobilia caused by hemorrhage into a pancreatic pseudocyst anti erosion inlo the corn-
Vol. 120, July ]970
Figure 2. T tube cholangiogram obtained on eleventh postoperative day.
mort bile duct is Ycporled. It was treated successfully by ligation of the bleeding vessel and cystoduodcnostomy.
References 1. Cogbilt CL: Hemorrhage in pane: , ic pseudocysts. Re, view of literature and report o :wo cases. Ann Surg 167: ] 12. 1968. 2. Hillis W: Surgical m a n a g e m e n t of pseudocysts of the pancreas. Amer J Surg 105: 651. 1963. 3. Glass RL. Newstedt JR: Hemobilta: an unusual com. plication of chronic pancreatitis. MisSouri ~ "d 61: 853, 1964. 4. Robin B, Vuyre P: Les hemobities post-operato ; dan la chirurgie des voies biliares extra.hepat.~, les. J Chit (Pari~J 91 : 273, 1966, 5. MacKay AG, Page HG: Hematemests associated with hemobilia. Report of a case due to an intrahepatic~ artery aneurysrn, with survival. New Eng J Med 260: 468. 1959. 6. Grove WJ: Biliary tract hem~rrhage as ~ cause of hema + temesis. Arch SurE, 83: 83, 196J. 7. Koch H: Ursachen kryptoginer inteslenalblutungen I. Die hamobilie. Bruns Beitr K/In Chir 211; 246. 1965. 8. Patel J, Robin B: Hemobilie et hemocllolecyste atgu par cancer de la vesicule. La Presse Med 76: 577. 1968. 9. Ton That TunE, Nguyen Duong Quane, Neo Dinh Mac: Les hemobiles tropicales, Bul Mere Sac Chit Paris 55: 302. 1965. ]0. Bradl~am G: Hemobilia. J S Carolina Med Ass 62: 137, 1966. ] 1 . Gundersen AE. Green RM: Traumatic hemobtlia: ac. curate preoperative diagnosis by hepatic artery an. giogram. Surgery 62: 862. ] 9 6 7 . 12, Graft R J: Considerations in tile t r e a t m e n t of t r a u m a t i c hemobilia. Amer J Surg ] 0 5 : 662. 19163.
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