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World J Gastroenterol. Nov 21, 2014; 20(43): 16132-16137
Published online Nov 21, 2014. doi: 10.3748/wjg.v20.i43.16132
Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm
Kun-Chun Chiang, Tsung-Hsing Chen, Jun-Te Hsu
Kun-Chun Chiang, Department of Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, Taoyuan 333, Taiwan
Tsung-Hsing Chen, Department of Gastroenterology, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 333, Taiwan
Jun-Te Hsu, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan 333, Taiwan
Author contributions: Chiang KC and Hsu JT designed and performed research; Chiang KC and Hsu JT wrote the manuscript; all authors revised and approved the final edition of manuscript.
Correspondence to: Jun-Te Hsu, MD, Department of Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, No. 5, Fu-Hsing Street, Kwei-Shan Shiang, Taoyuan 333, Taiwan. hsujt2813@adm.cgmh.org.tw
Telephone: +886-3-3281200-3219 Fax: +886-3-3285818
Received: February 25, 2014
Revised: June 8, 2014
Accepted: July 24, 2014
Published online: November 21, 2014
Processing time: 268 Days and 9.1 Hours
Abstract

Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues. With disease progression, patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss. Among them, a pseudoaneurysm, mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas, is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs. At present, no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation. The role of arterial embolization, the timing of surgical intervention and even surgical procedures are still controversial. In this review, we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleeders and to evaluate the associated complications such as pseudocyst formation, followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient’s condition. With advances and improvements in endoscopic devices and techniques, therapeutic endoscopy for pancreatic pseudocysts is technically feasible, safe and effective. Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition, for those in whom arterial embolization of the bleeding pseudoaneurysm fails, and when endoscopic management of the pseudocyst is unsuccessful. If a bleeding pseudoaneurysm is located over the tail of the pancreas, resection is a preferential procedure, whereas if the lesion is situated over the head or body of the pancreas, relatively conservative surgical procedures are recommended.

Keywords: Chronic pancreatitis; Pseudocyst; Pseudoaneurysm bleeding; Arterial embolization; Endoscopy; Surgery

Core tip: Chronic pancreatitis complicated with a bleeding pseudoaneurysm is a life-threatening condition. Therapeutic strategies for this rare disease remain controversial. In this review, surgical treatment as a first-line therapy is associated with a high mortality rate in emergency situations. Dynamic abdominal computed tomography and angiography should be performed as the initial management strategy to localize the bleeder, followed by embolization to control the bleeding to achieve early stabilization of the patient’s condition. Surgical intervention should be performed for patients who are unable to undergo or who fail arterial embolization for pseudoaneurysm bleeding, or when endoscopic management of the pseudocyst is unsuccessful.