THE AMERICAN JOURNAL OF GASTROENTEROLOGY
12, 1999
© 1999 by Am. Coll. of Gastroenterology
Published by Elsevier Science Inc.
Massive Intraperitoneal
Hemorrhage From a Pancreatic Pseudocyst
S. B. Kelly, M.D., F.R.C.S., T. Gauhar, M.Sc., F.R.C.S., and R. Pollard, F.R.C.S.
Department of Surgery, North Tyneside General Hospital, North Shields, Tyne & Wear, England
ABSTRACT
Massive bleeding from a pancreatic pseudocyst is a rare
condition that poses a diagnostic and therapeutic challenge.
A 36-yr-old woman presented with acute pancreatitis due to
gallstones. Twenty-two days later, she developed severe
abdominal pain and hypotension. CT scan revealed hemor-
rhage into a pancreatic pseudocyst and a large amount of
free blood in the peritoneal cavity. At laparotomy, 8 L of
blood was evacuated from the peritoneal cavity and 14 units
of blood were transfused. The gastroduodenal artery was
found to be the cause of the bleeding and was undersewn. A
pancreatic necrosectomy was performed and the cavity was
packed. The packs were removed the following day. Post-
operatively, pancreatic collections were aspirated under ul-
trasound guidance on three occasions. She was discharged
50 days after admission and had an open cholecystectomy 1
month later. She remains well 1 yr after surgery. (Am J
Gastroenterol 1999;94:3638 –3641. © 1999 by Am. Coll. of
Gastroenterology)
INTRODUCTION
Hemorrhage from a pancreatic pseudocyst is a rare and often
fatal complication of pancreatitis with a reported mortality
of approximately 50% (1). The reported prevalence of acute
hemorrhage associated with pancreatic pseudocysts is
8 –31% (1–3). Pseudoaneurysms occur in 10% of patients
with chronic pancreatitis (4). The incidence of hemorrhage
into a pseudocyst in patients with chronic pancreatitis is
6 –10% (4, 5). Although hemorrhage is not a frequent com-
plication of pancreatic pseudocysts, it accounts for about
30% of the mortality (2, 6). It carries a high mortality if
treated conservatively, and early diagnosis followed by ap-
propriate surgical or radiological intervention is recom-
mended. In acute pancreatitis, elastase and other pancreatic
enzymes can erode into adjacent vessels, resulting in pseu-
doaneurysm formation in 7–12% of cases (7, 8). This can
cause intracystic hemorrhage or bleeding into the peritoneal
cavity, pancreatic duct (hemosuccus pancreaticus), stomach,
duodenum, colon (9), or retroperitoneum.
The arteries most commonly involved in pseudoaneurysm
formation are the splenic artery (45–50%), the gastroduo-
denal artery (15%), and the pancreaticoduodenal arteries
(15%) (10, 11). Aneurysms of the hepatic, celiac, superior
Vol. 94, No.
ISSN 0002-9270/99/$20.00
PII S0002-9270(99)00515-8
mesenteric, and gastric arteries have been reported, although
they rarely bleed. In 78% of cases, the site of bleeding is
from the splenic, gastroduodenal, and pancreaticoduodenal
arteries (11). Bleeding occurs from the splenic artery in
approximately half of the cases. The incidence of bleeding
from the gastroduodenal (10, 12–14) and pancreaticoduo-
denal arteries (15) is slightly less. Other sites of bleeding
include the superior mesenteric artery, renal artery, visceral
veins, e.g., the splenic vein, spleen and aorta (2, 4, 16 –18).
Erosion or aneurysmal degeneration of vessels adjacent to
the pancreas has been reported in 10% of patients with
chronic pancreatitis (4, 18). Bleeding can occur into the
gastrointestinal tract, the duodenum being the most common
site. Other sites include the stomach, jejunum, and colon. It
can present as massive bleeding into the gastrointestinal
tract with shock or as chronic gastrointestinal blood loss.
Alternatively, the patient may present with hematemesis,
melena, lower gastrointestinal bleeding, anemia, or abdom-
inal pain. Pseudocysts that rupture into the colon have a
worse prognosis because of fulminating sepsis and massive
bleeding (9).
Treatment is either by surgery or embolization. The in-
volved segment of pancreas, including the pseudocyst, may
be resected; or the bleeding vessel may be ligated and the
pseudocyst drained. Surgery is often difficult, as the tissues
are inflamed and there may be profuse bleeding. Conserva-
tive management alone has a 90% mortality and surgical
treatment a 29% mortality (11). We report a 36-yr-old
woman with massive intraperitoneal and extraperitoneal
hemorrhage from a pancreatic pseudocyst and review the
natural history, diagnosis, and management of this condi-
tion.
CASE REPORT
A 36-yr-old woman was admitted with severe epigastric
pain, nausea, and vomiting. On examination, she had
marked epigastric tenderness. Abnormal blood results in-
cluded serum amylase 2,680 IU/L, white cell count (WCC)
18.3 ⫻ 109/L, ALT 200 IU/L, ␥GT 390 IU/L, and ALP 136
IU/L. Abdominal ultrasound revealed a thick walled gall-
bladder containing multiple calculi. The common bile duct
and pancreas appeared normal. She was treated with intra-
venous fluids, nil orally and i.m. pethidine, 50 mg i.v. every
AJG – December, 1999
Figure 1. Spiral CT scan demonstrating a large pseudocyst of the
pancreas.
4 – 6 h p.r.n. Two days later, the pain and abdominal ten-
derness became worse. She developed a pyrexia of 38°C and
was commenced on metronidazole 500 mg i.v. t.i.d., genta-
mycin 120 mg i.v. t.i.d., and ampicillin 1 g i.v. q.i.d. Ten
days after admission, she stabilized and was discharged.
She was readmitted 3 days later with epigastric pain and
tenderness. Abnormal blood results included serum amylase
827 IU/L and WCC 14.7 ⫻ 109/L. She was treated with
intravenous fluids, nil orally and nasogastric suction. An
abdominal ultrasound scan revealed an enlarged hypoechoic
pancreas with fluid collections surrounding the head, body,
and tail of the pancreas, suggestive of pancreatitis. Spiral CT
scan revealed a large pseudocyst of the pancreas (Fig. 1).
Nine days after admission, she developed severe abdominal
pain, guarding, rebound, and abdominal distension. Her
pulse was 123 beats/min and blood pressure 100/50 mm Hg.
Her hemoglobin had fallen from 14.0 g/dl to 9.5 g/dl. She
was transferred to the intensive care unit. Repeat CT scan
revealed hemorrhage into the pseudocyst with a large
amount of blood in the peritoneal cavity (Fig. 2).
At laparotomy, 8 L of blood was evacuated from the
peritoneal cavity. The gastroduodenal artery was bleeding
and was undersewn with 2/0 Vicryl. The body and tail of the
pancreas were necrotic and a pancreatic necrosectomy was
performed. The cavity was packed and three large drains
were placed in the right and left subhepatic region and in the
pelvis. She was transfused with 14 units of blood and 2 units
of fresh frozen plasma. Total parenteral nutrition and intra-
venous antibiotics (i.e., cefuroxime 750 mg i.v. t.i.d. and
metronidazole 500 mg i.v. t.i.d.) were commenced. The
packs were removed the following day. A feeding jejunos-
tomy was inserted and enteral feeding was commenced.
Two days later, 650 ml of dark fluid and pus were dis-
charged through the left subhepatic drain, which on culture
revealed enterococci. She was treated with amoxycillin 1 g
i.v. q.i.d., ciprofloxacin 400 mg i.v. b.d., and metronidazole
500 mg i.v. t.i.d. Seven days later, she developed right sided
Intraperitoneal Hemorrhage From Pancreatic Pseudocyst 3639
Figure 2. Spiral CT scan demonstrating hemorrhage in the pseudo-
cyst and a large amount of blood in the peritoneal cavity.
abdominal pain, tenderness, and guarding. Abdominal ul-
trasound revealed a pseudocyst in the head of the pancreas
and a large collection of fluid in the right subhepatic space.
The subhepatic collection was aspirated under ultrasound
control and 400 ml of brownish fluid was obtained. Twenty-
one days after the initial operation, she commenced oral
feeding. Pancreatic pseudocysts were aspirated under ultra-
sound guidance on days 18 and 33. She was discharged 50
days after admission and was readmitted for an open cho-
lecystectomy 28 days later. She remains well 1 yr later.
DISCUSSION
The operative management of bleeding pancreatic pseudo-
cysts is controversial. The two surgical options are resection
of the affected segment of the pancreas including the
pseudocyst, debridement of the pancreas, and ligation of
bleeding vessels or arterial ligation combined with external
or internal drainage of the pseudocyst.
Pancreatic resection is believed to decrease the incidence
of postoperative infection and rebleeding (14). However, it
has been claimed that proximal and transcystic ligation of
the bleeding vessel with internal or external drainage of the
cyst is superior to pancreatic resection (2, 11). Pitkaranta et
al. (1) found that four of five patients initially treated by
drainage and arterial ligation needed reoperation for bleed-
ing, whereas none of eight patients treated primarily by
pancreatic resection continued to bleed or needed reopera-
tion. Stabile et al. (11) reviewed 123 cases and found no
important differences in outcome between pancreatic resec-
tion with excision of the pseudocyst, debridement and liga-
tion of the bleeding vessels, and direct bipolar ligation of the
involved vessel with repair of the pseudocyst wall at the site
of vessel erosion. The mortality rate for resection (21%) was
similar to that of suture ligation (26%) (11). Resectional
mortality rates vary according to the bleeding site. Splenic
vessel hemorrhage is usually associated with pseudocysts of
3640 Kelly et al.
the tail of the pancreas and is usually treated by distal
pancreatectomy and splenectomy (8). Distal pancreatec-
tomy is associated with a 16% mortality, whereas resection
of the pancreatic head has a 43% mortality, suggesting that
suture ligation or embolization may be preferable in the
latter situation (11).
Transcystic suture ligation of bleeding vessels is appro-
priate for accessible arteries, but has a high rebleeding rate
(15). When oversewing alone is performed, there is a re-
bleeding rate of 30%, with a subsequent mortality of 75% in
those who require reoperation (16). Proximal and distal
ligation of the bleeding vessel may be more successful than
transcystic suture ligation; however, control of bleeding by
these two methods may not be technically possible in deeply
located cysts or in the presence of excessive inflammation
around the pancreas (15). Bresler et al. (17) reported five
cases of hemorrhage from pancreatic pseudocysts in which
intracystic suture ligation was performed with no postoper-
ative deaths and no further bleeding.
Visceral angiography should be performed preoperatively
in every patient with ultrasound or CT findings suggesting a
bleeding pseudoaneurysm. If angiography has not been per-
formed, it may be very difficult to identify the site of
bleeding at laparotomy. Angiography identifies the site of
bleeding, outlines the vascular anatomy, and provides a
topographical guide for surgical exploration. This shortens
the operative procedure and minimizes the risk of vascular
damage resulting from an intraoperative search for a bleed-
ing site. Stabile et al. (11) failed to find a bleeding source in
four of four patients at laparotomy without prior angiogra-
phy. All four patients required a repeat laparotomy. Three of
four patients with preoperative angiography had definitive
control of their bleeding at the initial operation. It has been
suggested that all patients with pancreatic pseudocysts
should undergo routine angiography to identify the inci-
dence of false aneurysms and, thereby, to anticipate hem-
orrhage (3).
Embolization is a valuable alternative to surgery in high
risk patients with massive hemorrhage from a pancreatic
pseudocyst. It may be used as a temporary procedure to stop
or slow bleeding, thus permitting elective rather than emer-
gency operation. Alternatively, embolization may be used as
the definitive form of treatment. The method of treatment
depends on the facilities and expertise available and the
condition of the patient. Facilities were available for embo-
lization in this case; however, it was believed that there was
a risk of subsequent infection because of the large amount of
blood in the peritoneal cavity and, therefore, an operative
approach was believed to be necessary. Embolization has
been followed by infection in one in four patients (18).
Embolization was first described in 1972 by Rosch et al.
(19), who used autologous blood clot. Many agents have
been embolized since, including gelfoam (absorbable gela-
tin sponge), Ivalon, fat, muscle, cellulose, tissue adhesives,
wool, cotton, steel coils, and plastic and metallic spheres
(20). Intra-arterial infusion of vasoconstrictive agents such
AJG – Vol. 94, No. 12, 1999
as vasopressin have been used as temporizing measures (15,
21, 22). If severe inflammation and fibrosis are present, the
patient’s response to vasoconstrictive agents is often poor
(21).
Reprint requests and correspondence: S. B. Kelly, M.D., De-
partment of Surgery, North Tyneside General Hospital, Rake Lane,
North Shields, Tyne & Wear, NE29 8NH, England.
Received July 22, 1998; accepted Nov. 4, 1998.
REFERENCES
1. Pitkaranta P, Haapiainen R, Kivisaari L, et al. Diagnostic
evaluation and aggressive surgical approach in bleeding
pseudoaneurysms associated with pancreatic pseudocysts.
Scand J Gastroenterol 1991;26:58 – 64.
2. Kiviluoto T, Kivisaari L, Kivilaakso E, et al. Pseudocysts in
chronic pancreatitis: Surgical results in 102 consecutive pa-
tients. Arch Surg 1989;124:240 –3.
3. Frey CF. Pancreatic pseudocyst—Operative strategy. Ann
Surg 1978;188:652– 62.
4. White AF, Baum S, Buranasiri S. Aneurysms secondary to
pancreatitis. AJR 1976;127:393– 6.
5. Woods MS, Traverso LW, Kozarek RA, et al. Successful
treatment of bleeding pseudoaneurysms of chronic pancreati-
tis. Pancreas 1995;10:22–30.
6. Maule WF, Reber HA. Diagnosis and management of pancre-
atic pseudocysts, pancreatic ascites and pancreatic fistulas. In:
Ulw G, ed. The exocrine pancreas: Biology, pathobiology and
disease. New York: Raven Press, 1986:601–10.
7. Sondenaa K, Soreide JA. Pancreatic pseudocyst causing spon-
taneous gastric haemorrhage. Eur J Surg 1992;158:257– 60.
8. Steckman ML, Dooley MC, Jaques PF, et al. Major gastroin-
testinal haemorrhage from peripancreatic blood vessels in pan-
creatitis. Treatment by embolotherapy. Dig Dis Sci 1984;29:
486 –97.
9. Santos JCM Jr, Feres O, Rocha JJR, et al. Massive lower
gastrointestinal hemorrhage caused by pseudocyst of the pan-
creas ruptured into the colon. Dis Colon Rectum 1992;35:
75–7.
10. Sams JS, Nostrant TT, Agha FP, et al. Gastroduodenal artery
aneurysm presenting as chronic gastrointestinal blood loss.
Am J Gastroenterol 1986;81:29 –32.
11. Stabile BE, Wilson SE, Debas HT. Reduced mortality from
bleeding pseudocysts and pseudoaneurysms caused by pan-
creatitis. Arch Surg 1983;118:45–51.
12. Bender JS, Levison MA. Massive hemorrhage associated with
pancreatic pseudocyst: Successful treatment by pancreati-
coduodenectomy. Am Surg 1991;57:653–5.
13. Fielding GA, Egerton WS. Two cases of pseudo-aneurysm of
the gastroduodenal artery. Aust New Zealand J Surg 1988;58:
671–3.
14. Stanley JC, Frey CF, Miller TA, et al. Major arterial hemor-
rhage. A complication of pancreatic pseudocysts and chronic
pancreatitis. Arch Surg 1976;111:435– 40.
15. Canakkalelioglu L, Gurkan A. The management of bleeding
from a pancreatic pseudocyst: A case report. Hepato-gastro-
enterol 1996;43:278 – 81.
16. Wu TK, Zaman SN, Gullick HD, et al. Spontaneous hemor-
rhage due to pseudocysts of the pancreas. Am J Surg 1977;
134:408 –10.
17. Bresler L, Boissel P, Grosdidier J. Major hemorrhage from
pseudocysts and pseudoaneurysms caused by chronic
pancreatitis: Surgical therapy. World J Surg 1991;15:649 –53.
AJG – December, 1999
18. Sand JA, Seppanen SK, Nordback IH. Intracystic haemor-
rhage in pancreatic pseudocysts: Initial experiences of a treat-
ment protocol. Pancreas 1997;14:187–91.
19. Rosch J, Dotter CT, Brown MJ. Selective arterial emboliza-
tion. A new method for control of acute gastrointestinal bleed-
ing. Radiology 1972;102:303– 6.
20. Huizinga WKJ, Kalideen JM, Bryer JV, et al. Control of
major haemorrhage associated with pancreatic pseudocysts
Intraperitoneal Hemorrhage From Pancreatic Pseudocyst 3641
by transcatheter arterial embolization. Br J Surg 1984;71:
133– 6.
21. Kuroda C, Kawamoto S, Hori S, et al. Pancreatic pseudocyst
hemorrhage controlled by transcatheter embolization. Cardio-
vasc Intervent Radiol 1983;6:167–9.
22. Walter JF, Chuang VP, Brookstein JJ, et al. Angiography of
massive haemorrhage secondary to pancreatic disease. Radi-
ology 1977;124:337.