Author(s): Johann Paulo S. Guzman, M.D.; Nilo C. Delos Santos, M.D., F.P.C.S.; Edgar A. Baltazar, M.D., F.P.C.S. and Allan Troy D. Baquir, M.D., F.P.C.S.
The authors report a patient who underwent elective cystogastrostomy for pancreatic pseduocyst and had three episodes of massive gastrointestinal bleeding postoperatively. The patient had bleeding vessels in the pseudocyst cavity of which conservative management of cold saline lavage and octreotide was instituted. Endoscopy was done after the 1st episode of bleeding and showed no active bleeding, no suture site bleeding and with blood clots inside the cavity. After the 2nd episode of gastrointestinal bleeding, there was a note of pinpoint hemorrhages on the pseudocyst wall. The plan was to do angiography but the patient succumbed to hypovolemic shock due to gastrointestinal bleeding hours after endoscopy. On retrospect, early angiography and possible embolization should have been done. Prompt surgical re-exploration is warranted among patients with hemodynamic instability.
Pseudocysts representing encapsulated collections of pancreatic juice commonly develop in both acute and chronic pancreatitis. They usually occur 4-6 months after the episode of pancreatitis. Fifteen percent to 40% of patients with pseudocysts develop complications. these include abscess, fistula formation and hemorrhage. Bleeding is the most rapidly lethal complication of established pseudocysts involving less than 5% of patients although carrying a mortality rate of greater than 40%. Postoperative hemorrhage after pancreatic cystogastrostomy may be technical in origin due to suture site bleeding of the anastomosis of the cystogastrostomy. Thus, continuous running sutures
applied to the cystogastric stomas are advised. Other causes of postoperative bleeding may be explained by the enzyme digestion of pancreatic secretions leading to erosion of arteries and veins in the pseudocyst wall or the peripancreatic vessels. These lead to pseudoaneurysms of splenic vessels and pseudocyst wall bleeding.
Key words: pancreatic pseudocyst, cystogastrostomy, post-operative bleed