DU ulcers increase in chronic pancreatitis

1
Misra Hemorrhagic complications of chronic
pancreatitis
Ulcer bleeds in chronic pancreatitis
3 main lesions causing hemorrhagic complications
in CP ulcers, pseudoaneurysm, portal hypertension

• DU ulcers increase in chronic pancreatitis
• Chebli et al, Brazil 14(n107) incidence
  mechanism- H.Pylori infn. Others- increased basal
  peak acid output increased duodenitis
• Hamel et al BJS 1991, 4/168 DU bleed
• Diagnosis - UGIE
• Stomal ulcer after LPJ Isa et al melena
• Our experience one death following bleed from
  LPJ anastomotic erosion.

2
Misra Hemorrhagic complications of chronic
pancreatitis
Portal hypertension in chronic pancreatitis

• Extrahepatic PHT in absence of cirrhosis
• Previous reports mainly of left
  sided/segmental/sinistral PHT
• SVT 10 earlier reports upto 50 Varices?17-51
  cases SVT
• Portal/SMV in 5 with GPH (Adam et al Surgery
  Apr 2004)
• Izbicki et al ( Ann Surg 2002) 36/154 EPH 67
  non occlusive SMV 25 SV 25 more than one 50
• Mechanism pressure (pseudocyst, pseudotumour,
  inflammation, fibrosis) SMV pressure i after
  head resection (Ruzicka et al, HGE,1999)
• Diagnosis US doppler, CECT, UGIE
• Significance bleed resectional surgery?h blood,
  complications
• Sakarofas et al Am J Sur 34/484 PHT 12/34
  varices 6/12 had bleed 0/23 with splenectomy
  bled 1/11 bled to death in asymptomatic PHT
  without splenectomy. (? Risk of splenectomy in
  asymptomatic sinistral PHT vs risk of variceal
  bleed)

3
Misra Hemorrhagic complications of chronic
pancreatitis
Arterial and aneurysmal bleeding

• Erosion of peri pancreatic vessel pseudo
  aneurysmal bleed massive hemorrhage
• Bleed GI, peritoneal or retroperitoneal
• 2-10 severe hg in chronic pancreatitis
• Conservative Rx nearly 100 mortality
• Aggressive surgery 25-47 mortality
• Diagnosis US, doppler, CECT, UGIE, angiography
• Angiographic embolization is first line Rx
• Blood loss 6.8 vs. 17.5 units in surgery
• Earlier reports more recurrence with
  embolization recently Bergert et al, 2004,
  (36/541 22 ulcer/varices 70 pseudo aneurysmal)
  more recurrence 25 vs. 11 after surgery

Splenic artery aneurysm (An)
Angiography showing bleeding
4
Misra Hemorrhagic complications of chronic
pancreatitis
Hemosuccus pancreaticus

• Hemosuccus pancreaticus through PD
• Rarelt100 cases described till 2000
• 50 enzymatic digestion of splenic vessel, 30
  stones, 10 other
• UGIE blood emanating from papilla ductography
  clots
• Angiographic embolization/ pancreatic resection

5
Misra Hemorrhagic complications of chronic
pancreatitis
GB Pant experience

• GBPH gets more cases of aneurysmal bleed than
  variceal ulcer bleed
• Part of data reported by SS Negi et al 8/13
  cases with chronic pancreatitis splenic
  commonest site CT diagnostic in 84
• Last 10 months 3 cases 2 successfully treated
  by trans cystic ligation and one by embolization
• Stable patient- embolize unstable, angiography
  NA surgery. Higher mortality, blood loss

6
Misra Hemorrhagic complications of chronic
pancreatitis
Summary and conclusions

• G I bleeding is a common complication of chronic
  pancreatitis bleeding may be due to ulcer,
  varices or aneurysmal bleed
• Diagnosis is by UGIE, Doppler, CECT angiography
• Aneurysmal bleed represents catastrophic event
  with 25-47 reported mortality
• Angiographic embolization with/without surgery is
  the treatment of choice
• Immediate surgery in unstable patients