A 55-year-old male with pancreatic adenocarcinoma is now 3 weeks status post an uncomplicated pancreaticoduodenectomy (Whipple procedure). He was discharged home 7 days following his procedure and has been feeling well until yesterday morning when he developed gradually worsening abdominal discomfort and recent onset of nausea. Although in the emergency department he is noted to be:
His laboratory evaluation is notable for:
His Hgb at discharge was 9 g/dL. While in the emergency department, he vomits a small amount of bloody emesis. He is admitted to the ICU, has large bore peripheral intravenous access established, is transfused 2 U PRBC, and his Hgb increases to 8.0 g/dL. A CT scan is ordered for further evaluation. That night, before the CT scan is done, he starts vomiting large amounts of bright red blood and becomes hypotensive.
What is the most likely cause for his presentation?
Correct Answer: A
The patient above is presenting 3 weeks after a Whipple procedure with a bleeding visceral artery pseudoaneurysm, likely from the gastroduodenal artery stump. Although the other four answer choices are in the differential diagnosis for a patient presenting with an acute upper gastrointestinal bleed, given the patient’s history, classic presentation, and recent Whipple procedure, a ruptured visceral artery pseudoaneurysm is the most likely etiology. A delay in diagnosis in this situation is lifethreatening. Management is time sensitive and requires placement of adequate venous access, transfusion as indicated, and emergent angioembolization. Visceral artery pseudoaneurysms typically present with a “sentinel bleed” in which a small amount of upper GI bleeding occurs before rupture of the pseudoaneurysm and massive hemorrhage ensues. If this entity is not recognized and time is wasted performing an upper GI endoscopy as would be performed for most patients with upper gastrointestinal bleeding, the window of time for intervention may be lost and the patient may exsanguinate. When a pseudoaneurysm is suspected, even in a stable patient, diagnosis and treatment must proceed urgently. A CT angiogram can diagnose a pseudoaneurysm before frank rupture.
Choose the correct statement regarding acute pancreatitis from the list below:
Correct Answer: C
A diagnosis of gallstone pancreatitis is made with the appropriate clinical history, evidence of cholelithiasis on imaging, and elevated serum lipase in the setting of acute onset abdominal pain. ERCP is not indicated in the routine diagnosis and evaluation of gallstone pancreatitis unless there is evidence of ongoing biliary obstruction or concomitant cholangitis. Although alcohol is one of the two leading causes of acute pancreatitis in the United States, it accounts for approximately 30% of cases. A diagnosis of post-ERCP pancreatitis is made in patients with signs and symptoms of acute pancreatitis in addition to elevations in serum amylase and lipase. In patients with acute pancreatitis secondary to hypertriglyceridemia, initial treatment is with apheresis and intravenous insulin therapy. Long-term therapy with lifestyle modification and initiation of pharmacologic therapy, typically gemfibrozil, is recommended for prevention of future episodes. It is important to note that hypertriglyceridemia is often a consequence of acute pancreatitis and is much less commonly the inciting cause. Routine evaluation for all patients presenting with a first episode of pancreatitis includes serum triglyceride levels, serum calcium, liver biochemical tests, and an abdominal ultrasound. In cases of acute pancreatitis of unclear etiology or recurrent episodes, initial evaluation with endoscopic ultrasound is recommended given the ability to detect small pancreatic cancers, periampullary masses, strictures, and microlithisias with fewer associated risks when compared to ERCP.
A 50-year-old male with a past medical history of hypertension and recent hospitalization for acute pancreatitis presents to the emergency department with complaints of increasing abdominal discomfort, anorexia, and intermittent emesis. He reports that he had been feeling well since his discharge from the hospital 3 weeks ago but has noticed the gradual onset of symptoms that have now increased in severity. All of the following are true regarding the diagnosis and management of a suspected pancreatic pseudocyst EXCEPT:
Correct Answer: E
Acute peripancreatic fluid collections that form in the setting of acute pancreatitis or pancreatic trauma usually resolve, but can eventually form a well-defined wall, maturing into a pancreatic pseudocyst. Pancreatic pseudocysts lack a true epithelial layer and typically contain fluid without the presence of solid material or pancreatic necrosis. This process takes approximately 4 to 6 weeks after the initial episode of pancreatitis and is best identified on cross-sectional imaging using CT and MRI. Initial management of pancreatic pseudocysts includes monitoring and supportive care in the absence of symptoms. The majority of patients experience decrease in pseudocyst size and does not require further intervention. Nutritional assessment is recommended in all patients, with supplemental enteral feeding if necessary. Indications for invasive intervention on pancreatic pseudocysts include symptomatic patients not responsive to medical therapy, rapidly enlarging pseudocysts, and infected pseudocysts not responsive to antibiotics alone. Drainage into the gastrointestinal tract is the first choice of treatment for pseudocyst, as any ongoing leakage of pancreatic fluid is controlled without the need for external drains. Internal drainage is usually performed endoscopically but can be performed surgically. Occasionally pseudocysts can be drained percutaneously, but this runs the risk of resulting in a pancreatic fistula requiring prolonged drain placement.
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