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Confusing delayed hematemesis, unusual arterial hemorrhage after pancreaticoduodenectomy: a case report.

ABSTRACT: Pancreaticoduodenectomy (PD) is one of the most complex surgeries and is associated with a high rate of complications, including bleeding, delayed gastric emptying (DGE), and pancreatic fistula. Although the frequency of postoperative hemorrhage is not high, this complication results in severe adverse outcomes. A 67-year-old man was diagnosed with pancreatic cancer and underwent PD. On the tenth day after surgery, he developed hypovolemic shock with hematemesis. Urgent digital subtraction angiography identified the bleeding artery as the jejunal mesenteric artery at the afferent loop, and the bleeding artery was embolized with two coils. After digital subtraction angiography, the patient had an uneventful recovery with no further complications. Therefore, we concluded that it is possible that bleeding may occur in the afferent loop when hemorrhage occurs after PD.

SUBMITTER: Wang L

PROVIDER: S-EPMC9251987 | biostudies-literature | 2022 Jun

REPOSITORIES: biostudies-literature

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Confusing delayed hematemesis, unusual arterial hemorrhage after pancreaticoduodenectomy: a case report.

Wang Luna L Guo Gaoli G Yu Jianhua J Lin Ling L Yang Jianhui J Lu Baochun B

The Journal of international medical research 20220601 6

Pancreaticoduodenectomy (PD) is one of the most complex surgeries and is associated with a high rate of complications, including bleeding, delayed gastric emptying (DGE), and pancreatic fistula. Although the frequency of postoperative hemorrhage is not high, this complication results in severe adverse outcomes. A 67-year-old man was diagnosed with pancreatic cancer and underwent PD. On the tenth day after surgery, he developed hypovolemic shock with hematemesis. Urgent digital subtraction angiog ...[more]

PMID: 35770952

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Project description:BackgroundAlthough arterial hemorrhage after pancreaticoduodenectomy (PD) is not frequent, it is fatal. Arterial hemorrhage is caused by pseudoaneurysm rupture, and the gastroduodenal artery stump and hepatic artery (HA) are frequent culprit vessels. Diagnostic procedures and imaging modalities are associated with certain difficulties. Simultaneous accomplishment of complete hemostasis and HA flow preservation is difficult after PD. Although complete hemostasis may be obtained by endovascular treatment (EVT) or surgery, liver infarction caused by hepatic ischemia and/or liver abscesses caused by biliary ischemia may occur. We herein discuss therapeutic options for fatal arterial hemorrhage after PD.AimTo present our data here along with a discussion of therapeutic strategies for fatal arterial hemorrhage after PD.MethodsWe retrospectively investigated 16 patients who developed arterial hemorrhage after PD. The patients' clinical characteristics, diagnostic procedures, actual treatments [transcatheter arterial embolization (TAE), stent-graft placement, or surgery], clinical courses, and outcomes were evaluated.ResultsThe frequency of arterial hemorrhage after PD was 5.5%. Pancreatic leakage was observed in 12 patients. The onset of hemorrhage occurred at a median of 18 d after PD. Sentinel bleeding was observed in five patients. The initial EVT procedures were stent-graft placement in seven patients, TAE in six patients, and combined therapy in two patients. The rate of technical success of the initial EVT was 75.0%, and additional EVTs were performed in four patients. Surgical approaches including arterioportal shunting were performed in eight patients. Liver infarction was observed in two patients after TAE. Two patients showed a poor outcome even after successful EVT. These four patients with poor clinical courses and outcomes had a poor clinical condition before EVT. Fourteen patients were successfully treated.ConclusionTranscatheter placement of a covered stent may be useful for simultaneous accomplishment of complete hemostasis and HA flow preservation.

Project description:Introductionand Importance: Melanomas are capable of metastasizing to both regional and distant sites and are notably known to metastasize to the skin, lungs, brain, liver, bone, and gastrointestinal tract. Metastatic melanoma is infrequently diagnosed in vivo, and usually found only on post-mortem evaluation at autopsy.Case presentationHere we present the case of a 64-year-old male who originally presented with melena, fatigue, exertional dyspnea and one episode of near-syncope. He was found to have a hemoglobin of 5.4 gm/dL on initial presentation with largely unremarkable abdominal examination. CTAP demonstrated an area of circumferential small bowel wall thickening, concerning for malignancy. The patient underwent an EGD that was noted for mild gastric fundal erosions, which failed to explain his presenting symptoms. VCE was later performed following discharge to visualize the small bowel, which revealed two bleeding lesions within the small bowel. This was complicated by the device becoming lodged on the more proximal mass, and he was admitted again for push-enteroscopy and device retrieval. At the time of this admission, he continued to be symptomatic and was profoundly anemic with a hemoglobin of 4.7 gm/dL.Clinical discussionEGD with push enteroscopy was performed, revealing two small masses in the mid-distal duodenum and jejunum, which were tattooed and biopsied. He underwent robotic-assisted laparoscopic small bowel resection of the affected portions of the small bowel, without complications. Surgical samples were consistent with melanoma, and further dermatologic examination revealed a suspicious lesion located on the patient's posterior right shoulder was biopsied and also consistent with melanoma, confirming the suspicion for metastatic process from primary cutaneous lesion.ConclusionsWe present this case as a rare diagnostic opportunity to observe metastatic melanoma of the small bowel, including a review of pertinent symptomatology and epidemiological data from previous literature. Our case serves as a reminder to consider metastatic melanoma as a rather uncommon cause of severe blood loss anemia, while also providing an overview of endoscopic modalities available for visualizing the small bowel in the management of suspected small bowel malignancy.

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Confusing delayed hematemesis, unusual arterial hemorrhage after pancreaticoduodenectomy: a case report.

Publications

Confusing delayed hematemesis, unusual arterial hemorrhage after pancreaticoduodenectomy: a case report.

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