You are working a busy day shift on your 2nd week
of practice out of residency when you are asked by the nurse to eyeball the
patient in Room 2. The
patient is a 45 year old male presenting for near syncope. As you walk into the room, you see a
pale, sweating, middle age male lying on the gurney with his eyes closed.
He is arousable and reports that he thinks he had several
episodes of near syncope this morning. He recently had a Whipple procedure done 2 weeks ago
at Mayo for a mucinous pancreatic cystadenoma. He was discharged 7 days ago. He reports RUQ abdominal pain that has been worsening over
the last 3 days. He has felt
chilled but has not checked a temperature. He has been nauseous but no vomiting. Bowel movements have been regular. The near syncopal episodes
occurred when going from sitting to standing. No associated chest pain or
shortness of breath.
PMH:
Mucinous pancreatic cystadenoma.
Mucinous pancreatic cystadenoma.
PSH:
Pancreaticoduodenectomy performed 2 weeks ago
Pancreaticoduodenectomy performed 2 weeks ago
Social History:
Nonsmoker
No alcohol use
Vital Signs:
T 99.0 HR 105
RR 20 BP 90/50 SpO2 95%
Physical Exam:
Patient pale and ill appearing. Opens eyes and converses but somnolent.
Tachycardic rate, regular rhythm
Healing incision from pancreaticoduodenectomy with no
erythema or drainage.
Moderate RUQ tenderness with guarding.
Differential diagnosis of syncope: cardiac arrhythmia,
hypotension due to hypovolemia, hemorrhage, or sepsis, pulmonary embolism, MI,
AAA, aortic dissection.
Differential diagnosis of abdominal pain: bile leak,
intraabdominal infection, intraabdominal hematoma, small bowel obstruction, pneumonia,
pulmonary embolism.
Workup:
CBC - WBC
14.0 Hemoglobin 8.0 (from 10 at
discharge 1 week ago) platelets 140
CMP – Creatinine 1.3, AST 55, ALT 55, otherwise normal
Lipase – 60
Lactate – 4.0
UA - normal
ECG – sinus tachycardia
Trop – 0.032
CT abdomen/pelvis – fluid collection in the right upper quadrant
concerning for a bile leak with intraabdominal abscess. Also seen is active extravasation of
contrast from a presumed hepatic artery pseudoaneurysm.
Diagnoses:
1. Bile leak after pancreaticoduodenectomy
2. Intraabdominal abscess
3. Hepatic artery pseudoaneurysm
Management:
Patient’s blood pressure began to drift despite an IV fluid
bolus. Given blood pressure in the
80s with active arterial bleeding seen on CT, massive transfusion protocol was
initiated. Blood cultures sent
(these would later return positive for E. coli). Cefepime and vancomycin given.
CT findings discussed with Radiologist and United Hospital
surgeon along with Mayo Clinic surgeon. One of the most
serious life-threatening complications after pancreatectomy is erosive
hemorrhage due to pseudoaneurysm formation and rupture. The pseudoaneurysm was likely caused by the enzymes released
by the bile leak. Ultimately, we arranged consultation by Interventional Radiology emergently for treatment of
bleeding hepatic pseudoaneurysm. Patient’s blood pressure began to stabilize with 2nd unit of pRBC.
Hepatic pseudoaneurysm was successfully stented and patient
was stabilized in the ICU with blood products, antibiotics and fluids prior to
transfer back to Mayo for treatment of his bile leak and E. coli sepsis.
Questions:
1. What are potential complications
after a Whipple procedure?
a. pancreatic leakage
b. biliary leakage
c. intraabdominal abscesses
d. hemorrhage
e. delayed gastric emptying
f. pulmonary embolism
g. pneumonia
h. peri-procedure MI
i. all of the above
2. True or
False:
Hemorrhagic
complications occur in fewer than 10% of patients after Whipple pancreatoduodenectomy
but account for as many as 40% of deaths.
3. In delayed
hemorrhage due to hepatic pseudoaneurysm rupture, what is the preferred
approach to management?
a. Open
surgical control
b. Interventional
radiology approach with endovascular coiling and/or stenting
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