Mock Online Case March 2016: Abdominal Madness

You are working a busy day shift on your 2^nd 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. 

PSH:
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

4. Syncope likely multifactorial due to both hemorrhagic and septic shock

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 2^nd 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