Overview
Definition:
Delayed post-pancreatectomy hemorrhage refers to bleeding occurring more than 24 hours after pancreatic surgery, typically from the pancreatic stump, vessels near the pancreas, or the pancreaticojejunostomy
It is a significant and potentially life-threatening complication.
Epidemiology:
The incidence of delayed post-pancreatectomy hemorrhage varies widely in literature, ranging from 1% to 15% depending on the type of pancreatectomy, surgical technique, and definition used
It is a major cause of morbidity and mortality following pancreaticoduodenectomy (Whipple procedure) and distal pancreatectomy.
Clinical Significance:
This complication requires prompt recognition and aggressive management
Delays in diagnosis and treatment can lead to hypovolemic shock, multi-organ failure, and death
Understanding the diagnostic algorithm and management strategies is crucial for surgical residents preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Hemodynamic instability: Tachycardia
Hypotension
Signs of hypovolemic shock
Abdominal pain, which may be severe or colicky
Nausea and vomiting
Fever may be present if associated with infection or inflammatory response
Melena or hematochezia if the bleeding is significant and significant gastrointestinal tract involvement.
Signs:
Tachycardia and hypotension are cardinal signs
Abdominal distension and tenderness
Palpable abdominal mass in some cases
Signs of anemia (pallor, jaundice if severe bleeding occurs into the biliary tree or duodenum)
Decreased urine output
Altered mental status in severe shock.
Diagnostic Criteria:
Diagnosis is primarily clinical, supported by laboratory and imaging findings
Hemodynamic instability in a patient with recent pancreatic surgery is highly suggestive
Evidence of active bleeding on imaging or during endoscopy
Drop in hemoglobin levels
Absence of other obvious causes of bleeding.
Diagnostic Approach
History Taking:
Detailed history of the recent pancreatic surgery, including type of procedure, intraoperative findings, and any immediate postoperative complications
Medications, especially anticoagulants or antiplatelet agents
History of bleeding diathesis
Review of fluid balance and urine output
Any recent changes in abdominal pain or symptoms.
Physical Examination:
Comprehensive abdominal examination assessing for tenderness, guarding, rigidity, distension, and presence of masses
Assessment of hemodynamic status (heart rate, blood pressure, capillary refill)
Examination of skin for pallor and signs of coagulopathy
Rectal examination for melena.
Investigations:
Complete blood count (CBC) to assess hemoglobin and hematocrit levels, and platelet count
Coagulation profile (PT, PTT, INR) to assess for coagulopathy
Liver function tests (LFTs) and renal function tests (RFTs)
Blood typing and crossmatching for transfusion
Imaging: Contrast-enhanced CT (CECT) abdomen is the investigation of choice to localize the bleeding source, assess active extravasation, and identify pseudoaneurysms or vascular injury
Upper gastrointestinal endoscopy may be useful to identify intraluminal bleeding sources or anastomatic leaks, and sometimes to tamponade bleeding
Angiography can be both diagnostic and therapeutic (embolization).
Differential Diagnosis:
Bleeding from the pancreatic stump (e.g., from pancreatic fistula or stump dehiscence)
Bleeding from mesenteric or splenic vessels
Bleeding from anastomatic sites (pancreaticojejunostomy, choledochojejunostomy)
Pseudoaneurysm formation
Hemobilia
Visceral artery erosion
Stress ulcers or gastritis
Complications related to coagulopathy.
Management Algorithm
Initial Management:
Immediate resuscitation: Secure airway, administer oxygen
Establish intravenous access with large-bore cannulas
Aggressive fluid resuscitation with crystalloids and colloids
Transfuse packed red blood cells (PRBCs) to maintain adequate hemoglobin levels (target >7-8 g/dL)
Correct coagulopathy with fresh frozen plasma (FFP), cryoprecipitate, and platelet transfusion as indicated
Monitor vital signs closely and institute continuous cardiac monitoring.
Conservative Management:
If bleeding is slow and patient is hemodynamically stable, initial conservative management with close monitoring may be attempted
This includes bowel rest, nasogastric tube decompression, and intravenous proton pump inhibitors (PPIs) to prevent stress ulceration
Hemostatic agents like tranexamic acid may be considered in select cases, but evidence is limited and should be used cautiously.
Endoscopic Management:
Upper GI endoscopy can be diagnostic and therapeutic
If active bleeding from an accessible site (e.g., anastomosis) is identified, endoscopic techniques like bipolar electrocoagulation, hemoclips, or argon plasma coagulation (APC) may be used to achieve hemostasis
This is often reserved for superficial bleeding or as an adjunct to other therapies.
Interventional Radiology:
Angiography is a cornerstone of management for moderate to severe bleeding
It can precisely localize the bleeding site and allow for therapeutic embolization of the bleeding vessel
This is highly effective for arterial bleeding, particularly from pseudoaneurysms or injured vessels
Embolization reduces the need for repeat surgery and is associated with lower morbidity.
Surgical Management:
Surgical re-exploration is indicated for patients who fail to stabilize with conservative measures, endoscopic therapy, or interventional radiology
Indications include ongoing massive hemorrhage, hemodynamic instability despite resuscitation, or failure of endovascular hemostasis
Surgical options include ligation of bleeding vessels, oversewing of anastomoses, resection of damaged bowel segments, or completion pancreatectomy
Careful exploration to identify and control the bleeding source is paramount.
Complications
Early Complications:
Hypovolemic shock
Multi-organ failure (acute kidney injury, acute respiratory distress syndrome)
Sepsis from infected hematoma or abscess
Re-bleeding after initial hemostasis
Anastomotic leak.
Late Complications:
Chronic anemia
Pseudoaneurysm recurrence
Adhesions and bowel obstruction
Pancreatic fistula
Incisional hernia.
Prevention Strategies:
Meticulous surgical technique, including careful handling of vascular structures and secure pancreatic stump closure
Prophylactic use of PPIs in the postoperative period
Judicious use of anticoagulants and antiplatelet agents
Early recognition and prompt management of any signs of bleeding
Close hemodynamic monitoring
Careful preoperative assessment of coagulopathy.
Prognosis
Factors Affecting Prognosis:
The severity of hemorrhage, promptness of diagnosis and treatment, hemodynamic stability, and presence of other comorbidities significantly impact prognosis
Patients who require emergent re-exploration have a poorer prognosis
The presence of infection or multi-organ failure also worsens outcomes.
Outcomes:
With prompt and effective management, many patients can achieve good outcomes
However, delayed post-pancreatectomy hemorrhage remains a significant cause of mortality, with reported rates ranging from 10% to 30% in some series
Successful angiographic embolization generally leads to better outcomes than surgical re-exploration.
Follow Up:
Patients who have experienced delayed post-pancreatectomy hemorrhage require close follow-up
This includes monitoring for signs of recurrent bleeding, anemia, and complications related to their underlying condition and previous surgery
Long-term follow-up may involve nutritional assessment and monitoring for pancreatic exocrine or endocrine insufficiency.
Key Points
Exam Focus:
Recognize delayed hemorrhage as bleeding >24 hours post-pancreatectomy
CECT abdomen is the gold standard for diagnosis
Angiography with embolization is often the first-line interventional therapy
Re-exploration is reserved for refractory bleeding or hemodynamic instability
Risk factors include pancreatic stump integrity and vascular proximity.
Clinical Pearls:
Always suspect delayed hemorrhage in any patient with unexplained hemodynamic instability after pancreatic surgery
Have blood products readily available
Early involvement of interventional radiology is crucial
The pancreaticojejunostomy site is a common source of bleeding.
Common Mistakes:
Delaying resuscitation and aggressive fluid management
Underestimating the severity of bleeding
Inadequate investigation to localize the source
Failing to involve interventional radiology early
Performing unnecessary explorations without a clear bleeding source identified.