Overview
Definition:
Post-pancreatectomy hemorrhage (PPH) is defined as bleeding originating from the pancreatic bed or surrounding vascular structures after pancreatectomy
It is a significant and potentially life-threatening complication, categorized by the International Study Group on Pancreatic Surgery (ISGPS) based on timing and severity.
Epidemiology:
The incidence of PPH ranges from 1.6% to 12%, with most cases occurring within the early postoperative period
Mortality rates can be as high as 40% for severe bleeding, making it a major determinant of outcomes following pancreatic resections.
Clinical Significance:
PPH necessitates prompt recognition and aggressive management to prevent hemodynamic compromise, organ hypoperfusion, and subsequent multi-organ failure
Understanding its classification and management 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, often severe and localized to the surgical site
Hematemesis or melena
Nausea and vomiting
Reduced urine output
Increasing abdominal girth or distension.
Signs:
Generalized signs of shock: pallor, diaphoresis, cool extremities
Abdominal tenderness, guarding, and rigidity
Presence of abdominal drain output, which may be serosanguinous, bloody, or frank blood
Increasing abdominal distension or pulsatile mass suggestive of pseudoaneurysm rupture.
Diagnostic Criteria:
ISGPS classification of PPH: Grade A: No clinical consequence
Grade B: Requiring transfusion of 1-4 units of packed red blood cells or resolution without intervention
Grade C: Requiring surgical or endoscopic intervention or transfusion of >4 units of packed red blood cells within 24 hours
Hemoglobin drop of >2 g/dL within 24 hours, or requiring active resuscitation.
Diagnostic Approach
History Taking:
Detailed review of the operative procedure (e.g., Whipple, distal pancreatectomy, total pancreatectomy)
Assessment of patient's baseline coagulation status
History of anticoagulation or antiplatelet use
Presence of any recent trauma or injury
Prior abdominal surgery or interventions.
Physical Examination:
Thorough abdominal examination for tenderness, rigidity, distension, and palpable masses
Assessment of vital signs for tachycardia, hypotension, and signs of hypoperfusion
Evaluation of surgical drain output for color, volume, and character
Digital rectal examination to assess for melena.
Investigations:
Laboratory tests: Complete blood count (CBC) to monitor hemoglobin and hematocrit
Coagulation profile (PT/INR, aPTT) to assess for coagulopathy
Liver function tests (LFTs) and renal function tests (RFTs) to assess organ perfusion and function
Blood type and crossmatch for transfusion
Imaging: Contrast-enhanced computed tomography (CECT) scan of the abdomen is the investigation of choice to identify the source of bleeding, including arterial pseudoaneurysms, venous bleeding, or anastomotic leak
Angiography can be both diagnostic and therapeutic for active arterial bleeding.
Differential Diagnosis:
Anastomotic leak with secondary erosion into vessels
Splanchnic artery pseudoaneurysm formation
Pancreatic fistula with erosion into adjacent vessels
Injury to major vascular structures during surgery
Postoperative stress gastritis or peptic ulcer disease with bleeding
Retroperitoneal hematoma formation.
Management
Initial Management:
Hemodynamic resuscitation: Intravenous fluid administration (crystalloids, colloids)
Blood product transfusion (packed red blood cells, fresh frozen plasma, platelets)
Placement of a nasogastric tube for decompression
Strict bowel rest and NPO status
Continuous monitoring of vital signs and urine output
Pain control with appropriate analgesics.
Medical Management:
Proton pump inhibitors (PPIs) to reduce gastric acidity and prevent stress ulceration
Octreotide may be considered in select cases of pancreatic fistula-related bleeding, though its efficacy for direct vascular bleeding is limited
Management of coagulopathies with specific factor replacement if indicated.
Surgical Management:
Indications for reoperation include massive hemorrhage (Grade C PPH), failure of endovascular intervention, hemodynamic instability despite resuscitation, or suspicion of ongoing significant bleeding
Surgical strategies involve direct ligation of bleeding vessels, resection of pseudoaneurysms with vascular reconstruction, or re-exploration and packing of the pancreatic bed
Transarterial embolization (TAE) is the preferred first-line interventional radiology treatment for most arterial bleeding sources, including pseudoaneurysms.
Supportive Care:
Close monitoring in an intensive care unit (ICU)
Nutritional support, often via jejunostomy tube if oral intake is not possible
Antibiotic prophylaxis or treatment if infection is suspected
Management of electrolyte imbalances
Psychological support for the patient and family.
Complications
Early Complications:
Hemorrhagic shock
Acute kidney injury
Respiratory distress
Sepsis
Multi-organ dysfunction syndrome
Rebleeding post-intervention.
Late Complications:
Chronic pancreatitis
Pancreatic insufficiency (exocrine and endocrine)
Biliary strictures
Formation of large pseudoaneurysms that may rupture later
Incisional hernias.
Prevention Strategies:
Meticulous surgical technique with careful identification and control of vascular structures
Prophylactic use of octreotide in high-risk patients (controversial)
Careful management of drains and monitoring of drain output
Early recognition and management of pancreatic fistulas
Optimization of patient's nutritional status preoperatively
Careful anticoagulation management postoperatively.
Prognosis
Factors Affecting Prognosis:
Severity of hemorrhage (ISGPS grade)
Hemodynamic stability
Time to diagnosis and intervention
Presence of comorbidities
Source and control of bleeding
Patient's overall health status and nutritional reserve.
Outcomes:
Mortality is directly related to the severity of PPH and delay in management
Grade C PPH carries a significantly higher mortality rate than Grade B
Successful interventional radiology or surgical control of bleeding improves prognosis considerably.
Follow Up:
Long-term follow-up is essential to monitor for late complications such as pseudoaneurysm formation, pancreatic insufficiency, and nutritional deficiencies
Regular clinical assessment and imaging may be required depending on the extent of resection and complications encountered
Patients may require lifelong pancreatic enzyme and/or insulin replacement.
Key Points
Exam Focus:
ISGPS classification of PPH (Grades A, B, C) is critical for DNB/NEET SS
CECT abdomen is the cornerstone of diagnosis
Transarterial embolization (TAE) is often the first-line intervention for arterial bleeding
Re-exploration is indicated for massive, uncontrolled bleeding or failed endovascular management.
Clinical Pearls:
A sudden drop in drain output, especially if previously bloody, can herald catastrophic arterial bleeding
Always consider pseudoaneurysm formation in patients with persistent or recurrent bleeding post-pancreatectomy
Multidisciplinary approach involving surgeons, interventional radiologists, and intensivists is vital.
Common Mistakes:
Delaying investigation or intervention in a hemodynamically unstable patient
Inadequate resuscitation before definitive management
Misinterpreting CECT findings, leading to missed vascular injuries or pseudoaneurysms
Aggressive oral feeding in the presence of active bleeding or suspected leak.