Background

Pancreatic pseudoaneurysm is an abnormal dilations of blood vessels near the pancreas. It forms a sac-like structure. They are not true aneurysms. It is a rupture which contains blood inside the nearby tissue. It is associated with the pancreatitis and inflammation of the pancreas. 

It is caused by the degeneration of the pancreatic artery or peripancreatic into a pseudocyst. A true aneurysm and a pseudocyst are differ by the wall composition. A pseudocyst wall consists of connective and fibrous tissue. 

Epidemiology

Pancreatic pseudoaneurysms is a rare vascular abnormality. It is associated with conditions like pancreatitis. They can occur in people with various age and gender. 

Traumatic events like abdominal injuries can also lead to this condition. Pancreatitis is the primary cause.  

Anatomy

Pathophysiology

Pancreatic pseudoaneurysm is a type of a vascular cystic structure. It develops from the autodigestion and deterioration of the splenic artery wall. It exposed to the pancreatic juices or leakage from the pancreatic anastomosis. The splenic artery is the most common site for visceral pseudoaneurysms because it is near by to the pancreas. 

Pancreatic pseudoaneurysm can grow and rupture into pseudocysts. It fills up the biliopancreatic ducts. This will lead to bleeding through the ampulla of Vater into the GI tract or the retroperitoneum or peritoneal cavity. This is known as pancreatitis or Hemosuccus pancreaticus. The splenic artery is affected in pancreatitis. 

Etiology

Connective Tissue Diseases 

Connective tissue diseases are associated with the pancreatic pseudoaneurysm. These conditions affect the integrity of blood vessel walls. 

Infectious Pancreatitis 

Infection which affects the pancreas can lead to inflammation and vascular complications. This is also lead to the pancreatic pseudoaneurysm. 

Pancreatic Surgery 

pancreaticoduodenectomy (Whipple procedure) can also lead to pancreatic pseudoaneurysm mainly if there is leakage from the pancreatic anastomosis. 

Trauma

Trauma to the abdomen can lead to vascular injury near the pancreas. This will lead to pancreatic pseudoaneurysm.  

Genetics

Prognostic Factors

Patients with pancreatic pseudoaneurysms face high mortality rates. The rates are between 20 to 30 % after the surgery. The location of lesion affects the mortality rate.  

The highest mortality rates occur in the pancreatic head. The lowest mortality rate occurs in the pancreatic tail. 

Clinical History

Pancreatic pseudoaneurysms is associated with pancreatitis, history of a recurrent episodes and an abdominal trauma or injury. Till the pseudoaneurysm ruptures., most of the patients remain asymptomatic. 

Symptoms of this disease include like abdominal pain, nausea, vomiting, and signs of shock, active bleeding. If the pancreatic pseudoaneurysm ruptures into the gastrointestinal tract, gastrointestinal bleeding may occur. It leads to the conditions like melena (black, tarry stools) or hematemesis (blood in vomiting). 

Physical Examination

Abdominal Tenderness  

Abdominal palpation may indicate the tenderness in the upper abdomen. The tenderness location can provide the involvement of the pancreas. 

Hypotension and Tachycardia: 

In active bleeding, symptoms of hemodynamic instability may involve the low blood pressure or hypertension and fast heart beat or tachycardia. 

Hematoma or Bruising 

External symptoms of hematoma or bruising in the abdomen area appear after trauma or surgery.  

Jaundice:  

Pancreatic pseudoaneurysms may cause rupture in the biliary system. This can lead to jaundice. The symptoms include yellow skin and sclera. 

Signs of Gastrointestinal Bleeding:  

Pancreatic pseudoaneurysms may cause the rupture into gastrointestinal tract. The symptoms include gastrointestinal bleeding, melena (black, tarry stools) or hematemesis.  

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

• Aortic aneurysm  
• Cystic adenocarcinoma   
• Hydatid cyst  
• Pancreatic absces 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

The current treatment for hemorrhage is either endovascular catheter embolization or a covered stent. If embolization fails or rebleeding occurs, surgery is the primary choice. Direct ligation of the vessel or excision of the pancreas is associated with the pancreatic pseudoaneurysm.

Supportive Care 

In cases where the pancreatic pseudoaneurysm is stable and bleeding is not occurring, simple treatment and supportive care is enough. This involves pain management, regular monitoring, and treating conditions like pancreatitis.  

Embolization 

Endovascular procedures like embolization are commonly used. During embolization, a catheter is inserted to the location of the pancreatic pseudoaneurysm, and materials like coils and embolic agents are used to stop the blood flow. It promotes clotting and heal the pancreatic pseudoaneurysm.  

Surgical Resection or Repair 

Surgery may be necessary in cases of large and symptomatic pancreatic pseudoaneurysms. It is also necessary in cases of rupture. The damaged section of the artery may be removed and the vessel can be repaired or recreated.  

Pancreatic Surgery Considerations 

Pancreatitis is the main cause of the pancreatic pseudoaneurysm, then management of the pancreatitis is important. This involves medical therapy, lifestyle changes or pancreatic surgery in severe cases.   

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

role-of-proton-pump-inhibitors-ppis

Omeprazole 

Pancreatic pseudoaneurysms is associated with pancreatic inflammation or conditions like pancreatitis. The PPIs will reduce the gastric acid production. This will reduce the gastrointestinal bleeding. 

Esomeprazole 

PPIs may be suggested for endovascular transarterial catheter embolization or surgery. They help to create an ideal healing environment by reducing the gastric acid, stress on the gastrointestinal tissues. It promotes the post-surgery recovery.   

role-of-antibiotics

Metronidazole 

After surgical procedures such as direct ligation of the bleeding vessel or resection of the pancreas antibiotics are suggested. They will reduce the risk of post surgery infections. These antibiotics treat a wide range of bacteria includes those are seen in the gastrointestinal tract. 

Ciprofloxacin 

Ciprofloxacin is a fluoroquinolone antibiotic. It is effective against a range of bacteria. Metronidazole is effective against anaerobic bacteria. The combination of these antibiotics treats a wide range of pathogens. The time and duration of the administration of the antibiotics is important to prevent the infection.  

for-management-of-pain

Diclofenac 

Diclofenac is used for pain relief which is associated with inflammation. It works by inhibiting cyclooxygenase enzymes. It reduces the production of inflammatory mediators. It also helps to reduce the pain after surgery.   

intervention-with-embolization

Embolization is a minimally invasive procedure. It is used as an initial or primary treatment for pancreatic pseudoaneurysms. It is a simple and safer alternative to open surgery. It controls bleeding and reduces recurrence. Embolization can also be part of a comprehensive treatment. 

surgical-intervention

Surgery is necessary to treat the pancreatic pseudoaneurysms when other treatment fail. This may include direct ligation or pancreas resection. The treatment aim to control the bleeding and mitigate risks. They provide an effective alternative when endovascular techniques fail. 

Medication

Future Trends

Media Gallary

References

Pancreatic Pseudoaneurysm – StatPearls – NCBI Bookshelf (nih.gov)