Q) 50 year old male undergoes Whipple pancreaticoduodenectomy. On post op day 4 patient presented with fever, tachycardia and pain. Ultrasound showed collection in lesser sac which was drained percutaneously. On pod 10 there is frank blood of 100ml in drain, What is the next line of management?
a. CT angiography
b. Emergency laparotomy
c. Flush the drain with noradrenaline
d. Observe
Ans a
This is extraluminal bleed on 10th POD following most likely a pancreatic fistula.
Clinical condition is mentioned for day 4 which is because of pancreatic leak.
A pancreatic fistula can cause vascular pseudo aneurysm so answer is A CT angiography
Early extraluminal PPH requires reexploration.
Intraluminal bleeding may manifest as extraluminal if there is associated anastomotic breakdown and this may be amenable to angiographic intervention when involving the pancreaticojejunostomy.
Patients present with septic complications and/or a sentinel bleed. Radiographic embolization has become a more successful modality, with up to 80% success,13 but is limited by the initially intermittent nature of the bleeding
Exploration - if patient is not stable
PPH can result from vascular erosion or pseudoaneurysm formation, commonly in the gastroduodenal artery or other surrounding vessels.
In this scenario, a CT angiography is indicated as the next step to:
Identify the source of bleeding.
Determine if there is a vascular injury or pseudoaneurysm, which may allow for endovascular intervention, such as embolization, rather than an emergency surgery.
Emergency laparotomy (Option b) is generally reserved for cases where endovascular management is unavailable or ineffective.
Observation (Option d) and Flushing the drain with noradrenaline (Option c) are inappropriate, as they do not address the source of bleeding and may worsen the patient's condition.
