Post Whipple’s Bleeding

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

Ref SKF  page 1241

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