Management of chronic pancreatitis complicated with a bleeding pseudoaneurysm

Chronic pancreatitis is an ongoing disease characterized by persistent inflammation of pancreatic tissues.With disease progression,patients with chronic pancreatitis may develop troublesome complications in addition to exocrine and endocrine pancreatic functional loss.Among them,a pseudoaneurysm,mainly induced by digestive enzyme erosion of vessels in proximity to the pancreas,is a rare and life-threatening complication if bleeding of the pseudoaneurysm occurs.At present,no prospective randomized trials have investigated the therapeutic strategy for this rare but critical situation.The role of arterial embolization,the timing of surgical intervention and even surgical procedures are still controversial.In this review,we suggest that dynamic abdominal computed tomography and angiography should be performed first to localize the bleedersand to evaluate the associated complications such as pseudocyst formation,followed by arterial embolization to stop the bleeding and to achieve early stabilization of the patient’s condition.With advances and improvements in endoscopic devices and techniques,therapeutic endoscopy for pancreatic pseudocysts is technically feasible,safe and effective.Surgical intervention is recommended for a bleeding pseudoaneurysm in patients with chronic pancreatitis who are in an unstable condition,for those in whom arterial embolization of the bleeding pseudoaneurysm fails,and when endoscopic management of the pseudocyst is unsuccessful.If a bleeding pseudoaneurysm is located over the tail of the pancreas,resection is a preferential procedure,whereas if the lesion is situated over the head or body of the pancreas,relatively conservative surgical procedures are recommended.

Application of double-balloon enteroscopy in jejunal diverticular bleeding

AIM:To evaluate the efficacy of endoscopic diagnosis and therapy for jejunal diverticular bleeding.METHODS:From January 2004 to September 2009,154 patients underwent double-balloon enteroscopy (DBE) for obscure gastrointestinal bleeding.Ten consecutive patients with jejunal diverticula (5 males and 5 females) at the age of 68.7 ± 2.1 years (range 1995 years) at Chang Gung Memorial Hospital,Academic Tertiary Referral Center,were enrolled in this study.RESULTS:Of the 10 patients,5 had melena,2 had hematochezia,2 had both melena and hematochezia,1 had anemia and dizziness.DBE revealed ulcers with stigmata of recent hemorrhage in 6 patients treated by injection of epinephrine diluted at 1:10 000,Dieulafoylike lesions in 4 patients treated by deploying hemoclips on the vessels,colonic diverticula in 2 patients,and duodenal diverticula in 3 patients,respectively.Of the 2patients who underwent surgical intervention,1 had a large diverticulum and was referred by the surgeon for DBE,1 received endoscopic therapy but failed due to massive bleeding.One patient had a second DBE for recurrent hemorrhage 7 mo later,which was successfully treated with a repeat endoscopy.The mean follow-up time of patients was 14.7 ± 7.8 mo.CONCLUSION:DBE is a safe and effective treatment modality for jejunal diverticular bleeding.