P0058 - An Unexpected Fatal Case of Hemorrhagic Pancreatitis

Roshni Jain, MD¹, Sarang Thaker, MD, MS¹, Halit Akcicek, MD², Kashif Osmani, BS¹, Cemal Yazici, MD^1
1University of Illinois at Chicago College of Medicine, Chicago, IL; ²Mustafa Kemal University, Faculty of Medicine, Antakya, Hatay, Turkey

Introduction: Hemorrhagic pancreatitis is described as an often fatal but late complication of acute pancreatitis (AP), most commonly in those with parenchymal necrosis. We present a case who presented with mild AP without features suggestive of pseudoaneurysm or necrosis on initial imaging and rapidly decompensated to severe AP and death due to hemorrhagic pancreatitis.

Case Description/Methods: A 42-year-old male with alcohol use disorder, hypertension, and seizures presented with acute onset sharp intermittent epigastric pain, nausea, and non-bloody emesis. His last stated drink was the morning prior to presentation. On exam he was afebrile, tachycardic, hypertensive, and appeared to be in distress. Labs were notable for leukocytosis and elevated lactate, lipase, and ethanol levels (Table 1). Contrast-enhanced abdominal/pelvic computed tomography demonstrated AP without necrosis or fluid collections (Figure 1a). Initial severity of AP was mild per the revised Atlanta classification. The patient was started on lactated ringer’s for resuscitation, and his pain was treated with improvement in vital signs and lactate level. One day after admission the patient developed an unstable tachyarrhythmia refractory to cardioversion and was transferred to the intensive care unit for further management. Shortly thereafter he became pulseless, and cardiopulmonary resuscitation (CPR) was initiated. Labs revealed an acute drop in hemoglobin and elevated lactate (Table 1). CPR was ultimately discontinued due to medical futility. Autopsy revealed hemorrhagic pancreatitis as the cause of death with 1.6L sanguineous fluid and blood clot noted in the abdomen (Figure 1b-1c). Microscopic evaluation of the pancreas demonstrated acute and chronic pancreatic hemorrhage and fat necrosis (Figure 1d-1e). Extensive hemorrhage was noted around the pancreas and hindered identification of a culprit vessel.

Discussion: Hemorrhage is a rare and late complication of AP with fatal bleeding occurring in a minority of cases. Causes of hemorrhagic AP include pseudoaneurysm rupture, bleeding pseudocysts, small vessel or venous bleeding, or iatrogenic trauma. However, patients who present with mild AP without signs of pancreatic necrosis or pseudoaneurysm on initial imaging may also rapidly decompensate to severe AP complicated by fatal hemorrhagic pancreatitis. Close monitoring of symptoms and clinical signs can help with early diagnosis and treatment of potential AP-related complications.


Figure: Figure 1a: Abdominal/pelvic CT with intravenous contrast. Coronal view with arrow highlighting area of peri-pancreatic fat stranding without necrosis or acute fluid collection.
Figure 1b: Gross pathology. The hemorrhagic pancreas (P) in relation to the enlarged liver (L), gallbladder (G), and spleen (S). The pancreatic ducts and ampulla could not be identified due to extensive hemorrhage.
Figure 1c: Gross pathology. The hemorrhagic head of the pancreas with pre-pancreatic hemorrhage.
Figure 1d: Microscopic evaluation of the pancreas. Inflammatory cells, such as plasma cells, leukocytes, and polymorphonuclear leukocytes (PMNs), consistent with acute and chronic inflammation.
Figure 1e: Microscopic evaluation of the pancreas. Hemorrhage extending to area of pre-pancreatic fat (arrow).

	Labs on Admission	Labs during CPR
Hemoglobin (g/dL)	17.2	8.5
White Blood Cells (thous/uL)	13.5	8.5
Platelets (thous/uL)	323	175
Lactate (mmol/L)	6.7	6.4
Lipase (u/L)	813	Not Obtained
Total Bilirubin (mg/dL)	0.7	1.8
Direct Bilirubin (mg/dL)	0.2	0.8
Alkaline Phosphatase (u/L)	99	48
Aspartate Aminotrasferase (u/L)	46	26
Alanine Aminotransferase (u/L)	40	18
Creatinine (mg/dL)	0.79	0.97
Ethanol (mg/dL)	269	Not Obtained

Table: Table 1. Laboratory Data.


Disclosures:
Roshni Jain indicated no relevant financial relationships.
Sarang Thaker indicated no relevant financial relationships.
Halit Akcicek indicated no relevant financial relationships.
Kashif Osmani indicated no relevant financial relationships.
Cemal Yazici indicated no relevant financial relationships.


Roshni Jain, MD¹, Sarang Thaker, MD, MS¹, Halit Akcicek, MD², Kashif Osmani, BS¹, Cemal Yazici, MD¹. P0058 - An Unexpected Fatal Case of Hemorrhagic Pancreatitis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.