Intracystic hemorrhage in pancreatic pseudocysts: initial experiences of a treatment protocol

The treatment recommendations for intracystic hemorrhage in pancreatic pseudocysts are various. We have used a defined treatment protocol in these difficult cases. The experiences gained are reported here. Patients with clinical signs of ongoing bleeding and with hemorrhagic pancreatic pseudocyst in ultrasonography and computed tomography (CT) were studied with urgent angiography. Patients showing a pseudoaneurysm were treated with immediate embolization and delayed elective surgery whenever candidates for surgery. During a 5-year period 10 patients were treated according to the protocol. Pseudoaneurysm was demonstrated and subsequent embolization performed in six. Angiography was negative in four patients. During the study period two additional patients were treated conservatively without angiography because the bleeding had stopped 2 weeks prior to the referral to our institution. Two patients were electively operated on and the remaining 10 patients were treated conservatively. Fever and elevated transaminases developed in one of the six patients after the embolotherapy. One of the four embolized patients who were not operated on developed pseudocyst infection 4 months after the embolization. One of the 10 conservatively treated patients died (1/10 = 10%; total mortality, 1/12 = 8%) during the follow-up for infection complications of necrotizing pancreatitis 2 months after the initial bleeding. Another conservatively treated patient with negative angiography had recurrent bleeding during the follow-up but could not be operated on due to severe liver cirrhosis. In the remaining eight patients pseudocysts resolved during the 3-month to 3.5-year follow-up as confirmed by CT. The low rates of mortality and rebleeding support a fairly conservative approach for hemorrhagic pancreatic pseudocysts.