Spontaneous retroperitoneal haemorrhage from pancreatoduodenal artery (PDA) rupture and associated complications

Patient 1

A woman in her 50s with no relevant medical history presented with acute generalised abdominal pain radiating to both flanks. On examination, she was hypotensive with a blood pressure of 86/46 mm Hg and had significant generalised abdominal tenderness and guarding. No medical or surgical history including prior trauma, pancreatitis or autoimmune diseases were reported.

Patient 2

A woman in her 60s with no relevant medical or surgical history developed sudden onset of severe epigastric pain and tenderness that radiated to her back. On examination, she was haemodynamically stable but had significant epigastric tenderness. No signs of peritonitis were observed, and no abdominal masses were located. The patient reported no history of trauma, pancreatitis, autoimmune disorders or coagulopathies and no use of any traditional or anti-inflammatory medications.

Patient 3

A man in his 50s without significant medical or surgical history presented with right upper abdominal pain and fever. The physical examination revealed tenderness along the epigastrium and right hypochondrium with guarding. The patient denied a history of trauma, pancreatitis and autoimmune disorders. Ultrasound findings led to a diagnosis of acute cholecystitis, and laparoscopic cholecystectomy was scheduled for the following day.

During laparoscopy, significant haemoperitoneum was noted on entry into the peritoneum. The preoperative imaging was reviewed, confirming no preoperative evidence of free fluid in the abdomen. A second hepato-pancreato-biliary surgeon was consulted, and a diagnosis of gallstone-related haemorrhagic pancreatitis was proposed as the hemoperitoneum and bruising were observed around the head of pancreas.

As the patient was haemodynamically stable, the laparoscopic cholecystectomy was completed and a postoperative CT angiogram was scheduled. The cholecystectomy was successful with no complications.

Patient 1

Laboratory tests revealed a low haemoglobin (10.6 g/dL), while renal function tests, liver function tests and the serum amylase level were unremarkable. An ultrasound revealed fluid in the retroperitoneum around the right kidney. Urgent CT imaging was obtained, revealing active bleeding in the region of the pancreatic uncinate process with associated fluid in the retroperitoneum (figure 1A).

Figure 1

(A) CT coronal section: large retroperitoneal haematoma around the uncinate process of the pancreas. (B) Angiography: aneurysm (black arrow) along inferior pancreatoduodenal artery branch (PDA). MCA, middle colic artery; SMA, superior mesenteric artery. (C) Repeat CT coronal section: retroperitoneal haematoma seen around the second and third part of the duodenum.

Patient 2

Emergent CT imaging revealed a large haematoma over the retroperitoneum that extended into the lesser omental sac with no evidence of active bleeding (figure 2A). On day 2 of hospitalisation, the patient reported worsening abdominal pain and had tachycardia (134 beats per minute) and a significant drop in haemoglobin compared with baseline (15.0 to 8.1 g/dL).

Figure 2

(A) CT coronal section: large retroperitoneal haematoma around the duodenum and pancreas. (B) Angiography: aneurysm (arrow) along the inferior pancreatoduodenal artery (PDA).

Patient 3

Postoperative CT imaging revealed a retroperitoneal haematoma of 17 cm×3.7 cm×9.4 cm with extension into the small bowel mesentery and an inferior PDA aneurysm (figure 3A,B). There was no active contrast extravasation suggesting active bleeding.

Figure 3

(A) CT coronal section: a massive retroperitoneal haematoma and inferior PDA aneurysm (arrow). (B) CT axial section: a coeliac axis stenosis near the origin with a hypodense linear band-like structure. (arrow). PDA, pancreatoduodenal artery.

The CT images were reconstructed into three-dimensional images (figure 4A). The patient was diagnosed with coeliac stenosis, likely due to medial arcuate ligament syndrome (MALS) based on a hypodense linear band-like structure demonstrated on the CT scan (figure 3B).

Figure 4

(A): Three-dimensional CT recon (Saggital view) showing coeliac axis stenosis (yellow arrow); inferior PDA aneurysm postangioembolisation (white arrow). (B) Angiography: aneurysm (white arrow) along inferior PDA. MCA, middle colic artery; PDA, pancreatoduodenal artery; SMA, superior mesenteric artery.

Patient 1

Transcatheter angiography was performed, localising the source of the bleeding as an inferior PDA aneurysm (figure 1B). Embolisation was performed successfully.

Patient 2

An emergency transcatheter angiography was performed. An actively bleeding inferior PDA aneurysm was observed and promptly embolised (figure 2B).

Patient 3

Transcatheter angiography was performed, confirming coeliac artery stenosis (figure 4B). Angioembolisation of the inferior PDA aneurysm was successful.

Patient 1

Following angioembolisation, the patient developed worsening early satiety with multiple episodes of bilious vomiting. CT images were obtained on day 4 of the patient’s illness, revealing a persistent retroperitoneal haematoma in the region of the uncinate process of the pancreas, encasing the second and third part of the duodenum, resulting in GOO. The patient was managed conservatively with the initiation of total parenteral nutrition and enteral nutrition via a nasojejunal tube.

After 6 days, the patient’s symptoms improved, and a gastrograffin contrast study confirmed the resolution of GOO. She was discharged and remains symptom-free. A CT scan of the abdomen obtained 6 months postoperatively suggested complete resolution of the retroperitoneal haematoma, and no suspicious masses were observed in the uncinate process. No pathology was observed along the coeliac axis or superior mesenteric vessels. An autoimmune vasculitis screen was negative. The cause of the inferior PDA aneurysm remains unclear.

Patient 2

The patient was unable to tolerate oral feeding following the angioembolisation. A repeat CT scan was performed 3 days after angioembolisation, revealing a large retroperitoneal haematoma involving the second part of the duodenum, resulting in GOO with concomitant biliary obstruction and extrahepatic biliary tree dilatation (figure 5A). Initially, the patient was managed conservatively with parenteral nutrition via a nasojejunal tube. However, the patient’s symptoms did not improve after 4 weeks of nutritional support.

Figure 5

(A) Postangioembolisation CT: retroperitoneal haematoma encasing the second part of the duodenum and distal common bile duct (CBD) with upstream dilatation of the biliary ducts (arrow). (B) Liver function tests trend throughout admission (arrow indicating the time of surgical intervention). ALP, alkaline phosphatase; ALT, alanine transaminase; AST, aspartate aminotransferase; GGT, gamma-glutamyl transferase.

A 4-week postoperative CT image revealed persistence of the large retroperitoneal haematoma surrounding the duodenum with worsening biliary dilatation and liver function (figure 5B). The size of the retroperitoneal haematoma was stable. The patient underwent diagnostic laparoscopy and laparoscopic evacuation of the haematoma. Postoperatively, her oral intake and liver function gradually improved.

Two months later, a CT scan suggested complete resolution of the retroperitoneal haematoma. This patient had a similar presentation to patient 1, as both patients had no significant medical history or pathology to suggest a cause of the PDA aneurysm.

Patient 3

The patient developed recurrent episodes of vomiting on postoperative day 5. On postoperative day 6, CT images revealed persistent retroperitoneal haematoma that was unchanged in size, extrinsically compressing the duodenum, resulting in an upper intestinal obstruction. A gastrograffin contrast study confirmed delayed transit of the contrast at the second part of the duodenum.

The patient was managed conservatively with parenteral nutrition and a small amount of enteral nutrition. His gastrointestinal function was restored after 5 weeks, and he remains symptom-free at 6 months postoperative.

No autoimmune conditions were found. The patient declined treatment for MALS to prevent recurrences of inferior PDA aneurysms, though he attends regular follow-up visits for surveillance of any inferior PDA aneurysm recurrences.