Three weeks after severe acute necrotising pancreatitis, a 50-year-old man develops massive haematemesis. Contrast-enhanced CT shows a 15 mm contrast-filled outpouching arising from the splenic artery adjacent to a peripancreatic fluid collection. The most appropriate immediate management is:

• A Emergency laparotomy with splenectomy
• B Percutaneous drainage of the fluid collection
• C Transcatheter angiographic embolisation ✓
• D Endoscopic variceal band ligation

Explanation

Arterial erosion by pancreatic enzymes produces pseudoaneurysms of the splenic, gastroduodenal or pancreaticoduodenal arteries, and rupture into the pancreatic duct causes hemosuccus pancreaticus. Transcatheter angiographic embolisation is the first-line treatment because it is rapid, allows control of bleeding in unstable patients, and avoids surgery in a friable, inflamed retroperitoneum. Endoscopic therapy addresses varices, not arterial bleeding, and laparotomy is reserved when embolisation fails.

Reference: Grainger and Allison's Diagnostic Radiology, 7th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.