S3599 Bleeding Out Inside: When Pancreatitis Turns Deadly

Introduction: This case involves rare, rapidly progressing necrotizing pancreatitis with complications including splenic vein thrombosis, intraperitoneal hemorrhage, and abdominal compartment syndrome. While each of these issues can happen on their own in acute pancreatitis, having them all occur one after another, and so quickly, led to severe instability and multi-organ failure, making this a particularly dangerous and unusual case. Case Description/Methods: A 60-year-old woman with a history of hypertension, hyperlipidemia, type 2 diabetes, and cholecystectomy (2010) presented to the emergency room with 3 days of sharp, localized epigastric pain, bilious vomiting, and watery diarrhea. She denies fever, chest pain, flank pain, urinary symptoms, alcohol use, or recent surgeries. Initially hemodynamically stable, she had epigastric tenderness and labs showed elevated lipase, transaminitis, and leukocytosis. Computed tomography showed peripancreatic inflammation and possible splenic vein thrombosis. Doppler ultrasound confirmed splenic vein occlusion. She was managed with fluids, pain control, and started on a heparin infusion. She was admitted for pancreatitis of unclear etiology, complicated by splenic vein thrombosis. Her diet was slowly advanced with occasional epigastric pain, until a rapid response occurred 1 week later. She developed encephalopathy, hypotension, tachycardia, and a hemoglobin dropped to 5.6. Heparin was reversed, massive transfusion protocol initiated, and she was intubated and transferred to the intensive care unit. Once stable, Computed tomography showed no active bleed, but abdominal distension and firmness prompted emergent surgery. She underwent decompressive laparotomy with evacuation of 2 L of blood and splenic artery embolization. Nine days post-op, she was extubated, tolerated diet advancement, and resumed normal bowel function. After a month-long hospital stay, she was discharged home in stable condition. Discussion: This case highlights the critical importance of early recognition of complications in severe pancreatitis. Careful, ongoing assessment, including timely imaging in response to changes in pain or clinical status, is key to identifying abdominal necrosis. Acting quickly can help prevent serious complications like hemorrhage and abdominal compartment syndrome. Overall, this case underscores the need for close clinical attention and a well-coordinated, multidisciplinary approach when managing complex pancreatitis cases.