S3476 From Inflammation to Exsanguination: A Case of Severe Pancreatitis Complicated by a Fatal Hemorrhagic Pseudoaneurysm in a 23-Year-Old

Introduction: Severe acute pancreatitis (SAP) refers to AP with persistent organ failure in 1 or more organs for >48 hours and has mortality rates as high as 50%. Scoring systems & imaging alone do not accurately determine which patients develop severe pancreatitis. This case highlights clinical deterioration in a patient with an indolent presentation of alcoholic pancreatitis. Case Description/Methods: A 23-year-old woman with a history of alcohol use presented to the ED with worsening abdominal pain, nausea & retching over 2 weeks. She had prior visits for nausea & diarrhea; initially attributed to IBS. Patient was hemodynamically stable on admission & labs were notable for WBC 41.1 K/µL, Hb 15.1 g/dL Na 117 mEq/L, BUN 23 mg/dL, Ca 12.4 mg/dL, lactate 4.2 mmol/L, lipase 48 U/L. Contrast-enhanced computed tomography of the abdomen & pelvis demonstrated severe pancreatitis with swelling, necrosis, and peripancreatic/free abdominal fluid. She received intravenous hydration and pain control. By day 4, hemoglobin dropped to 5.9 g/dL, with increased fluid collection & hemorrhagic features on computed tomography. She was intubated for respiratory failure and required vasopressor support & blood transfusions in the intensive care unit. Due to persistent abdominal pain, she underwent endoscopic retrograde cholangiopancreatography (ERCP) and cystogastrostomy and prophylactic interventional radiology embolization of the gastroduodenal artery & a dorsal pancreatic artery pseudoaneurysm. She later suffered a PEA arrest with ROSC achieved after 6 rounds of CPR. Due to a Hb of 5.3 & active hemorrhage on CTA massive transfusion protocol was initiated. She continued to decompensate with abdominal compartment syndrome and was not a candidate for extracorporeal membrane oxygenation. She was transitioned to comfort measures. Discussion: Early (<24 hours) prognostication of SAP remains challenging, despite the existence of scoring criteria. Only 20% of patients develop SAP, & sequelae such as pseudoaneurysms occur in 1.3-10% of patients, with 3% developing active bleeding independent of size. Management is guided by the size, anatomy, and hemodynamic status of the patient. Transcatheter arterial embolization is first line therapy however has a rebleeding rate of 10-20%. Other approaches include endovascular techniques such as coil embolization, endoscopic ultrasound (EUS)-guided procedures, percutaneous embolization, and surgical options in severe cases. Combined approaches with EUS-guided drainage are often used in patients with pancreatic fluid collections. Despite embolization, and transient improvement, our patient suffered fatal rupture, highlighting its unpredictable course.