S3495 Pancreatic Hematoma Secondary to Trauma Leading to Biliary Obstruction Requiring Intervention

Introduction: Pancreatic injuries following blunt abdominal trauma carry high morbidity and mortality. Postoperative complications, including biliary obstruction and gastric outlet obstruction, can be challenging to manage. We present a case of a rare peripancreatic hematoma secondary to trauma causing biliary obstruction, further complicated by peptic ulcers and left gastric artery pseudoaneurysm. Case Description/Methods: A 73-year-old man presented as a level 1 trauma after a high-speed motor vehicle collision. Emergent exploratory laparotomy revealed severe intra-abdominal trauma requiring distal pancreatectomy, partial colectomy, and total splenectomy. Following initial stabilization, the patient’s total bilirubin steadily rose from 2.3 on admission to 12.0 mg/dL (direct 6.7 mg/dL) over several days, despite stable transaminases (AST 50s, ALT 40s), ALP (50s), and INR (1.2). Hemoglobin remained stable (0–11 g/dL). HIDA scan was negative. Magnetic resonance cholangiopancreatography (MRCP) revealed a distended gallbladder and proximal common bile duct (CBD) with extrinsic compression of the mid-CBD due to a peripancreatic fluid collection. Computed tomography pancreas protocol confirmed a 2.7 × 3.1 cm pancreatic hematoma at the head/neck junction. GI was consulted and endoscopic retrograde cholangiopancreatography (ERCP) was performed, which demonstrated a 2.5 cm smooth, low-grade, extrinsic-appearing mid-CBD stricture with mild upstream dilation (8–9 mm). A biliary sphincterotomy was performed and 10 Fr × 7 cm plastic biliary stent and a prophylactic 5 Fr pancreatic duct stent were placed. Pancreaticogram confirmed no ductal leak. Three days later, the patient developed upper GI bleeding with NG output of coffee-ground emesis and CTA showed gastric distension, a 5 mm pseudoaneurysm of the left gastric artery with active extravasation. Esophagogastroduodenoscopy revealed a dilated stomach with multiple 3–4 clean-based gastric ulcers, and a 7 mm cratered duodenal bulb ulcer which was clipped successfully. Unfortunately the patient’s prolonged, complicated course with other comorbidities led the family to opt for comfort-focused care. Discussion: This case illustrates the complex cascade of complications that can occur following pancreatic trauma-particularly hematoma-induced biliary obstruction. the combination of rising bilirubin, imaging findings, and progressive GI symptoms required multidisciplinary coordination for therapeutic endoscopy. Timely endoscopic retrograde cholangiopancreatography (ERCP) with biliary decompression, endoscopic hemostasis, and supportive care were crucial.