EURORAD ESR

Case 13174

Postoperative bleeding after pancreaticoduodenectomy: CT findings and role

Author(s)
Tonolini Massimo, MD.

"Luigi Sacco" University Hospital, Radiology Department; Via G.B. Grassi 74 20157 Milan, Italy; Email:mtonolini@sirm.org
 
Patient
male, 76 year(s)
 
 
  • Figure 1
    Preoperative contrast-enhanced multidetector CT study
     

    Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads)....

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads)....

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads)....

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;

    Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads)....

     
    Area of Interest: Biliary Tract / Gallbladder; Imaging Technique: CT; Procedure: Diagnostic procedure; Special Focus: Neoplasia;
     
     
  • Figure 2
    Emergency early postoperative CT - unenhanced acquisition
     

    Preliminary unenhanced images showed multi compartmental peritoneal effusion (+) with higher-than water attenuation consistent with haemoperitoneum.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    The pancreatic body-tail remnant (short arrows) showed normal size and structure. Abundant mixed hyperattenuating blood (*) collected near to the site of pancreatico-jejunostomy, and extended ventrally and laterally...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    Abundant mixed hyperattenuating blood (*) collected near to the site of pancreatico-jejunostomy, and extended ventrally in the mesentery and laterally in the right lateroconal and anterior pararenal spaces.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    Sagittal maximum-intensity projection (MIP) reconstruction showed haemoperitoneum in the cul-de-sac (+) and hyperattenuating blood (*) collecting nearby the surgical site and extending ventrally in the mesentery.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;
     
     
  • Figure 3
    Emergency early postoperative CT - arterial phase post-contrast acquisition
     

    The pancreatic body-tail remnant (short arrows) showed normal size, morphology and enhancement.

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    Abundant mixed attenuation blood (*) was seen collecting near the pancreatico-jejunostomy site and flowed ventrally in the mesentery and in the right lateroconal and anterior pararenal spaces. Contrast extravasation...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    Abundant mixed attenuation blood (*) was seen collecting near the pancreatico-jejunostomy site and flowed ventrally in the mesentery and in the lateroconal and anterior pararenal spaces. Contrast extravasation...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    Abundant mixed attenuation blood (*) was seen collecting near the pancreatico-jejunostomy site and flowed ventrally in the mesentery and in the lateroconal and anterior pararenal spaces. Contrast extravasation...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    CT-angiographic maximum-intensity projection (MIP) reconstructions confimred absence of contrast extravasation indicating active arterial bleeding, particularly at the typical site represented by the gastroduodenal...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    CT-angiographic maximum-intensity projection (MIP) reconstructions confimred absence of contrast extravasation indicating active arterial bleeding, particularly at the typical site represented by the gastroduodenal...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;
     
     
  • Figure 4
    Emergency early postoperative CT - venous phase post-contrast acquisition
     

    Venous-phase acquisition confirmed normal aspect of pancreatic remnant (short arrows), haemoperitoneum (+), abundant mixed hyperattenuating blood (*) collecting near the pancreatico-jejunostomy and extending in the...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    Venous-phase acquisition confirmed haemoperitoneum (+) and abundant mixed hyperattenuating blood (*) collecting near the pancreatico-jejunostomy and extending in the mesentery and in the right lateroconal and anterior...

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    Additionally, serpiginous active contrast extravasation (arrows) consistent with venous bleeding was seen within the mesenterial blood (*). Note haemoperitoneum (+).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    MIP reconstructions (d,e) depicted serpiginous contrast extravasation (arrows) consistent with active venous bleeding within the mesenterial blood (*). Note drainage tube (thin arrows).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;

    MIP reconstructions (d,e) depicted serpiginous contrast extravasation (arrows) consistent with active venous bleeding within the mesenterial blood (*). Note drainage tube (thin arrows).

     
    Area of Interest: Pancreas; Imaging Technique: CT; Procedure: Surgery; Special Focus: Haemorrhage;
     
     
Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads). Signs of vascular invasion and distant metastases were not seen.
 
Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads). Signs of vascular invasion and distant metastases were not seen.
 
Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads). Signs of vascular invasion and distant metastases were not seen.
 
Multiplanar images from preoperative CT showed moderately dilated intrahepatic bile ducts (+), overdistended gallbladder (§), common bile duct dilatation (short arrows) with distal "tapering" stricture (arrowheads). Signs of vascular invasion and distant metastases were not seen.
 
Preliminary unenhanced images showed multi compartmental peritoneal effusion (+) with higher-than water attenuation consistent with haemoperitoneum.
 
The pancreatic body-tail remnant (short arrows) showed normal size and structure. Abundant mixed hyperattenuating blood (*) collected near to the site of pancreatico-jejunostomy, and extended ventrally and laterally in the right abdomen. Note haemoperitoneum (+).
 
Abundant mixed hyperattenuating blood (*) collected near to the site of pancreatico-jejunostomy, and extended ventrally in the mesentery and laterally in the right lateroconal and anterior pararenal spaces.
 
Sagittal maximum-intensity projection (MIP) reconstruction showed haemoperitoneum in the cul-de-sac (+) and hyperattenuating blood (*) collecting nearby the surgical site and extending ventrally in the mesentery.
 
The pancreatic body-tail remnant (short arrows) showed normal size, morphology and enhancement.
 
Abundant mixed attenuation blood (*) was seen collecting near the pancreatico-jejunostomy site and flowed ventrally in the mesentery and in the right lateroconal and anterior pararenal spaces. Contrast extravasation indicating active arterial bleeding was not seen.
 
Abundant mixed attenuation blood (*) was seen collecting near the pancreatico-jejunostomy site and flowed ventrally in the mesentery and in the lateroconal and anterior pararenal spaces. Contrast extravasation indicating active arterial bleeding was absent. Note haemoperitoneum (+).
 
Abundant mixed attenuation blood (*) was seen collecting near the pancreatico-jejunostomy site and flowed ventrally in the mesentery and in the lateroconal and anterior pararenal spaces. Contrast extravasation indicating active arterial bleeding was absent. Note haemoperitoneum (+).
 
CT-angiographic maximum-intensity projection (MIP) reconstructions confimred absence of contrast extravasation indicating active arterial bleeding, particularly at the typical site represented by the gastroduodenal artery stump (arrow in f).
 
CT-angiographic maximum-intensity projection (MIP) reconstructions confimred absence of contrast extravasation indicating active arterial bleeding, particularly at the typical site represented by the gastroduodenal artery stump (arrow in f).
 
Venous-phase acquisition confirmed normal aspect of pancreatic remnant (short arrows), haemoperitoneum (+), abundant mixed hyperattenuating blood (*) collecting near the pancreatico-jejunostomy and extending in the mesentery and in the right lateroconal and anterior pararenal spaces.
 
Venous-phase acquisition confirmed haemoperitoneum (+) and abundant mixed hyperattenuating blood (*) collecting near the pancreatico-jejunostomy and extending in the mesentery and in the right lateroconal and anterior pararenal spaces.
 
Additionally, serpiginous active contrast extravasation (arrows) consistent with venous bleeding was seen within the mesenterial blood (*). Note haemoperitoneum (+).
 
MIP reconstructions (d,e) depicted serpiginous contrast extravasation (arrows) consistent with active venous bleeding within the mesenterial blood (*). Note drainage tube (thin arrows).
 
MIP reconstructions (d,e) depicted serpiginous contrast extravasation (arrows) consistent with active venous bleeding within the mesenterial blood (*). Note drainage tube (thin arrows).
 
 
 
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