Post-Pancreatectomy Haemorrhage (PPH)

Classify PPH

1. Onset

Early (≤24h post-op) Late (>24h post-op)

2. Location

Intraluminal (GI tract bleeding) Extraluminal (abdominal / drain bleeding)

3. Severity

Haemoglobin Drop (g/dL)

Units of Blood Transfused

Invasive intervention required (angiography or re-laparotomy)

ISGPS PPH Classification

Grade	Onset	Severity	Clinical Impact	Management
A	Early	Mild (Hb drop <3 g/dL; <2 units; no intervention)	No haemodynamic change; no or minimal transfusion	Conservative; observation
B	Early severe OR Late (any severity)	Moderate (Hb drop ≥3 or ≥2 units or intervention needed)	Transfusion ≤2 units; angiography or endoscopy may be needed	IR embolisation; endoscopy; re-operation if needed
C	Late	Severe (Hb drop ≥3, ≥2 units, invasive intervention required)	Life-threatening; haemodynamic compromise	Emergency angiography or re-laparotomy; ICU admission

Sentinel Bleed Concept

Up to 70% of Grade C PPH events are preceded by a sentinel bleed — a minor, self-limiting bleed from a drain or the GI tract that occurs 12–72 hours before the catastrophic haemorrhage. The sentinel bleed represents early pseudoaneurysm formation or anastomotic erosion by amylase-rich POPF fluid.

Management of sentinel bleed: Urgent CT angiography + GI endoscopy. Do not observe and wait — treat as Grade B PPH until proven otherwise. Identify and embolise any pseudoaneurysm before it ruptures catastrophically.

Any drain output that is blood-stained, fresh red blood in NGT, or unexplained haemodynamic instability in the early post-pancreatectomy period should trigger immediate CT angiography and surgical team escalation.

Causes of PPH by Timing

Timing	Causes
Early (≤24h)	Inadequate intraoperative haemostasis; perioperative coagulopathy; slipped ligature; raw surface ooze
Late (>24h)	Pseudoaneurysm formation (splenic, hepatic, gastroduodenal artery stump); anastomotic disruption; visceral artery erosion by amylase-rich POPF fluid; marginal ulceration

Clinical Application

POPF (Grade B/C) is the most common cause of late PPH — treat the underlying fistula (drainage, antibiotics, octreotide) alongside managing the haemorrhage
CT angiography is the investigation of choice for suspected pseudoaneurysm — can identify the vessel and plan embolisation in the same setting
Angiographic embolisation is first-line for extraluminal PPH in haemodynamically stable patients — success rate 70–90% for pseudoaneurysm
GI endoscopy first-line for intraluminal PPH (anastomotic bleed, marginal ulcer) — haemostatic clips or injection therapy
Re-laparotomy if angiography fails, patient is haemodynamically unstable, or anastomotic dehiscence is suspected
PPH mortality by grade: Grade A ~0%, Grade B ~5%, Grade C ~20–30%

References

Wente MN, et al. Postpancreatectomy hemorrhage (PPH): an International Study Group of Pancreatic Surgery (ISGPS) definition. Surgery. 2007;142(1):20–25.