Case Report: Fatal recurrent rupture of multiple pancreatic pseudoaneurysms following acute alcoholic pancreatitis

BackgroundPancreatic pseudoaneurysm (PPA) is a severe and life-threatening vascular complication of pancreatitis. This case highlights the critical need for comprehensive vascular assessment and surveillance in patients with alcoholic pancreatitis to prevent fatal adverse outcomes.Case presentationA 53-year-old man with a 30-year history of heavy alcohol intake (500 mL of 52% ABV Baijiu daily, corresponding to an estimated 205 g pure ethanol per day) presented to our emergency department with hematemesis and hemorrhagic shock on 2 April 2026. He was diagnosed with acute pancreatitis complicated by a pancreatic pseudocyst at another hospital in November 2025 but did not receive standardized follow-up and treatment. Contrast-enhanced CT confirmed rupture of a pancreatic head pseudoaneurysm with hemorrhage extending into the duodenum. Emergency transarterial embolization of the gastroduodenal artery was performed, and hematemesis resolved temporarily. Subsequently, the patient developed progressive abdominal pain, distension, and peritoneal irritation signs. Repeat CT confirmed recurrent intra-abdominal hemorrhage. A second digital subtraction angiography (DSA) identified an unrecognized feeding branch arising from the superior mesenteric artery (SMA) supplying the pancreatic head pseudoaneurysm, which was successfully embolized. The patient's condition stabilized temporarily, with a gradual increase in hemoglobin levels. On 14 April 2026, the patient suffered sudden severe abdominal pain and abdominal distension. Follow-up contrast-enhanced CT revealed enlargement and rupture of a pre-existing tiny pseudoaneurysm in the splenic hilum, resulting in massive intra-abdominal hemorrhage. The patient developed refractory hemorrhagic shock followed by cardiac arrest during preparation for emergency endovascular intervention and ultimately died. Post-embolization hemodynamic changes may have contributed to progressive enlargement and subsequent rupture of the pre-existing lesion, although this causal mechanism cannot be definitively proven in this single case.ConclusionThis case illustrates that pancreatitis-associated pseudoaneurysms may be multifocal. Successful control of a dominant bleeding lesion does not eliminate the risk of rupture of the separate pre-existing small pseudoaneurysm, and incomplete initial angiography limited only to the celiac trunk may miss SMA feeding branches, even after technically successful initial endovascular intervention for pancreatitis-associated pseudoaneurysm.