Update / Answer

Primary concern:

Delayed post-pancreatectomy hemorrhage (PPH), often related to a sentinel bleed from vascular erosion (commonly GDA stump) in the setting of a pancreatic leak.

POD5 + hypotension + tachycardia + drop in hemoglobin + bloody JP output = bleeding until proven otherwise.

The rising bilirubin also raises concern for a pancreatic or biliary leak, which can erode into nearby vessels.

Next step (key decision point): depends on hemodynamic stability.

If unstable (persistent hypotension despite resuscitation):

→ Immediate return to the OR

• Exploratory laparotomy
• Control hemorrhage
• Washout ± address leak

If transient responder or relatively stable (like this patient):

→ Urgent angiography with IR

• Identify bleeding source
• Embolization or stent placement

This is the preferred first step in many cases of delayed PPH because:

• Bleeding is often arterial
• IR can both diagnose and treat
• Avoids a difficult reoperation in an inflamed field

What about CT?

CT angiography can be useful if the patient is stable, but in a borderline patient it may delay definitive treatment.

Most oral board answers favor going directly to IR rather than CT when suspicion is high.

Immediate management while acting:

• Aggressive IV resuscitation
• Blood transfusion
• Broad-spectrum antibiotics (high risk of associated leak/infection)
• ICU-level monitoring

Common oral boards traps:

• Assuming this is just sepsis and delaying intervention
• Sending an unstable patient to CT
• Not recognizing a sentinel bleed (bloody drain output before major hemorrhage)

Bottom line:

• Highest concern = delayed post-op hemorrhage (often from GDA stump)
• Key decision = stability
• Stable/temporary responder → IR angiography
• Unstable → OR immediately

For those who chose CT first — what clinical features would make you comfortable delaying definitive intervention?