Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding

Abstract

Hemosuccus pancreaticus (bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater) is a rare, potentially life-threatening and obscure cause of upper gastrointestinal bleeding. It is caused by rupture of the psuedoaneurysm of a peripancreatic vessel into pancreatic duct or pancreatic psuedocyst in the context of pancreatitis or pancreatic tumors. It can pose a significant diagnostic and therapeutic dilemma due to its anatomical location and that bleeding into the duodenum is intermittent and cannot be easily diagnosed by endoscopy. A 61-year-old female with HIV and alcoholism presented with 3 weeks of intermittent abdominal pain and melena. Examination revealed hypotension with pallor and mild epigastric tenderness. She was found to have severe anemia and a high serum lipase. It was decided to perform a contrast-enhanced computed tomography (CT) scan that demonstrated a hemorrhagic pancreatic pseudocyst with possible active bleeding into the cyst. An emergent angiogram showed a large pseudoaneurysm of the pancreaticoduodenal artery that was successfully embolized. Subsequent endoscopy showed blood near ampulla of Vater confirming the diagnosis of hemosuccus pancreaticus. Thus the bleeding pseudocyst was communicating with pancreatic duct. The patient had no further episodes of gastrointestinal bleeding. Hemosuccus pancreaticus should be considered in patients with intermittent crescendo-decrescendo abdominal pain, gastrointestinal bleeding and a high serum lipase. Contrast-enhanced CT scan can be an excellent initial diagnostic modality and can lead to prompt angiography for embolization of the bleeding pseudoaneurysm and can eliminate the need for surgery.

Upper Gastrointestinal Bleed: Do not Forget a Look at Ampulla

“…It is important to know about the two rare causes of extra luminal source of gastrointestinal bleeding into the duodenum which can be missed easily and Bleeding from ampulla via Pancreatic Duct  Hemosuccus Pancreaticus [6] Bile Duct/gall bladder  Hemobilia [5]…”

Rare presentation of a massive intermittent upper gastrointestinal bleed

“…Frequency of rupture in the setting of pancreatitis is 5-10% and with a pseudocyst present, this can rise up to 20%. Mortality of a ruptured PA can be as high as 90-100% and if treated, the mortality risk is reduced to 12-57% [7][8][9][10].…”

“…If bleeding is observed from the major ampulla, this is a strong indicator of hemosuccus pancreaticus, though seldom seen. Other signs may include residual blood clots located near the ampulla, which may be difficult to visualize with no signs of peptic ulcer disease, varices or gastritis [7]. If no clear bleeding source, CT scan of the abdomen is the first line imaging modality of choice to identify pancreatic pathology followed-by angiography, which is considered the gold standard for detecting PAs and first line treatment [5,10].…”

“…Some of these complications can be avoided with the use of a non-coated metallic stent and the stent can be used as bridge to surgery in high risk patients or those with pancreatic disease that is in need of surgical treatment. The advantages to embolization include precise location, assessment of proper collateral flow, and excellent alternative for patients that are poor surgical candidates [7][8][9][10].…”

“…Aneurysms and pseudoaneurysms are commonly formed in the setting of both acute and chronic pancreatitis [2]. However, these are not the only causes of hemosuccus pancreaticus (Table 1) [2][3][4][5][6][7].…”