Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access
Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc
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Case Report

Volume 7, Number 1, February 2014, pages 32-37

Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding

Figures

Figure 1.
Figure 1. Contrast-enhanced CT scan of the abdomen reveals a 5 × 6 × 7 cm complex cystic mass in the region of uncinate process of pancreatic head with an enhancing capsule and a small hyperdensity consistent with pseudoaneurysm of a peripancreatic vessel with active bleeding into the pancreatic pseudocyst.
Figure 2.
Figure 2. Contrast-enhanced CT scan of the abdomen reveals dilated pancreatic duct possibly filled with blood.
Figure 3.
Figure 3. Abdominal angiography demonstrates an actively bleeding large pseudoaneurysm in the peripancreatic vessel arcade likely in the branch of pancreaticoduodenal artery.
Figure 4.
Figure 4. Post embolization angiogram shows embolization of the pancreaticoduodenal artery with resolution of contrast opacification of the bleeding pseudoaneurysm.
Figure 5.
Figure 5. Esophagogastroduodenoscopy shows with no bleeding source in the stomach.
Figure 6.
Figure 6. Esophagogastroduodenoscopy shows old blood in the duodenum near the ampulla of Vater, which is likely the source of bleeding into gastrointestinal tract. Arrow pointing towards the ampulla of Vater.

Table

Table 1. Comparison of the Three Rare Causes of Upper Gastrointestinal Bleeding
 
Hemosuccus pancreaticusHemobiliaPrimary aortoenteric fistula
DefinitionBleeding from the pancreatic duct into duodenum via the ampulla of Vater.Bleeding from the biliary tract into duodenum via ampulla of Vater.Bleeding from the aorta into the duodenum (most common) via fistula between aorta and duodenum.
SourcePancreas, pancreatic pseudocyst.Intrahepatic, extrahepatic like gall bladder or bile duct.Aorta.
Bleeding vesselPeripancreatic vessels like splenic, gastroduodenal, pancreaticoduodenal, splenic and sometimes hepatic artery.Hepatic artery, branch of right or left hepatic artery.Aorta.
Site of bleeding into the gastrointestinal tractSecond part of duodenum (ampulla of Vater).Second part of duodenum (ampulla of Vater).Third part of duodenum (most common).
Classic triadAbdominal pain, gastrointestinal hemorrhage and hyperamylasemia.Abdominal pain, gastrointestinal hemorrhage and jaundice.Abdominal pain, gastrointestinal hemorrhage and pulsatile abdominal mass.
Characteristic pictureCrescendo-decrescendo abdominal pain followed by hemorrhage with a repeat cycle of pain followed by hemorrhage.Abdominal pain and hemorrhage usually with a recent history of instrumentation.“Herald” hemorrhage followed hours, days, or weeks later by catastrophic hemorrhage.
CausesChronic pancreatitis, pancreatic pseudocyst, pancreatic tumors, iatrogenic like EUS/ERCP, vascular malformations, and so on.Iatrogenic (liver biopsy, percutaneous transhepatic cholangiography, instrumentation, and so on), trauma, hepatobiliary malignancy, inflammation (cholangitis, vasculitis, gallstone disease), parasitic infection, vascular malformation, and so on.Aortic aneurysm (majority atherosclerotic, followed by mycotic aneurysms), septic aortitis, radiation, carcinoma, ulcers, and so on.
Diagnostic testContrast CT scan very helpful, EGD (diagnostic in 30%), angiography.Contrast CT scan very helpful, EGD (diagnostic in 12%), ERCP in some cases, technitium red cell scan in some cases, angiography.Contrast CT scan the most diagnostic. EGD in initial phase when bleeding is herald. Angiography usually not performed as most patients are critically ill when considered for angiography.
TreatmentTranscatheter arterial embolization of the pancreatic vessel, Surgery is TAE fails; includes ligation of bleeding vessel, excision of aneurysm, central/distal pancreatectomy.Transcatheter arterial embolization of hepatic artery (first approach). Surgery if TAE fails; includes ligation of bleeding vessel, excision of aneurysm. Further options depend on site of bleeding; partial hepatectomy, cholecystectomy.Emergent laparotomy. Debridement of diseased aorta and repair with prosthetic graft along with primary repair of the gastrointestinal tract.