Gastroduodenal Artery Pseudoaneurysm Causing Hemosuccus Pancreaticus

Abstract

Patient is a 66 year old male with an extensive past medical history including chronic pancreatitis secondary to alcohol abuse and chronic portal vein/SMV thrombus with CT scan for abdominal pain in October 2014 revealing for a pancreatic mass. Subsequent MRI revealed a pseudoaneurysm in the pancreatic head, and patient underwent gastroduodenal artery embolization by IR. In January 2015, patient was readmitted with severe epigastric abdominal pain. He was noted to have elevated amylase and lipase with hemoglobin of 5. Abdominal exam on admission revealed a distended abdomen with positive fluid wave. No peritoneal signs were present. Repeat CT scan revealed new large volume ascites with evidence of hemoperitoneum. Given the history of previous GDA aneurysm, IR angiography was pursued which revealed no evidence of extravasation from previous pseudoaneurysm. Peritoneal catheter was placed for symptomatic relief revealing dark serosanguinous fluid with fluid analysis revealing >100,000 RBCs, 535 WBC (33% PMN) suggestive of hemoperitoneum with no bacterial peritonitis. Repeat fluid analysis revealed amylase >99,000 suggestive of pancreatic ascites, which raised concern for possible pancreatic duct disruption. ERCP was subsequently performed, and pancreatogram revealed an ansa deformity of the ventral pancreatic duct with a very narrow ductal connection between the ventral and dorsal duct, consistent with incomplete pancreatic divisum. Only the proximal dorsal duct could be visualized revealing a filling defect, however, upstream duct could not be filled likely due to partial divisum and ductal obstruction. At that point, we elected for EUS guided access to better evaluate the dorsal pancreatic duct for leak. EUS revealed a fluid collection adjacent to the pancreatic head representing residual GDA pseudoaneursym with pancreatic duct dilation to 4mm starting at the neck. A 25 gauge needle was used to access the dorsal duct, and 20 cc of maroon colored fluid consistent with old blood was aspirated until clear fluid was noted. Pancreatogram of the dorsal duct revealed beaded appearance of the dorsal pancreatic duct with dilated side branches, likely due to partial pancreatic duct obstruction by clot from partial communication with GDA pseudoaneurysm. Stent placement to facilitate pancreatic drainage and prevent further obstruction from hemosuccus pancreaticus was not technically possible in setting of incomplete divisum. During the course of admission, patient was also diagnosed with a DVT, and an IVC filter was placed. Anticoagulation was deferred given concern for recurrent hemoperitoneum and pancreatic duct obstruction.This is the first reported case of a GDA aneurysm with pancreatic ductal communication resulting in hemosuccus pancreaticus, and this should be considered in the differential for gastrointestinal bleeding in these patients.Figure 1Figure 2