Hemosuccus Pancreaticus: A Potentially Life-threatening Cause of Gastrointestinal Bleeding

Abstract

Hemosuccus pancreaticus (HP) is the least frequent cause of gastrointestinal bleeding (GIB) and even though HP is potentially life threating, it is rarely identified by endoscopy due to its intermittent bleeding and difficulty in obtaining adequate views of the ampulla. We report a case of HP identified by esophagogastroduodenoscopy (EGD) that was successfully treated with microcoil embolization. A 76 year old male with unknown medical history was admitted after being found unresponsive. On initial presentation the patient's vital signs were stable and he was severely anemic with a hemoglobin of 4.5 gm/dl, stools were brown and guaiac positive. CT abdomen was pertinent for chronic calcific pancreatitis with a 2x0.8cm pseudoaneurysm within the body of the pancreas and large stool burden. After transfusion of 3 units of packed red blood cells the patient continued to have worsening of his anemia. EGD was performed and positive for active bleeding coming from the ampulla. Interventional radiology identified the large bleeding pseudoaneurysm at the junction of the dorsal pancreatic and superior pancreaticoduodenal arteries on arteriogram and the patient was treated with microcoil embolization of the transverse pancreatic artery, dorsal pancreatic artery and superior pancreaticoduodenal arteries. HP is defined as bleeding from the pancreas or surrounding structures into the pancreatic duct and ampulla of Vater and occurs approximately once for every 1,500 cases of GIB. HP most commonly occurs from chronic pancreatitis, pancreatic tumors or bleeding of a pseudoaneurysm usually from the splenic artery but approximately 15% will bleed from the pancreaticduodenal artery, as in our case. Due to its location, intermittent bleeding and overall rarity, HP is difficult to identify by endoscopy and must be diagnosed with angiography and treated with surgery or angiographic embolization. Due to the life threating potential of HP, one most thoroughly investigate the ampulla for signs of bleeding and consider HP in the differential diagnosis to allow for early radiologic diagnosis and treatment.Figure: Bleeding from the Ampulla of Vater (Black arrow).