Hemosuccus Pancreaticus: A Rare Cause of Gastrointestinal Bleeding

Abstract

Introduction: Hemosuccus pancreaticus is a rare cause of GI bleeding. The bleeding varies from intermittent occult bleeding to massive acute hemorrhage, which may be difficult to diagnose. We present a case of hemosuccus pancreaticus with challenging endoscopic and radiologic features. Case Report: An 83-year-old woman with a history of chronic pancreatitis had multiple admissions for recurrent pancreatitis and GI bleeding over 2 years. Multiple EGDs, a bleeding scan, a capsule endoscopy, and a colonoscopies showed no etiology for her bleeding. She presented a fifth time with pancreatitis and bleeding. Contrast CT showed irregular thickening of the pancreas with multiple calcifi cations and inflammatory changes around the pancreatic tail. There was new dilation of the pancreatic duct (PD) to 10 mm, felt secondary to a 9-mm calcification obstructing the PD in the head. Also, a 1.1-cm, hyperenhancing, oval focus in the pancreatic tail was seen. EGD and colonoscopy were again unrevealing. The enhancing tail mass was diagnosed as a pseudoaneurysm, but angiography showed no pseudoaneurysm. It was felt to have thrombosed. She was transfused and discharged home with plans for ERCP to remove the obstructing calcification in the head. Two months later she was admitted for abdominal pain. Abdominal CT showed resolution of the prior enhancing pancreatic tail mass and dilated PD, and the pancreatic head calcification was not present. She developed hematemesis, massive bleeding per rectum, and hemorrhagic shock. EGD showed fresh blood with no obvious source. Repeat EGD with a duodenoscope showed blood gushing from the major papilla consistent with hemosuccus pancreaticus. Repeat angiography demonstrated a distal splenic artery pseudoaneurysm hemorrhaging into the pancreatic duct. Coil embolization of the pseudoaneurysm stopped the bleeding and the patient recovered. At 3-month follow-up, she has had no recurrent bleeding. Discussion: Hemosuccus pancreaticus, or bleeding from the pancreatic duct, is a rare cause of GI bleeding. The cause is usually an aneurysmal dilation of an artery (splenic, hepatic, gastroduodenal, or pancreaticoduodenal) adjacent to an area of pancreatic injury (1). Our patient had chronic pancreatitis with recurrent acute pancreatitis and a resultant pseudoaneurysm of the splenic artery. This bled intermittently into the pancreatic duct causing massive hemorrhage. Coil embolization can achieve definitive hemostasis (2). Surgery is often reserved for situations not amenable to radiologic intervention (1). Conclusion: In cases of obscure upper GI hemorrhage, especially in patients with prior pancreatic injury, the diagnosis of hemosuccus pancreaticus should be considered (3).