Hemosuccus Pancreaticus and Hematochezia: An Unusual Presentation of a Rare Disease

Abstract

Gastrointestinal bleed (GIB) is a major reason of hospitalization and can lead to worsened morbidity and mortality. Hemosuccus pancreaticus (HP) is a rare cause of upper GIB observed in patients with chronic pancreatitis, pancreatic pseudocysts, or pancreatic tumors. Patients with HP usually present with intermittent epigastric pain and GIB, most commonly hematemesis or melena, but rarely, may have hematochezia. We present a patient with recurrent GIB episodes whose evaluation revealed HP. A 52-year-old gentleman with history of excessive alcohol use was evaluated for recurrent abdominal pain and hematochezia. He had undergone esophagogastroduodenoscopy (EGD), colonoscopy, deep anterograde and spiral retrograde endoscopies as well as two Meckel scans with negative evaluation. Finally, intra-operative enteroscopy revealed a few non-bleeding small angioectasias in the jejunum and ileum that were ligated. However, the patient presented again with hematochezia. Initial CT scan of the abdomen was concerning for chronic pancreatitis change and a hypervascular lesion at the junction of the body and tail of the pancreas. He had no prior history of acute pancreatitis. Subsequent CT angiography revealed a 7mm mid-splenic artery saccular aneurysm arising from the inferior wall of the splenic artery, abutting the tail of the pancreas with pancreatic duct dilatation. Selective angiography with embolization was performed at this lesion. The procedure was complicated by downstream migration of the coils into the splenic artery bifurcation resulting in segmental splenic infarction. He has had no further bleeding and his condition and hemoglobin have been stable since the procedure. Follow up endoscopic ultrasound (EUS) showed chronic pancreatitis changes, there was no mass lesion. GIB from HP usually results when a direct communication is established between the blood vessel and pancreatic duct as a result of erosion. Intermittent abdominal pain and GIB are hallmarks for this disease. Abdominal CT usually establishes the diagnosis but it can also be confirmed by MRCP, ERCP or intra-operatively. Angiography with coil embolization is the initial treatment which was also successful in our patient. Our patient was unique in that he presented with recurrent hematochezia, which is uncommon in this rare disorder. This case demonstrates that HP should be considered in patients with GIB, particularly in those with a pancreatic disorder and negative evaluation of more common causes.Figure: Angiogram of splenic artery revealing pseudoaneurysm off of the mid splenic artery.Figure: Angiogram of the splenic artery after successful coil embolization.Figure: CT angiogram reveals mid-splenic artery pseudoaneurysm.