HEMOSUCCUS PANCREATICUS PRESENTING IN A MALE WITH CHRONIC PANCREATITIS AND SUSPECTED PANCREATIC MALIGNANCY

Abstract

Hemosuccus pancreaticus is a rare cause of GI bleeding. It is associated with chronic pancreatitis, pancreatic pseudocyst and tumors. The usual mechanism is erosion of a blood vessel or pseudoaneurysm in to a pancreatic pseudocyst that communicates with the pancreatic duct. 59 year old male with a history of chronic pancreatitis from alcoholism presented with a 6 month history of worsening periumbilical abdominal pain, nausea, weight loss and anorexia. Physical examination revealed cachexia and peri-umbilical tenderness with no organomegaly, mass or peritonitis. The CBC, chemistry panel, liver functional panel, coagulation profile and pancreatic tumor markers (CA 19–9 & CEA) were normal. A CT and MRI of abdomen showed a heterogeneous mass in the head of pancreas. During an attempt to perform EUS and FNA, he became hypotensive. Blood was seen emanating from the ampullary orifice (Figure 1) with a subsequent drop in hemoglobin (from 11.3 to 6.2 g/dl). After instituting aggressive resuscitation and obtaining an urgent surgical consultation, a selective mesen-teric angiogram was performed that revealed a ruptured pseudoaneurysm off the superior pancreaticoduodenal artery (Figure 2). After embolization of aneurysm, bleeding stopped and patient remained hemodynamically stable. A repeat EUS directed FNA of the mass revealed no malignant cells. The presence of a large pseudocyst communicating with the pancreatic duct was later confirmed with ERCP.FigureFigureHemosuccus pancreaticus should be suspected in patients with chronic pancreatitis who present with unexplained massive GI bleeding, hemodynamic instability and/or increased abdominal pain from a sudden expansion of a pseudocyst. Prompt recognition is crucial for adequate therapeutic interventions, [Figure 1] [Figure 2]