Hemosuccus Pancreaticus: Side-Viewing Endoscopic Diagnosis of a Rare but Fatal Cause of Gastrointestinal Hemorrhage

Abstract

Hemosuccus pancreaticus (HP) is an extremely rare disease that is usually defined as bleeding in the pancreatic duct. Although it is infrequent, HP can lead to massive gastrointestinal bleeding, which is potentially life threatening. 70-year-old male with a history of chronic alcohol abuse, chronic pancreatitis and UGIB presented with melena. Initial physical examination was unremarkable and vitals were stable. Laboratory studies were significant for hemoglobin of 8.7 g/dL. Endoscopy was insignificant. Patient had repeat episode of melena but repeat endoscopy was again insignificant for cause of bleed. After 3 days, LFT's increased: possibly from drug-induced liver injury or obstructing lesion. CT scan showed a large 4.2x2.9 cm pseudoaneurysm in the head of the pancreas possibly from gastroduodenal artery. Interventional radiology (IR) performed coil embolization, but follow-up ultrasound showed vascular mass enlarged to 5.6x5.8cm. Patient reported melena again and dark blood noted on rectal examination. CT angiography also could not identify the cause of his bleeding. The patient underwent repeat endoscopy with side-viewing scope, Blood extravasation was noted from the ampulla consistent with HP (Figure 1A,B,C). Patient continued to have intermittent bleeding requiring transfusions. After discussion with IR, decision was made to attempt repeat embolization, but the patient clinically worsened and passed away. Although HP is a rare cause of gastrointestinal hemorrhage, it is very important to include it in the differential in patients with history of chronic pancreatitis. HP frequently occurs as a complication of pancreatitis with rupture of a visceral artery aneurysm, but can be caused by trauma, neoplasms, or iatrogenic causes. [1,2] Although CT angiography is the gold standard, it can fail to diagnose HP. In terms of management, surgery or endovascular therapy by interventional radiology showed promising outcomes. [3] In this case, repeated attempt with endoscopy and CT angiography could not identify the HP lesion, which was subsequently successfully detected utilizing a side-viewing endoscope.1378_A.tif Figure 1: No Caption available.1378_B.tif Figure 2: No Caption available.1378_C.tif Figure 3: Repeat endoscopy using side-viewing endoscope showing blood extravasation from ampulla in the duodenum consistent with hemosuccus pancreaticus.