Post-Pancreatitis Gastrointestinal Bleed: A Key Association for a Difficult Diagnosis

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Hemosuccus pancreaticus (HP) is defined as bleeding from the pancreatic duct into the duodenum through the ampulla of Vater and is a rare cause of gastrointestinal bleeding. We present a 37-year-old man with history of alcohol induced recurrent pancreatitis with recent hospitalization for acute pancreatitis with a stable pseudocyst. He presents with periumbilical abdominal pain for 4 days, bright red blood per rectum and melanotic stools. Physical examination was significant for guarding and diffuse abdominal tenderness, with rectal exam notable for melena. He was hemodynamically stable. Labs were consistent with hemoglobin of 10.2 g/dl with a baseline of 12 g/dl, lipase of 305 U/L, and negative autoimmune pancreatitis workup. EGD showed active bleeding from the ampulla of Vater with no intraprocedural intervention (Fig. 1). He was managed conservatively and discharged with a stable hemoglobin level. Five days later, he was readmitted with ongoing abdominal pain and melena. Hemoglobin decreased to 6.9 g/dl, and lipase was 2205 U/L. Patient received 2 units of packed RBC. Abdominal CT angiogram showed arterial blushing along the anterior aspect of the pancreatic head consistent with pseudoaneurysm posterior to the gastroduodenal artery (Fig. 2&3). Celiac and SMA angiography were performed with successful direct percutaneous puncture and thrombin injection into pseudoaneurysm with resolution of the latter on repeat CTA. The patient was closely monitored for 2 days and discharged with a stable hemoglobin with instructions to follow up in 3 weeks.1259_A.tif Figure 1: Esophagogastroduodenoscopy showing active bleeding from the ampulla of Vater1259_B.tif Figure 2: Cross-sectional view of CT Abdomen showing arterial blushing along the anterior aspect of pancreatic head, consistent with aneurysm/pseudoaneursym1259_C.tif Figure 3: Coronal view of CT Abdomen showing arterial blushing along the anterior aspect of pancreatic head, consistent with aneurysm/pseudoaneursymHP is a rare cause of gastrointestinal bleeding with an incidence of 1 in 1500 patients. It should be included in the differential diagnosis of acute, intermittent GI bleeding in patients with a history of chronic pancreatitis and pseudocysts. The presence of lytic enzymes in the cyst may lead to corrosion and rupture of the peripheral vascular wall leading to HP. The most common arteries affected are the splenic (45%), gastroduodenal (17%), and pancreaticoduodenal (16%) arteries. Pseudocysts occur in approximately 10% of all cases of acute pancreatitis, of which 10% can develop HP. Prompt diagnosis with EGD and/or angiography can help prevent life threatening complications, however, early diagnosis is difficult because the bleeding is intermittent and often missed on EGD. If seen, it presents as blood oozing from the ampulla of Vater in 30% of cases, thus making arterial embolization the gold standard treatment.