S1530 A Catastrophic Complication of Pancreatic Adenocarcinoma

Abstract

INTRODUCTION: Gastrointestinal bleeding (GIB) is often times a medical emergency. Determining the source of bleed is important for management and treatment. Some common causes of upper GIB are known as peptic ulcers, Mallory-Weiss tears, esophageal varices, and gastric cancer. A less frequent cause of GIB occurs due to an extremely rare disease called hemosuccus pancreaticus (HP), defined as bleeding from ampulla of Vator through the pancreas. HP is caused by pancreatitis, arterial pseudoaneurysms, and pancreatic tumors causing bleeding from the pancreatic duct or adjacent vessels such as the splenic or gastric artery. We present a rare case of HP causing massive upper GIB in a patient with known pancreatic adenocarcinoma. CASE DESCRIPTION/METHODS: We describe a case of a 79 year old male with history of melena and stage IV pancreatic adenocarcinoma who presented to the hospital for fatigue. Upon arrival the patient was hypotensive and tachycardic. He complained of extreme generalized weakness above his baseline. He appeared pale with icteric sclera and conjunctival pallor. Intravenous fluids were started. Significant lab values showed hemoglobin 7.4 g/dL, which was 2 grams less from outpatient labs 1 day prior. Therefore, 1 unit of packed red blood cells was initiated. During the interview, he had sudden onset of profuse hematemesis and systolic pressure decreased to 60 mmHg. Patient was started on massive transfusion but blood pressure continued to fall and he went into cardiac arrest requiring cardiopulmonary resuscitation. Return of systemic circulation was achieved after 8 minutes. After stabilization, an esophagogastroduodenoscopy revealed active bleeding from the duodenal papilla, requiring endovascular treatment. Notably, there was recent sonographic evidence of tumor invasion into the celiac trunk likely causing rupture of a splenic pseudoaneurysm into the pancreatic duct causing HP. Despite interventional embolization, hemodynamic compromise continued leading to demise. DISCUSSION: HP remains a clinical and diagnostic challenge. The acuity of bleed can be massive and mortality rate remains high. The importance of this report is to include HP as a differential diagnosis, especially in patients with known pancreatic adenocarcinoma. A common manifestation of HP is melena, and if detected early in these patients, prior to massive bleeding with hemodynamic instability, it can allow safe intervention and life saving measures. The gold standard for diagnosis and treatment of HP remains angiography.Figure 1.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.Figure 2.: CT Abdomen Pelvis: Diffusely dilated main pancreatic duct with hypoenhancement of the pancreatic head. There is a small foci of pneumoperitoneum within the lesser sac posterior to the stomach and adjacent to the mid to distal aspect of the biliary stent concerning for pneumobilia.