S2157 An Unusual Cause of Hematochezia in a Patient with Chronic Pancreatitis

Abstract

INTRODUCTION: Pancreatic pseudocyst formation can lead to fistulization with nearby vessels which can lead to melena and hemodynamic instability. We report a rare case of a patient with chronic pancreatitis who presented with hematochezia from a pancreatic pseudocyst eroding into the splenic artery, forming a splenic pseudoaneurysm (SPA) with simultaneous fistula formation with the descending colon. To our knowledge, this has not been reported in the literature. CASE DESCRIPTION/METHODS: A 46 year old male with a history of chronic pancreatitis presented to the hospital with epigastric pain for 1 month. He also reported three episodes of hematochezia over the past 2 days. He reported drinking Vodka daily for 20 years. Vital signs were stable. Rectal exam showed brown mixed with maroon colored stool. Lab values: Hg 9.7 g/dL (baseline Hg 15), MCV 96 fl, RDW 16.8%. EGD showed a white clean based duodenal ulcer, portal hypertensive gastropathy and no varices. Colonoscopy showed no blood in the ascending colon however with a large amount of blood and clots in the descending and sigmoid colon, with no identifiable source of bleeding (Figures 1–2). Given continuous bleeding, CTA abdomen pelvis was done and showed an actively bleeding SPA into the pancreatic pseudocyst that had fistulalized with the descending colon causing rectal bleeding. IR angiogram showed SPA which was embolized successfully (Figure 3). After embolization, he had no further episodes of bleeding and was discharged home. He was lost to follow up after discharge. DISCUSSION: Chronic pancreatitis cases can be complicated by pancreatic pseudocysts. Complications from pancreatic pseudocyst formation include fistulization, infection or bleeding. Commonly, patients with chronic pancreatic pseudocysts can form gastroduodenal pseudoaneurysms, which present as upper GI bleeding. In rare cases, vessels near the pancreatic pseudocyst such as the splenic artery have been known to form fistulas with the transverse colon, which presents as hematochezia. Our patient presented with hematochezia from a SPA that eroded into the pancreatic pseudocyst which also formed a fistula with the descending colon. To our knowledge, this has not been reported in the literature. Rupture of SPA into the pseudocyst with concomitant fistula creation to the left colon can lead to a massive gastrointestinal bleed. Once suspected, IR guided embolization of the involved vessel and/or endovascular repair can be life-saving.Figure 1.: Colonoscopy findings in descending colon.Figure 2.: Colonoscopy findings in sigmoid colon.Figure 3.: IR angiogram findings.