Utility of Endoscopic Ultrasound and Lumen-Apposing Metal Stent in the Management of Hemorrhagic Pancreatic Fluid Collection and Hemosuccus Pancreaticus

Abstract

Hemosuccus pancreaticus is a rare cause of gastrointestinal bleed and refers to the bleeding from the pancreatic duct into the gastrointestinal tract. Hemorrhage occurs when a pseudocyst or a tumor erodes into a vessel typically a pseudoaneurysm forming a direct communication between the pancreatic duct and the vessel. It is well established that endoscopic drainage of a hemorrhagic pancreatic pseudocyst is usually contraindicated. We report a challenging case of hemosuccus pancreaticus complicated by symptomatic hemorrhagic pancreatic pseudocyst successfully drained by Endoscopic ultrasound (EUS) guided cystogastrostomy using Lumen Apposing Metal Stent (LAMS). A 52 year old man with past medical history of HIV on antiretroviral therapy, hypertension, and diabetes mellitus presented with severe epigastric pain, vomiting and melena for 3 days. Two months prior, he was treated for an episode of acute pancreatitis complicated by splenic vein thrombosis treated with Warfarin. On admission he was noted to be tachycardic. Physical exam was significant for epigastric tenderness and melena. Laboratory studies revealed a high prothrombin time (>40 sec), hemoglobin level of 6.6 g/dl compared to his baseline of 11.6 and lipase of 560 U/L. Computed tomography (CT) of abdomen showed a 15.4 × 10.2 × 17.9 cm pancreatic pseudocyst with heterogeneous high density material consistent with hemorrhage (fig1). CT angiography of the abdomen confirmed these findings without evidence of pseudoaneurysm or active extravasation. The patient received adequate resuscitation. Endoscopic evaluation revealed bleeding from the pancreatic duct and fresh blood in the second portion of the duodenum (fig 2). The Hemorrhagic pseudocyst was successfully drained by EUS-guided endoscopic cystogastrostomy using LAMS. A total of 1500cc of clotted blood drained from the stent (Fig 3). Hemorrhagic pseudocyst of the pancreas carries a very high mortality rate reaching 40%. It is crucial to first identify the presence of a pseudoaneurysm in patients with pancreatic pseudocyst and unexplained gastrointestinal hemorrhage, drop in hemoglobin or expansion of the cyst size. Unless embolization is performed first, Endoscopic draining of a hemorrhagic pancreatic pseudocyst is usually contraindicated. This case highlights the practicability of using Endoscopic draining of a pancreatic pseudocyst using LAMS in the setting of pseudocyst hemorrhage.Figure: (A&B) Endoscopic images post LAMS stent placement showing large amount of dark brown bloody material draining from the stent which represents hemorrhagic pseudocyst (C&D) Repeat CT abdomen images showing the stent in place and a significant decrease in size of the pancreatic pseudocyst.Figure: Coronal and axial view of abdominal CT scan showing a 15.4 × 10.2 × 17.9 cm pancreatic pseudocyst with heterogeneous high density material.Figure: (A&B) Endoscopic images showing blood in the duodenum and blood tinged pancreatic secretions originating from the papilla (C&D) Endoscopic Ultrasound images showing a 15 cm pancreatic cyst with echogenic material and debris.