Case Of Hemosuccus Pancreaticus Research Articles

A case of situs inversus totalis with hemosuccus pancreaticus due to intrapancreatic pseudocyst perforation of the common hepatic artery treated with a vascular stent graft.

Hemosuccus pancreaticus (HP) is characterized by gastrointestinal bleeding from the papilla of Vater via the pancreatic duct. In this report, we describe a case of HP due to arterial perforation in a pancreatic pseudocyst and discuss the computed tomography (CT) findings and efficacy of stent graft placement. A 64-year-old man with a history of heavy alcohol use, situs inversus totalis, and total gastrectomy was hospitalized with hematochezia. Enhanced CT revealed a pseudoaneurysm in the common hepatic artery (CHA) with mildly high density in the main pancreatic duct. Subsequent CT revealed an enlarged cystic lesion with inflow of contrast medium. Angiography confirmed blood flow from the CHA into the pancreatic pseudocyst, and the patient was diagnosed with HP due to intrapancreatic pseudocyst perforation of the CHA pseudoaneurysm. Coil packing into the pseudocyst failed to block the blood flow, and a covered stent graft was placed into the CHA. The patient had an uneventful clinical course. The identification of a pseudoaneurysm and a high-density area in the main pancreatic duct on enhanced CT and changes in the pancreatic cyst diameter may indicate the acute phase of HP, and stent grafting is an effective treatment for intracystic arterial perforation.

A Case of Hemosuccus Pancreaticus Caused by a Pseudoaneurysm of the Dorsal Pancreatic Artery in a Patient with Severe Motor and Intellectual Disabilities Treated with Direct Puncture and Transcatheter Arterial Embolization

A Case of Hemosuccus Pancreaticus Caused by a Pseudoaneurysm of the Dorsal Pancreatic Artery in a Patient with Severe Motor and Intellectual Disabilities Treated with Direct Puncture and Transcatheter Arterial Embolization

S1530 A Catastrophic Complication of Pancreatic Adenocarcinoma

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.

S1434 Hemosuccus Pancreaticus From the Minor Papilla

INTRODUCTION: Hemosuccus Pancreaticus (HP), typically defined as bleeding from the major papilla, is an exceedingly rare cause of gastrointestinal bleeding. Even rarer, is the subset due to bleeding from the minor papilla via the duct of Santorini, with data limited to few case reports. We present a case of HP with bleeding from the minor papilla secondary to rupture of a gastroduodenal artery (GDA) branch pseudoaneurysm into a pancreatic pseudocyst from a previous episode of gallstone pancreatitis. CASE DESCRIPTION/METHODS: A 63-year-old female with history of end stage renal disease on hemodialysis, coronary artery disease status post recent drug eluting stent on dual antiplatelet therapy, and remote history of gallstone pancreatitis with known pseudocysts presented with 1 day of nonspecific abdominal pain and 4 episodes of small volume black stool. Exam revealed normal vital signs, benign abdomen, and black stool in the rectal vault. Labs notable for hemoglobin 7.6g/dL (baseline 8.5), and elevated lipase to 282 unit/L [13–60]. Endoscopy with side viewing scope revealed bile from the major papilla and frank bleeding from the minor papilla. CT angiogram demonstrated a lobulated pancreatic head, with multiple cysts and 1cm enhancing nodule concerning for a pseudoaneurysm or islet cell tumor. IR angiography identified the blood supply of the nodule as a branch of the GDA with visible blush treated successfully with coil embolization. MRI of the abdomen showed fullness of the pancreatic head without a discrete mass or evidence of pancreas divisum. Endoscopic ultrasound was recommended, but patient declined. Overall, her presentation was consistent with ruptured pseudoaneurysm into a pseudocyst causing HP from the minor papilla. DISCUSSION: HP occurs from an abnormal communication between the pancreatic duct and a vascular structure. Pancreatitis (acute or chronic) is the most common cause of HP; others include arterial aneurysm, pancreatic tumors, iatrogenic, trauma, and pseudoaneurysm of the GDA seen in 20-25% of cases. Endoscopic visualization of bleeding from the papilla is diagnostic but occurs in only 30% of cases. CT is utilized to identify etiology and infrequently reveals a sentinel clot in the pancreatic duct. IR is the gold standard for therapy with immediate success rates of 79–100% and surgery reserved for hemodynamic instability. Effective therapy is crucial; left untreated, the mortality rate is as high as 90%.Figure 1.: Side-viewing gastroduodenoscopy of the minor duodenal papilla with frank blood (left) and major duodenal papilla with bile (right).Figure 2.: CT angiography of the abdomen and pelvis with IV contrast demonstrating arterial enhancing pancreatic head nodule (arrow).Figure 3.: IR angiography of gastroduodenal artery branch pre (left) and post (right) successful coil embolization.

ヨードアレルギーのため診断・治療手段を制限されたhemosuccus pancreaticusの1例

ヨードアレルギーのため診断・治療手段を制限されたhemosuccus pancreaticusの1例

Two cases of Hemosuccus pancreaticus after stereotactic radiotherapy to the pancreas: A case study

Hemosuccus Pancreaticus (HP) is a very rare upper gastro-intestinal haemorrhagic event whose causes can be aneurismal lesions, acute and chronic pancreatic inflammatory conditions, and pancreatic masses. We present 2 cases of patients who underwent stereotactic radiotherapy for pancreatic lesions who manifested signs of HP after treatment. Two male patients were diagnosed with an inoperable locally advanced pancreatic cancer and underwent 8 cycles of chemotherapy followed by stereotactic radiotherapy to the pancreatic lesion delivering 40Gy in 8 fractions. The first patient complained of melena and had a necrotic tumoural mass with a new aneurysmal bulge 3 months after the SBRT. A stent was placed in the aneurysmal lesion, however, a few days later, the bleeding occurred again and the patient died. The other patient had local tumour progression 12 months after SBRT with a pancreatic mass eroding the near vessels. He developed a fast and massive bleeding. HP may occur after SBRT. Inflammation of the tumour mass can lead to erosion of the vessels with subsequent bleeding. The radiotherapy treatment may have contributed to the HP genesis. The treatment is complex and consists of the placement of a stent or surgery.

3007 Santorinirrhage Due to Hemosuccus Pancreaticus as a Rare Manifestation of Upper Gastrointestinal Bleeding

INTRODUCTION: Hemosuccus pancreaticus (HP), bleeding from the pancreatic duct into the gastrointestinal (GI) tract via ampulla of vater, is extremely rare. Some causes include pancreatitis, pseudoaneurysm of the peri-pancreatic vessels, or malignancy. The rarity with which this condition is encountered makes HP difficult to diagnose. We present a case of HP with bleeding from the minor duodenal papilla from a pancreatic pseudocyst. CASE DESCRIPTION/METHODS: A 39-year-old male with alcohol use disorder and chronic pancreatitis presented to the hospital with complaints of abdominal pain and melena. Labs showed significant anemia: hemoglobin, 6.90 g/dL. He was admitted for blood transfusions and further investigation. Endoscopic evaluation showed portal hypertension gastropathy, without evidence of gross bleeding. CT abdominal scan showed cystic lesions at the pancreatic tail and within the pancreatic body (Figure 1). Endoscopic ultrasound fine needle aspiration biopsy of the cystic lesion was done. Fluid analysis was consistent with pancreatic pseudocyst with elevated amylase. He was discharged home in stable condition with gastroenterology follow-up. He returned to the hospital with recurrent episodes of melena and transfusion-dependent anemia. He had IR guided transjugular intrahepatic portosystemic shunt from right hepatic vein to right portal vein. He continued to have episodes of melena with new coffee-ground hematemesis. Repeat endoscopy was performed with frank bleeding noted from the minor duodenal papilla (Figure 2). MRI was unable to confirm pancreas divisum due to pancreatic atrophy and poor visualization of the pancreatic duct. CT abdominal scan now showed hemorrhage within the two pancreatic cysts. Mesenteric angiogram was performed which showed pseudoaneurysm off proximal splenic artery and gastroepiploic artery both of which were embolized (Figure 3). His abdominal distension and pain improved significantly after the procedure with no more episodes of melena or hematemesis. He was discharged home without recurrence of symptoms. DISCUSSION: Our case illustrates the diagnostic dilemma of obscure upper GI bleeding. HP with bleeding from the duct of Santorini has been reported twice. All hemodynamically stable patients with HP should undergo endoscopic, radiographic, and angiographic evaluation. Therapeutic options consist of selective embolization or surgery. A multidisciplinary team approach with a precise protocol is paramount to drastically reduce the mortality and morbidity of patients.

Upper Gastrointestinal Bleed: Do not Forget a Look at Ampulla

Hemosuccus pancreaticus (HP) and hemobilia (HB) are uncommon causes of upper gastrointestinal bleed. In this report, 4 cases of HP and 1 case of HB with intermittent bleeding are described. The causes of HP are rupture of splenic artery pseudoaneurysm in 3 and gastroduodenal artery aneurysm in one. The cause of HB is due to cystic artery bleed. HP can be secondary to chronic or acute pancreatitis with bleeding from pseudoaneurysm arising from peripancreatic arteries. Iatrogenic transhepatic techniques, trauma, operative injuries, malignancy, and inflammation in hepatobiliary system are the common causes of HB. All the cases are missed on first endoscopy and diagnosed on second‑look endoscopy. A strong clinical suspicion is required at first endoscopy for early diagnosis and management. This case report compares presentation of HP with HB, diagnosis, and their management.

Hemosuccus Pancreaticus: A Potentially Life-threatening Cause of Gastrointestinal Bleeding

Hemosuccus pancreaticus (HP) is the least frequent cause of gastrointestinal bleeding (GIB) and even though HP is potentially life threating, it is rarely identified by endoscopy due to its intermittent bleeding and difficulty in obtaining adequate views of the ampulla. We report a case of HP identified by esophagogastroduodenoscopy (EGD) that was successfully treated with microcoil embolization. A 76 year old male with unknown medical history was admitted after being found unresponsive. On initial presentation the patient's vital signs were stable and he was severely anemic with a hemoglobin of 4.5 gm/dl, stools were brown and guaiac positive. CT abdomen was pertinent for chronic calcific pancreatitis with a 2x0.8cm pseudoaneurysm within the body of the pancreas and large stool burden. After transfusion of 3 units of packed red blood cells the patient continued to have worsening of his anemia. EGD was performed and positive for active bleeding coming from the ampulla. Interventional radiology identified the large bleeding pseudoaneurysm at the junction of the dorsal pancreatic and superior pancreaticoduodenal arteries on arteriogram and the patient was treated with microcoil embolization of the transverse pancreatic artery, dorsal pancreatic artery and superior pancreaticoduodenal arteries. HP is defined as bleeding from the pancreas or surrounding structures into the pancreatic duct and ampulla of Vater and occurs approximately once for every 1,500 cases of GIB. HP most commonly occurs from chronic pancreatitis, pancreatic tumors or bleeding of a pseudoaneurysm usually from the splenic artery but approximately 15% will bleed from the pancreaticduodenal artery, as in our case. Due to its location, intermittent bleeding and overall rarity, HP is difficult to identify by endoscopy and must be diagnosed with angiography and treated with surgery or angiographic embolization. Due to the life threating potential of HP, one most thoroughly investigate the ampulla for signs of bleeding and consider HP in the differential diagnosis to allow for early radiologic diagnosis and treatment.Figure: Bleeding from the Ampulla of Vater (Black arrow).

内視鏡的に診断し胃十二指腸動脈瘤塞栓術後軽快した膵管出血の1例

内視鏡的に診断し胃十二指腸動脈瘤塞栓術後軽快した膵管出血の1例

脾仮性動脈瘤による繰り返す膵管出血の1例

脾仮性動脈瘤による繰り返す膵管出血の1例

Hemosuccus Pancreaticus with Superior Mesenteric Artery Branch Pseudoaneurysm

Introduction: Hemosuccus pancreaticus is a rare cause of gastrointestinal bleeding due to hemorrhage into the pancreatic duct, most commonly from pseudoaneurysms. Due to its rarity as well as the intermittent nature of the bleeding, diagnosis is commonly delayed. We report an interesting case of hemosuccus pancreaticus and the associated management issues. Case Report: We report a 32 year old man with 3 weeks of progressive melena found to have hemosuccus pancreaticus from an superior mesenteric artery branch pseudoaneurysm as a sequela of pancreatitis. The diagnosis was made with a combination of upper endoscopy, CT angiography. Ultimately this proved to be a management challenge as it required multiple angiographic embolizations to achieve hemostasis. Discussion: Hemosuccus pancreaticus was first coined by Sandblom in 1970. As it presents as gastrointestinal hemorrhage, initial workup is the same, with upper/lower endoscopy and CT angiographies as first line methods. Visceral angiography remains the gold standard for diagnosis of aneurysmal causes. Interventional angiography is the first line treatment of hemosuccus pancreaticus. However if this fails, operative intervention with vessel ligation or formal resection may be required for hemostasis.

A case of hemosuccus pancreaticus caused by rupture of an aneurysm of the splenic artery

A case of hemosuccus pancreaticus caused by rupture of an aneurysm of the splenic artery

慢性膵炎に起因したhemosuccus pancreaticusの2例

慢性膵炎に起因したhemosuccus pancreaticusの2例

経カテーテル的動脈塞栓術にて治癒しえた下膵十二指腸動脈を責任血管とするhemosuccus pancreaticusの1例

症例は44歳男性．大酒家で，8年前より慢性膵炎を指摘されていた．2012年1月に激烈な背部痛をきたし近医に入院．入院翌日に突然吐血し，上部消化管内視鏡にてVater乳頭部からの出血を確認した．MR angiographyにて下膵十二指腸動脈（IPDA）から膵嚢胞内出血を指摘され，当院へ紹介となる．CTにて，膵頭部に35mm大の仮性嚢胞を認め，IPDAに径7.7mm大の嚢胞内仮性動脈瘤がみられ，hemosuccus pancreaticus（HP）と診断した．転院時，止血が確認されており，待機的に経カテーテル的動脈塞栓術（TAE）を施行した．上膵十二指腸動脈中枢側から仮性動脈瘤を超えIPDAに至るまで塞栓した．術後は合併症なく退院となった．HPは比較的まれであり，IPDAが原因であることは極めて報告が少ない．TAEにて治療可能であったIPDAを責任血管とするHPを経験したため報告する．

Hemosuccus pancreaticus: Problems and pitfalls in diagnosis and treatment

Hemosuccus pancreaticus is a rare cause of intermittent upper gastrointestinal bleeding. We report two cases of hemosuccus pancreaticus with multiple episodes of upper gastrointestinal bleeding. The causes of hemorrhage were rupture of pseudoaneurysm of the splenic artery and bleeding from the wall of pancreatic pseudocyst. Interventional radiology is the first modality for early diagnosis and possible treatment of hemosuccus pancreaticus. When angiography shows no abnormal findings or interventional radiological therapy can not be successful, surgery should be considered without delay. Our patients herein underwent surgery without recurrence or sequelae. Intraoperative ultrasonography and pancreatoscopy were helpful modalities for confirming the source of hemorrhage and determining the cutting line of the pancreas. When we encounter intermittent upper gastrointestinal bleeding with an obscure source, hemosuccus pancreaticus should be included in differential diagnoses especially in patients with chronic pancreatitis, which would lead to a prompt and proper treatment.

Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.

超音波カラードップラーが診断に有用であった慢性すい炎によるｈｅｍｏｓｕｃｃｕｓ ｐａｎｃｒｅａｔｉｃｕｓの１例

超音波カラードップラーが診断に有用であった慢性すい炎によるｈｅｍｏｓｕｃｃｕｓ ｐａｎｃｒｅａｔｉｃｕｓの１例

An Unusual Cause of Upper Gastrointestinal Bleeding

Two cases of hemosuccus pancreaticus as the source of upper gastrointestinal bleeding of unknown cause are presented. The literature on this rare cause of gastrointestinal blood loss is reviewed. Also, the influences of time-course and clinical appearance on the diagnosis of this problem are described.