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.

S2697 A Veinous Twist: A Rare Case of Fistulization from Pancreatic Pseudocyst into Inferior Vena Cava Leading to Hemosuccus Pancreaticus

S2697 A Veinous Twist: A Rare Case of Fistulization from Pancreatic Pseudocyst into Inferior Vena Cava Leading to Hemosuccus Pancreaticus

Diagnostic utility of contrast-enhanced ultrasound endoscopy in a case of hemosuccus pancreaticus .

Diagnostic utility of contrast-enhanced ultrasound endoscopy in a case of hemosuccus pancreaticus .

A Case Report of Giant Splenic Artery Pseudoaneurysm with Splenic Infarctions

The splenic artery is a frequently affected site for pseudoaneurysms, abnormal bulges in the artery wall. Pseudoaneurysms of the splenic artery are typically linked to pancreatic issues, including acute pancreatitis, chronic pancreatitis, and the formation of pancreatic pseudocysts.[1,2,3,4] These pseudoaneurysms can rupture into nearby organs, leading to gastrointestinal bleeding.[5] Common symptoms associated with splenic artery pseudoaneurysms include the passage of bloody stools (hematochezia) or dark, tarry stools (melena), vomiting blood (hematemesis), abdominal pain, and a condition known as hemosuccus pancreaticus.[6] In the instance of our patient, hematemesis, anaemia, and stomach pain were observed.[6]
 The preferred imaging method for diagnosing splenic artery pseudoaneurysm is CT angiography.[7] Diagnosing a pseudoaneurysm of the splenic artery can be challenging due to its rarity. Still, splenic infarct can provide a valuable diagnostic clue, as was the case similar to our patient.[6]
 Pseudoaneurysm of the splenic artery is a relatively rare complication with associated pancreatitis.[1] While pseudoaneurysms can develop in any blood vessel near the pancreas, the splenic artery is most frequently affected, accounting for about 60% of cases due to its proximity to the pancreas.[8] In autopsy studies, the reported incidence of splenic artery pseudoaneurysms ranges from approximately 0.098% to 10.4%.[9] Identifying this less common vascular complication is crucial because it has the potential to rupture and lead to gastrointestinal bleeding.[5]

Hemosuccus pancreaticus treated using EUS-guided coil embolization and glue injection

Hemosuccus pancreaticus treated using EUS-guided coil embolization and glue injection

Synchronous IPMN and Pancreatic ductal adenocarcinoma with rare presentation of hemosuccus pancreaticus: a case report

Synchronous IPMN and Pancreatic ductal adenocarcinoma with rare presentation of hemosuccus pancreaticus: a case report

Hemosuccus Pancreaticus in a Patient with Hepatic Artery Variation: the Report of a Challenging Case

Hemosuccus Pancreaticus in a Patient with Hepatic Artery Variation: the Report of a Challenging Case

S2201 Unusual and Elusive: Investigating an Uncommon Hemosuccus Pancreaticus Case

S2201 Unusual and Elusive: Investigating an Uncommon Hemosuccus Pancreaticus Case

Hemosuccus Pancreaticus Caused by Splenic Artery Pseudoaneurysm: Two Cases Diagnosed and Treated With EUS

Hemosuccus Pancreaticus Caused by Splenic Artery Pseudoaneurysm: Two Cases Diagnosed and Treated With EUS

Hemosuccus Pancreaticus- A Concise Summary on Current Knowledge of this Rare Cause of Upper GI Bleed

Hemosuccus Pancreaticus- A Concise Summary on Current Knowledge of this Rare Cause of Upper GI Bleed

Hemosuccus pancreaticus as a rare cause of gastrointestinal bleeding

Hemosuccus pancreaticus is a life-threatening condition that should be considered in patients with abdominal pain, gastrointestinal hemorrhage and high serum amylase. The varied presentation of hemosuccus pancreaticus and the limited literature evidence due to its rarity make it challenging to diagnose. Diagnostic modalities include contrast-enhanced computed tomography scans, endoscopic procedures (esophagoduodenoscopy and endoscopic retrograde cholangiopancreatography) and angiography. Therapeutic management through an interventional radiology using coil embolization is safe and effective in hemodynamically stable patients with hemosuccus pancreaticus. Endosonography can be an innovative approach for the diagnosis and treatment of patients in whom contrast cannot be administered; however, its safety and efficacy need to be confirmed by future studies. This review presents current views on the diagnosis and treatment of patients with hemosuccus pancreaticus.

S1743 Hemosuccus Pancreaticus or Just a Bunch of Hocus Pocus

Introduction: Hemosuccus pancreaticus (HP) is a rare phenomenon defined as bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater. Many potential causes for HP exist, including pancreatic inflammation, arterial aneurysms, and bariatric surgery. A high degree of clinical suspicion and a multidisciplinary approach is key for early diagnosis and treatment. Case Description/Methods: 50-year-old female with a history of RYGB, cholecystectomy, pancreatitis, and iron deficiency anemia, was admitted to the intensive care unit after presenting with maroon stools, abdominal pain, and fatigue with a hemoglobin of 4.8. Within the prior 5 months, she had multiple admissions for abdominal pain and GIB and was diagnosed with alcohol-induced pancreatitis, diverticular bleed, anastomotic erosions, peptic ulcer disease, and a Dieulafoy lesion on numerous EGD/colonoscopies. EGD/enteroscopy performed during this admission revealed old blood in the stomach, without active or old blood in the roux or biliopancreatic limbs. Her colonoscopy showed dark tarry stool throughout. Over the subsequent few days, she required a total of 11 units of packed RBCs. Multiple imaging modalities including computed tomography angiography (CTA) and Meckel's diverticulum scan were negative. She experienced worsening abdominal pain, hematochezia and hematemesis, and required emergent intubation. EGD/enteroscopy was performed and revealed fresh blood at the jejuno-jejunal anastomosis, the roux and biliopancreatic limbs, and active bleeding at the ampulla, consistent with HP (Figure). Interventional Radiology was contacted immediately, and repeat angiography revealed a 6mm splenic artery pseudoaneurysm. A covered stent was placed, and our patient’s hemoglobin remained stable during the rest of her hospitalization, without further episodes of bleeding or abdominal pain. Discussion: HP is an obscure, and potentially life-threatening cause of GIB that is important to include in the differential diagnosis. The classic triad includes sporadic bleeding (upper and lower GIB), intermittent abdominal pain, and hyperamylasemia. There appears to be a significant association between HP and pancreatic inflammation, which our patient had. Additionally, our patient’s RYGB anatomy made the ampulla more challenging to reach, delaying the diagnosis. In addition to IR and surgery, advanced endoscopy has presented novel therapeutic options with endoscopic ultrasound, lumen apposing metal stents and fibrin glue/histoacryl adhesives.Figure 1.: Enteroscopy imaging showing evidence of brisk bleeding from the ampulla of Vater, consistent with hemosuccus pancreaticus.

S1912 A Rare Case of Recurrent Hemosuccus Pancreaticus

Introduction: Hemosuccus pancreaticus is a rare cause of GI bleeds characterized by intermittent bleeding from the major duodenal papilla. Chronic pancreatitis, via arterial wall necrosis, can form a visceral pseudoaneurysm in 10% of cases. Here is a rare case of recurrent hemosuccus pancreaticus caused by a gastroduodenal artery (GDA) pseudoaneurysm, despite repeated embolization. Case Description/Methods: A 65-year-old man with alcoholic pancreatitis and pancreaticoduodenal pseudoaneurysm status post embolization in 2019 was being evaluated for hematochezia for 6 months. The patient underwent several negative EGDs and colonoscopies. Video capsule endoscopy showed scant blood streaking in proximal small bowel. Initial CT showed an enlarged pancreas with dilated pancreatic duct. EUS showed a 3x2.5cm well-defined cystic lesion at the pancreatic head with an anechoic center with vascular flow. Repeat CT showed a 1.6cm saccular aneurysmal dilation of the superior pancreaticoduodenal artery (SPDA). Prior to follow-up, he was admitted with hematochezia, with his hemoglobin down from 12 to 7.8. EGD showed blood in the second part of duodenum with fresh oozing from ampulla. An aortogram showed a non-bleeding pseudoaneurysm of the GDA, which was successfully embolized. One month later, he presented again with hematochezia. CTA showed a recurrent 1.5cm pseudoaneurysmal dilation of the SPDA and possible lower GI bleed. Colonoscopy showed dark red blood mixed with stool. NM scan showed a slow bleed from left common/internal iliac artery. An angiogram showed extravasation from the GDA, which was embolized along with the recurrent pseudoaneurysm. Seen 45 days after discharge, the patient was asymptomatic (Figure). Discussion: Hemosuccus pancreaticus caused by GDA pseudoaneurysm is reported in less than 2% of population. Successful embolization in the first 6 months is estimated to be 67%, with rebleeding risk at 37%. Rebleeding is thought to be due to collateral vessels, but in this case, no extravasation was seen after each embolization. Our patient developed recurrent symptoms with development of an aneurysm involving the same artery 1 month later. Recurrence or formation of new pseudoaneurysms usually occur within the first 6 months after embolization. This case is unique in that the patient initially had a successful embolization in 2019 of an aneurysm involving the same artery without any bleeding for 2 years, showing that hemosuccus pancreaticus can recur even after the initial 6 month period after a successful embolization.Figure 1.: A: EGD showing bleeding from ampulla. B: Angiogram of celiac trunk with GDA pseudoaneurysm. C: CTA showed 1.5cm saccular pseudoaneurysmal dilatation of the superior pancreaticoduodenal artery. D: EUS showed a 3.4 x 2.5 cm cystic lesion with anechoic center.

S2673 If It Bleeds, It Leads: Endoscopic Presentation of Hemosuccus Pancreaticus

Introduction: A 65 year old male presented as a transfer for further evaluation of multifactorial shock. Pertinent medical comorbidities included active alcohol use disorder and mild alcohol associated hepatitis. On OSH presentation, he was treated for multifactorial shock in setting of new atrial fibrillation with rapid ventricular response and MSSA bacteremia, and was subsequently transferred to our facility. Case Description/Methods: On arrival, he had been started on systemic anticoagulation in light of his new diagnosis of atrial fibrillation and had downtrending hemoglobin from previously normal baseline ∼15 to a nadir of 7-8. Several episodes of witnessed melena were documented, and the gastroenterology service was consulted. He had no known prior history of GI bleeding or cirrhosis. Endoscopic evaluation noted a small amount of hematin in the stomach without concerning source lesions. Examination of the duodenum was initially only notable for scant fresh red blood and small, clean based ulcers thought secondary to recent hypotension and ischemia. On prolonged examination of the duodenum intermittent fresh blood was observed originating from the ampulla, consistent with a diagnosis of hemosuccus pancreaticus. Follow up dedicated CT angiography showed a thrombosed aneurysm in the pancreatic head, abutting the distal main pancreatic duct, that was concerning for the likely source lesion. The patient and family were offered interventional radiology intervention, but instead opted for hospice placement. Discussion: Hemosuccus pancreaticus is typically associated with pancreatic pathology that ultimately causes luminal bleeding via erosion of pancreatic blood vessels in communication with the pancreatic duct. The source of bleeding is often an arterial aneurysm or pseudoaneurysm and associated bleeding can be severe and life-threatening. Active hemorrhage from the duodenal ampulla is a rare endoscopic finding and bleeding in cases of hemosuccus pancreaticus is frequently intermittent. In patients with obscure upper GI bleeding and the appropriate risk factors, a high index of suspicion is required to ultimately make the diagnosis. (Figure) Given the frequency of associated vascular abnormalities, all patients with suspected or confirmed hemosuccus pancreaticus merit dedicated vascular imaging and if a vascular lesion is identified, angiography and coil embolization are the preferred definitive management.Figure 1.: Intermittent active bleeding from ampulla consistent with endoscopic diagnosis of hemosuccus pancreaticus.

S1949 An Unusual Case of Chronic Pancreatitis Presenting With Recurrent Obscure Gastrointestinal Bleeding

Introduction: Chronic pancreatitis (CP) is a sequela of repeated pancreatic injury resulting in loss of exocrine and endocrine function of the pancreas. In most cases, CP presents with chronic abdominal pain and patients usually have either clinical and radiological features of CP, with gastrointestinal bleeding (GIB) as a very rare occurrence. Herein is a presentation of recurrent obscure GIB caused by chronic pancreatitis. Case Description/Methods: A 48-year-old male with a prior history of PUD and recurrent GIB episodes for several years presents with dark red bleeding per rectum for two days. Of note, the patient had undergone several endoscopies and the most recent endoscopies done six months prior were all unremarkable. He denied hematemesis, NSAIDs, or anticoagulant use. Denied liver or pancreatic disease but endorsed a prior history of moderate alcohol intake. Physical examination was unremarkable except for tachycardia and epigastric tenderness. He was mildly anemic with leukocytosis. The abdominal and pelvic CT scan was unremarkable. EGD revealed a small gastric oozing site (Figure) suspected to be an AVM or dieulafoy's lesion and clipped. He continued to have a frank bloody stool and developed hemorrhagic shock requiring multiple transfusions and vasopressors. Findings on two additional EGDs were unremarkable. He had mesenteric angiography performed with ligation of the gastroduodenal artery empirically. Despite the intervention, he continued to bleed. Abdominal CTA (Figure) noted active extravasation in the 2nd segment of the duodenum. Explorative laparotomy revealed an edematous head and uncinate portion of the pancreas with venous engorgement. There was erosion into the duodenum with acute hemorrhage (Figure). A duodenotomy and Roux-en-y (duodenojejunostomy and jejunojejunostomy) were performed. On account of the above findings, a tissue biopsy was not obtained. Following surgery, he remained hemodynamically stable and got discharged. Discussion: Massive obscure GIB due to complications of pancreatitis rarely does occur. A few cases reported are due to complications resulting from hemosuccus pancreaticus, pseudoaneurysm from a vascular supply, or erosion into adjacent viscus in the setting of known pancreatitis. Our patient represents an unusual presentation in which his recurrent obscure massive GI bleeding was the initial presentation of CP. We present this case to broaden our knowledge that obscure GI bleeding can be a complication of CP and the only manifestation of the disease.Figure 1.: The image on the left shows an EGD with the gastric oozing site with clips, and the middle image shows CTA with extravasation in the second segment of the duodenum. The image on the right shows the posterior aspect of the head of the pancreas, the uncinate, and venous engorgement.

S2682 A Complicated Course of Pancreatic Pseudoaneurysm Presenting as Hemosuccus Pancreaticus

S2682 A Complicated Course of Pancreatic Pseudoaneurysm Presenting as Hemosuccus Pancreaticus

S2694 An Uncommon Cause of Upper Gastrointestinal Bleeding

Introduction: We present a case of GI bleeding due to a direct communication between a pancreatic fistula and the splenic vein. Case Description/Methods: A 55 year-old female with a history of endometrial cancer, superficial lower extremity thrombus, and alcohol use presented with abdominal pain and dark red blood in her stools requiring blood transfusion. She reported recent ibuprofen use. An upper endoscopy showed small esophageal varices without red wales or stigmata of recent hemorrhage. A CT demonstrated extensive subacute thrombosis of the right and left portal veins, main portal vein (PV), proximal superior mesenteric vein (SMV) and splenic vein (SV). The pancreas appeared atrophic and contained small cysts. There was small ascites. Liver biopsy demonstrated mild steatohepatitis without fibrosis. She underwent placement of a transjugular intrahepatic portosystemic shunt (TIPS) with thrombectomy from the PV, SMV, and SV and was started on anticoagulation. Due to bleeding recurrence, she underwent TIPS revision with tPA injection and additional mechanical thrombectomy. Subsequently on an ultrasound, TIPS thrombosis was again noted and during TIPS revision, a communication was noted between the pancreatic duct and splenic vein, finally identifying the likely source of bleeding. A splenic vein stent was placed. Discussion: This case highlights an uncommon cause of upper GI bleeding and reinforces the importance of keeping a broad differential diagnosis for a patient with portal hypertension. Our patient had a complicated course with 2 TIPS revisions and esophageal varices, but the source of her bleeding was neither variceal nor mucosal. (Figure) Splenic vein thrombus can result as a complication of pancreatitis and subsequently lead to “sinestrial” (left-sided) portal hypertension and the formation of gastric varices which can also present with gastrointestinal bleed (GIB). Our patient did not have the classic finding of sinestral portal hypertension associated with SV thrombosis: gastric varices. Furthermore, during her initial TIPS placement and even her initial thrombectomy, no pancreatic fistula was observed. Although not always visualized due to the intermittent nature of bleeding, hemosuccus pancreaticus in the setting of chronic alcoholic pancreatitis most commonly involves the splenic artery (60-65%) and less commonly involves the gastroduodenal artery. Our patient’s case is unusual because angiogram demonstrated direct communication between a pancreatic fistula and the splenic vein, not the splenic artery.Figure 1.: Large clot burden at superior mesenteric vein.

Hemosuccus Pancreaticus on Endoscopy.

Hemosuccus Pancreaticus on Endoscopy.

Can Empirical Segmental Angioembolization of Splenic Artery Salvage Pancreatic Intraluminal Bleed?

Background Postpancreatectomy hemorrhage (PPH) and Hemosuccus Pancreaticus (HP) may present with slow but significant intraluminal bleed which may not be evident on imaging. We evaluated the efficacy of empirical segmental-angioembolization of splenic artery in intraluminal PPH and HP. Result This is a cross-sectional study done by analyzing all consecutive patients with PPH and HP who underwent empirical coil embolization of splenic artery. There were total of 137 pancreaticoduodenectomies (PD), 68 distal pancreatectomies (DP), 11 patients with median pancreatectomies (MP) and 134 admissions for acute pancreatitis and exacerbation of chronic pancreatitis during the study period. Eleven (5.1%) patients had PPH, of which two were managed surgically. Among nine patients, 4/9 (44.4%) with pseudoaneurysm on computed tomography angiography (CTA) were excluded. Among pancreatitis, 7 (5.2%) had HP, and 5/7 (71.4%) patients with pseudoaneurysm on CTA were excluded. Hence, seven patients, PPH—5 and HP—2, were included. Both HP patients were managed successfully with empirical segmental coil embolization of splenic artery. Among PPH, one patient required laparotomy for failed embolization. Overall, 6/7 (85.7%) had successful coil embolization. No reintervention, continued bleed, or blood transfusions were required postprocedure, and no splenic infarct or abscess was seen in any of the seven patients postembolization. The 72-hour rebleed rate was 1/7 (14.3%), which was managed surgically. Conclusion Empirical segmental coil embolization of splenic artery in intraluminal pancreatic bleed holds promise as a salvage life-saving procedure even when no blush or pseudoaneurysm is evident.

Pseudohemobilia (Hemosuccus Pancreaticus) as a presenting feature of fibrocalcific chronic pancreatitis managed successfully with angioembolization and coiling – A case report

Pseudohemobilia (Hemosuccus Pancreaticus) as a presenting feature of fibrocalcific chronic pancreatitis managed successfully with angioembolization and coiling – A case report