Hemosuccus pancreaticus: problems and pitfalls in diagnosis and treatment

Abstract

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.

Figure 1

Case 1. Pseudoaneurysm of splenic artery communicating with pancreatic duct. A: Endoscopy reveals bleeding from papilla of Vater; B: CT scan shows a cystic mass at tail of pancreas; C: Angiography identifies aneurysms at distal portion of splenic artery and right hepatic artery (arrow); D: Operative ultrasonography demonstrates a low echoic mass at body of pancreas suspected as a hematoma (arrow).

Figure 2

Histology of Case 1. A: Pancreatic parenchyma; B: Wall of pseudoaneurysm of splenic artery; C: Orifice of pseudoaneurysm into pancreatic duct; D: Hematoma.

Figure 3

Case 2. Pseudoaneurysm in pancreatic pseudocyst. A: Angiography failed to detect a bleeding point; B: CT scan shows multiple calcifications at the whole pancreas and dilatation of main pancreatic duct; C: Endoscopic retrograde pancreatography displays a dilatated branch of pancreatic duct at head of pancreas (arrow); D: Endoscopy reveals bleeding from papilla of Vater.

Figure 4

Case 2. Intraoperative pancreatoscopy and specimen. A: Pancreatic head by pancreatoscopy; B: Pancreatic tail by pancreatoscopy, and bleeding source was seen; C: Bleeding source at pancreatic tail.