Endovascular management of hemosuccus pancreaticus, a rare case report of gastrointestinal bleeding

Abstract

Background: Hemorrhage from the pancreatic duct, or hemosuccus pancreaticus (HP), is an unusual cause of intermittent gastrointestinal bleeding. HP is most often diagnosed in patients with chronic pancreatitis, and is usually due to the rupture of an aneurysm in the splenic artery. The traditional treatment for HP is surgery, although most cases can be managed by angioembolization.

Case presentation: We present a case of HP in a patient with no history or evidence of chronic pancreatitis. Repeated endoscopy revealed fresh bleeding from the papilla of Vater. Angiography revealed an aneurysm of the splenic artery, which was the suspected cause of the intermittent bleeding from the pancreatic duct. Angiography demonstrated extravasation of contrast from the aneurysm. A peripheral Jostent stent-graft was hand-mounted on an angioplasty balloon and then inserted into the aneurysm. Arteriography revealed successful occlusion of the aneurysm with the stent-graft. No recurrent gastrointestinal bleeding was observed during the five years follow-up periods.

Conclusion: HP should be included in the differential diagnosis of intermittent gastrointestinal bleeding in patients with histories of chronic alcoholism, even when they do not have a history of chronic pancreatitis. We recommend an interventional procedure with a metal stent for the initial treatment of HP.

Fig. 1

Abdominal CT scan and Endoscopic findings. a 6.0 mm × 10.4 mm saccular aneurysm was evident in the splenic artery (pancreatic segment of the splenic artery) at the body-tail junction of the pancreas (arrow). The aneurysm was out-pouching from the splenic artery perpendicularly down to the pancreas parenchyma. The aneurysm contacted the pancreatic duct, and the pancreatic duct proximal to the aneurysm was not dilated. However, the distal pancreatic duct was slightly dilated (up to 4.0 mm) (arrow head). The surrounding pancreas, especially distal to the aneurysm, was slightly lower in density after contrast enhancement. This finding suggests swelling. b On admission day 9, esophagogastroduodenoscopy showed active hemorrhage from the major papilla

Fig. 2

Angiographic finding and endovascular treatment. a Angiography of the splenic artery revealed a 5-mm saccular aneurysm of the splenic artery (arrow). b The splenic artery aneurysm after implantation of a 28-mm Jostent. c On a contrast-enhanced abdominal angiography CT scan obtained 10 days after the procedure, the splenic artery aneurysm was completely excluded (Stent, arrow)