Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding

Abstract

Hemosuccus pancreaticus (bleeding from the pancreatic duct into the gastrointestinal tract via the ampulla of Vater) is a rare, potentially life-threatening and obscure cause of upper gastrointestinal bleeding. It is caused by rupture of the psuedoaneurysm of a peripancreatic vessel into pancreatic duct or pancreatic psuedocyst in the context of pancreatitis or pancreatic tumors. It can pose a significant diagnostic and therapeutic dilemma due to its anatomical location and that bleeding into the duodenum is intermittent and cannot be easily diagnosed by endoscopy. A 61-year-old female with HIV and alcoholism presented with 3 weeks of intermittent abdominal pain and melena. Examination revealed hypotension with pallor and mild epigastric tenderness. She was found to have severe anemia and a high serum lipase. It was decided to perform a contrast-enhanced computed tomography (CT) scan that demonstrated a hemorrhagic pancreatic pseudocyst with possible active bleeding into the cyst. An emergent angiogram showed a large pseudoaneurysm of the pancreaticoduodenal artery that was successfully embolized. Subsequent endoscopy showed blood near ampulla of Vater confirming the diagnosis of hemosuccus pancreaticus. Thus the bleeding pseudocyst was communicating with pancreatic duct. The patient had no further episodes of gastrointestinal bleeding. Hemosuccus pancreaticus should be considered in patients with intermittent crescendo-decrescendo abdominal pain, gastrointestinal bleeding and a high serum lipase. Contrast-enhanced CT scan can be an excellent initial diagnostic modality and can lead to prompt angiography for embolization of the bleeding pseudoaneurysm and can eliminate the need for surgery.

Keywords: Angiography; Endoscopy; Hemosuccus pancreaticus; Pancreatitis; Pseudoaneurysm; Upper gastrointestinal bleeding.

Figure 1

Contrast-enhanced CT scan of the abdomen reveals a 5 × 6 × 7 cm complex cystic mass in the region of uncinate process of pancreatic head with an enhancing capsule and a small hyperdensity consistent with pseudoaneurysm of a peripancreatic vessel with active bleeding into the pancreatic pseudocyst.

Figure 2

Contrast-enhanced CT scan of the abdomen reveals dilated pancreatic duct possibly filled with blood.

Figure 3

Abdominal angiography demonstrates an actively bleeding large pseudoaneurysm in the peripancreatic vessel arcade likely in the branch of pancreaticoduodenal artery.

Figure 4

Post embolization angiogram shows embolization of the pancreaticoduodenal artery with resolution of contrast opacification of the bleeding pseudoaneurysm.

Figure 5

Esophagogastroduodenoscopy shows with no bleeding source in the stomach.

Figure 6

Esophagogastroduodenoscopy shows old blood in the duodenum near the ampulla of Vater, which is likely the source of bleeding into gastrointestinal tract. Arrow pointing towards the ampulla of Vater.