Endoscopic Ultrasound-assisted Diagnosis of Obscure Gastrointestinal Bleeding

Abstract

Hemosuccus pancreaticus (HP) describes hemorrhage originating from the pancreatic duct. HP is an extremely uncommon source of upper gastrointestinal bleeding and is often misdiagnosed in most community hospitals. HP is believed to be associated with arterial aneurysm, pancreatitis (acute or chronic), local inflammation, pseudocyst, and tumor or cystic neoplasms. We report a case of a 62-year-old man with multiple cysts in the pancreas on CT scan who presented with an obscure upper GI bleed in which we performed step-wise investigations that led us to the diagnosis of hemosuccus pancreaticus, which was made through endoscopic ultrasound. After diagnosis, the patient was treated successfully by interventional radiology.

Keywords: gastrointestinal bleed; hemosuccus pancreaticus.

Figure 1. CT scan of the abdomen with peri-pancreatic stranding and multiple small fluid collections

The arrow points to the largest collection in the superior aspect of the pancreatic tail measuring 4.7 x 3.4 cm.

Figure 2. Endoscopic images (A. EUS, B. Upper esophagogastroduodenoscopy)

(A) Endoscopic ultrasound (EUS) demonstrating complex pancreatic collection containing hyperchogenic blood-like material. (B) Endoscopic confirmation of bleeding from the ampulla.

Figure 3. Angiogram images

(A) Transradial selective catheterization and angiogram of the gastro-epiploic artery demonstrated an area of contrast blush and accumulation at the midsection of the artery without active extravasation, and distal communication with the splenic artery. (B) Post-embolization selective run-off shows superselective microcoils embolization using the “sandwich technique” distal and proximal (arrows) to the area of abnormal angiographic blushing resulting in immediate disappearance of the blush.

Figure 4. Embolization angiogram images

(A) Transradial selective post-embolization angiogram of the splenic artery shows partial proximal embolization of the splenic artery with Penumbra™ POD detachable plug to further decrease the arterial pressure on the gastro-epiploic artery. The intra-parenchymal splenic vasculature remained patent. (B) Selective catheterization and angiogram of the gastro-epiploic artery demonstrated an area of contrast blush (arrow) and accumulation without active extravasation, and distal communication with the splenic artery.