Hemosuccus Pancreaticus: Culprit of Life-Threatening Upper Gastrointestinal Bleeding in Acute Pancreatitis.

Hemosuccus pancreaticus (HP), a term used for upper gastrointestinal bleeding (UGIB) from the ampulla of Vater through the pancreatic duct, is most commonly caused by the rupture of aneurysm of the splenic artery associated with acute or chronic pancreatitis. It is a rare cause of UGIB, and estimates of its rate (1/1500) are based on small case series. Because of its rarity, the diagnosis is easily overlooked. Here, we have described a case of alcohol-induced acute pancreatitis that developed hemorrhagic shock due to HP. Copyright:

INTRODUCTION

Acute pancreatitis is an acute inflammatory process of the pancreas. The severity of acute pancreatitis is classified as either mild or severe. Severe acute pancreatitis is signaled by evidence of organ failure (e.g., systolic blood pressure below 90 mmHg, arterial partial pressure of oxygen 60 mmHg or lower, and serum creatinine level 2 mg/dL or higher), local complications (e.g., necrosis, abscess, and pseudocyst), and Ranson score of 3 or higher or APACHE score of 8 or higher. Mild acute pancreatitis usually resolves with supportive medical management. However, patients with severe acute pancreatitis require intensive care. Initial intensive care includes fluid resuscitation and nutritional support. Surgical intervention (open or minimally invasive) is indicated for a local anatomic complication.

Acute gastrointestinal (GI) bleeding is a potentially life-threatening common abdominal emergency. Upper gastrointestinal bleeding (UGIB) is defined as bleeding originating from a source proximal to the ligament of Treitz. The causes of acute UGIB are peptic ulcers, gastric erosions, esophageal varices, Mallory-Weiss tear, and, less frequently, gastric cancer. Difficulties in diagnosing the site of bleed origin sometimes cause delay in treatment and adversely affect outcome. Here, we have described a case of young male who presented with acute pancreatitis and hemorrhagic shock due to UGIB.

CASE REPORT

A 35-year-old male presented with severe abdominal pain and vomiting for 3 days. There was no history of fever or jaundice in the past. He was chronic alcoholic; consuming 400–500 mL country liquor daily for the past 10 years. On examination, he was afebrile with a pulse rate of 124/min and blood pressure of 110/80 mmHg. He had pallor, icterus, and diffuse abdominal tenderness. The first differential diagnosis was alcoholic hepatitis and pancreatitis. Ryle's tube (RT) was inserted for gastric decompression. Initial management consisted of intravenous fluids, rabeprazole, and broad-spectrum antibiotics. Investigations revealed the following: hemoglobin: 10 g/dl, white blood cell count 13,000/mm3, platelet count 210,000/mm3, serum bilirubin 6 mg/dl, direct bilirubin 4.2 mg/dl, aspartate aminotransferase 242 U/L, alanine aminotransferase 188 U/L, gamma-glutamyltransferase 121 U/L, alkaline phosphatase 52 IU/L, serum creatinine 1.2 mg/dl, blood urea nitrogen 30 mg/dl, serum amylase 189 U/L, serum lipase 490 U/L, and normal chest X-ray. Ultrasound (USG) abdomen showed hepatomegaly with increased echotexture and a bulky pancreas. CT scan abdomen showed diffuse enlargement of the pancreas with heterogeneous enhancement and shaggy contour, blurring of peripancreatic fat planes with fat stranding, thickening of fascial planes, and the presence of intraperitoneal fluid collections. While on supportive medical management, his hemoglobin dropped to 8 g/dl in the next 2 days. RT aspiration was clear. Upper gastrointestinal (UGI) endoscopy was performed to identify the bleed source. UGI endoscopy showed no varices and no peptic ulcer, but oozing of fresh blood was identified from the ampulla of Vater [Figure 1]. As hemoglobin was low on admission also, the patient must have GI bleeding since the onset of acute pancreatitis. Computed tomography (CT) angiography identified aneurysms at the distal end of the splenic artery [Figure 2]. Continuous bleed from ruptured splenic artery aneurysm resulted in hemorrhagic shock. The patient was resuscitated with multiple units of packed red cell transfusions. In view of deteriorating general condition of the patient and suspected infected peripancreatic collection, open surgery was planned. Distal pancreatectomy and splenectomy were performed for the ruptured splenic artery aneurysm. Pathological examination showed giant cell reaction surrounded by fibrosis nearby a polymorphonuclear infiltrate suggestive of acute inflammation in a setting of chronic pancreatitis. It also confirmed peripancreatic hematoma and splenic artery pseudoaneurysm communicating with the pancreatic duct consistent with hemosuccus pancreaticus (HP). Postoperative course was uneventful, and the patient was discharged in stable condition after 2 weeks of surgery.

Figure 1

Upper gastrointestinal endoscopy showing fresh blood coming from ampulla of Vater

Figure 2

Computed tomography angiography showing aneurysms at the distal end of the splenic artery

DISCUSSION

HP, term used for UGIB from the ampulla of Vater through the pancreatic duct, is most commonly caused by the rupture of aneurysm of the splenic artery associated with acute or chronic pancreatitis. HP is a rare cause of UGIB, and estimates of its incidence (1/1500) are based on small case series.[123] As a result, the diagnosis may easily be overlooked.[4]

This condition was first reported in 1931 by Lower and Farrell, who described bleeding from an aneurysm of the splenic artery.[5] The expression “HP” was named by Sandblom in 1970.[6] Pseudoaneurysm of the hepatic, gastroduodenal, or pancreaticoduodenal artery has also been reported as causes of HP.[78] The principle management of HP is to control bleeding. Management options are endovascular coil embolization, covered stent placement, percutaneous thrombin injection under ultrasonographic guidance, and open surgical repair. Angioembolization is considered treatment of choice by many authors with a success rate ranging from 79% to 100%.[910] It is less invasive and has a lower morbidity and mortality rate than surgery; however, there are technical limitations such as difficulty in reaching the feeding vessel. In addition, endovascular-directed therapy is associated with few complications such as rupture of the pseudoaneurysm during embolization, rebleeding, splenic infarction, and coil migration. Another radiological alternative to embolization is thrombin injection. This can be achieved either by radiologically guided percutaneous injection or endoscopic USG-guided injection.

Surgical intervention is indicated when angiography fails to localize bleed site, for the failed endovascular interventional radiological procedure and for associated local pancreatic complication like pancreatic pseudocyst. At surgery, intraoperative sonography and pancreatoscopy are useful diagnostic modalities to facilitate localization of bleed site and, hence, appropriate level of pancreatic transection.

CONCLUSION

Establishing the diagnosis of HP is difficult because of intermittent hemorrhage from a source that is not readily accessible by endoscopy. Therefore, if a patient presents recurrent UGIB with an “obscure source” with the background of pancreatitis, repeated endoscopic examinations and CT angiography should be performed. HP should be strongly considered in the differential diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.