Hemosuccus Pancreaticus on Endoscopy.

CASE REPORT

A 55-year-old man with chronic alcohol use presented with epigastric pain radiating backward, vomiting, and 1 day of decreased colostomy output (created 1 year earlier for an infected hernia-repair mesh). He had no history of pancreatitis. Computed tomography angiography of the abdomen revealed pancreatic fat stranding, peripancreatic head fluid collection, and a portal vein thrombus (Figure 1). Heparin drip was started. On day 4, the patient developed maroon stools in the colostomy bag, requiring transfusion of 2 units of red blood cells. A magnetic resonance cholangiopancreatography found a 3.1 and a 2.6 cm necrotic fluid collection filled with debris and hemorrhage at the pancreatic head (Figure 2). An emergent esophagogastroduodenoscopy revealed a blood clot protruding from the ampulla (Figure 3). Next, interventional radiology performed a same-day visceral angiography; they discovered and coiled an eroded gastroduodenal artery and pancreaticoduodenal arcades of the superior mesenteric artery (Figure 4). This resolved the patient's bleeding. Roughly 20% of moderately severe acute pancreatitis cases have local complications (eg, pseudocysts, necrosis, and hemosuccus pancreaticus).[1] Hemosuccus pancreaticus is a rare cause of upper gastrointestinal bleeding, estimated at 1/1,500 cases, translating to difficult/delayed diagnosis and high mortality (overall estimated at 9.6%; 90% if untreated).[2] It is defined as bleeding into the pancreatic duct and often related to inflammatory pancreatic diseases, pancreatic pseudocysts, and pancreatolithiasis.[3] Workup with imaging such as magnetic resonance cholangiopancreatography or the gold-standard computed tomography angiography should be pursued when it is suspected. Endoscopy may make the diagnosis in up to 64% of patients and should be performed to rule out other causes of bleeding.[4] Intermittent bleeding renders visualization difficult, although side-viewing endoscopy may significantly enhance diagnostic yields.[4] Endoscopic ultrasound and endoscopic retrograde cholangiopancreatography may also aid in detecting filling defects of the pancreatic duct.[4] Visceral angiography successfully treats over 79% of cases, although severe cases may require pancreaticoduodenectomy.[5]

Figure 1.

Computed tomography abdomen showing peripancreatic fat stranding with a hypodense area in the pancreatic head/uncinate.

Figure 2.

Magnetic resonance imaging of abdomen showing acute pancreatitis with necrotic collections containing fluid, debris, hemorrhage.

Figure 3.

Endoscopy revealing blood clot protruding from ampulla.

Figure 4.

Angiography showing eroded gastroduodenal artery.

DISCLOSURES

Author contribution: S.L.—drafting and critical revisions to the article, literature review, provided images, and is the guarantor. M.G.—critical revisions and approval of the article.

Financial disclosure: None to report.

No Informed Consent was obtained for this report.