Hemosuccus Pancreaticus Associated

Sukanta Ray
1
, Khaunish Das
2
, Sujay Ray
2
,
Sujan Khamrui
1
, Mahiuddin Ahammed
2
, Utpal Deka
2
Divisions of
1
Surgical Gastroenterology and
2
Gastroenterology, School of Digestive and Liver
Diseases, Institute of Postgraduate Medical Education and Research. Kolkata, West Bengal, India
ABSTRACT
Context Hemosuccus pancreaticus is a rare cause of upper gastrointestinal hemorrhage. The intensity of bleeding ranges from
intermittent occult bleeding to massive acute bleeding leading to death. Although most cases can be managed by angioembolization,
surgery plays an important role. Case report We report two cases of hemosuccus pancreaticus managed at our institution in the past
three years. Both cases occurred associated with acute pancreatitis. A pseudocyst was found in one case. Angioembolization failed in
one case and was not tried in the other because of hemodynamic instability. Both cases were successfully managed by surgery.
Conclusion Timely intervention, either by embolization or by surgery, can control this potentially life-threatening bleeding. Choice
of treatment, surgery or embolization, depends on technological availability and expertise of the practitioner.
INTRODUCTION
Hemosuccus pancreaticus, defined as bleeding into the
pancreatic duct, is a rare cause of upper gastrointestinal
hemorrhage. The most common cause is a
pseudoaneurysm of the peripancreatic arteries due to
acute or chronic pancreatitis [1, 2]. Other infrequent
causes are trauma [3], rupture of a true aneurysm [4],
pancreatic tumors [5], arteriovenous malformations [6],
and EUS-guided FNA from a pancreatic cyst [7], etc.
Due to its rare occurrence and the insufficient
knowledge available which is limited to several case
reports and a few case series [4, 8], diagnosis is often
delayed or missed. But an astute clinician should
consider hemosuccus pancreaticus in the differential
diagnosis of all cases of obscure upper gastrointestinal
bleeding, particularly associated withacute or chronic
pancreatitis.
CASE REPORT
Case #1
A 46-year-old male with a history of chronic
alcoholism having a 3-week history of alcohol-related
severe acute pancreatitis was referred to our institution
for a necrosectomy. He was initially treated at a district
hospital and was referred to us owing to persistent high
fever not responding to antibiotics. After admission
injection meropenem and fluconazole were initiated.
He responded initially but fever recurred on the 7th day
after admission. After exclusion of other sources of
infection, a contrast-enhanced computed tomography
(CECT) of the abdomen was carried out which showed
more than 50% necrosis of the pancreas with a large
pseudoaneurysm of the splenic artery (Figure 1). As a
result of this, the patient was scheduled for a
necrosectomy and ligation of the pseudoaneurysm the
following day. Unfortunately, the patient hemorrhaged
that night. An upper gastrointestinal endoscopy was
Received May 17th, 2011 - Accepted July 20th, 2011
Key words Aneurysm, False; Embolization, Therapeutic;
Pancreatic Pseudocyst; Pancreatitis
Correspondence Sukanta Ray
Division of Surgical Gastroenterology; School of Digestive and
Liver Diseases; Institute of Postgraduate Medical Education and
Research; 244 A. J. C. Bose Road; Kolkata 700020, West Bengal;
India
 
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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 5 - September 2011. [ISSN 1590-8577]
470
performed and bleeding from the papilla was detected.
As the CECT showed a pseudoaneurysm of the splenic
artery, a ruptured pseudoaneurysm was diagnosed as
the source of the bleeding. Emergency surgery was
performed immediately. A necrosectomy was
performed with multiple drains placed for continuous
lavage, ligation of the pseudoaneurysm from the
necrosectomy cavity and a feeding jejunostomy.
Intraoperative blood loss was 1.5 liters. The patient
needed postoperative mechanical ventilation. Although
the postoperative course was difficult, the patient
recovered slowly over a period of 34 days and was well
at a 26-month follow-up.
Case #2
A 26-year-old female presented with a 2-month history
of abdominal pain. She was admitted to our institution
7 days after the onset of the pain. She was diagnosed as
having gallstone-induced severe acute pancreatitis with
a large peripancreatic fluid collection. She was
discharged on the 17th
day after admission; a
cholecystectomy and follow-up for the fluid collection
were recommended. Three weeks after discharge, she
developed sudden onset of severe abdominal pain with
passage of black tarry stool. Hemodynamic stability
was maintained. She was re-admitted to our institution.
At admission, her pulse was 96 min-1 and her blood
pressure was 100/70 mmHg. A lump was palpable in
the epigastric region which was non-pulsatile.
Hemoglobin was 7.8 g/dL (reference range: 11.5-15.5
g/dL). Upper gastrointestinal endoscopy showed blood
in the stomach and duodenum with erosions in the
body and antrum of the stomach. She was treated with
proton pump inhibitors and blood transfusions. Four
days after re-admission, she experienced one episode
of hematemesis, and an upper gastrointestinal
endoscopy showed blood trickling from the papilla; it
was diagnosed as a case of hemosuccus pancreaticus.
Contrast-enhanced computed tomography of the
abdomen showed a large pseudocyst with extravasation
of contrast within the cyst (Figures 2 and 3). The
source of bleeding was not identified. Angiography
identified a pseudoaneurysm of the gastroduodenal
artery. Angioembolization failed due to technical
reasons (partial embolization due to a rich collateral
supply) and the patient had to undergo emergency
surgery. We found that the pseudocyst was full of
blood clots and there was a blister-like area in the wall
of the cyst (Figure 4). After removal of the clots and
slight pressure on the blister-like area, arterial bleeding
was seen which was controlled with 4-0-polypropylene
sutures. The pseudocyst was drained into the stomach.
The patient had an uneventful postoperative course and
was well at a 7-month follow-up.
DISCUSSION
Lower and Farrell first described bleeding through the
pancreatic duct due to the rupture of a splenic artery in
1931 [9], but the term hemosuccus pancreaticus was
Figure 2. CECT abdomen (axial) showing a large pseudocyst with
extravasation of contrast within it (black arrow) (Case #2).
Figure 3. CECT abdomen (coronal) showing a large pseudocyst with
extravasation of contrast within it (black arrow) (Case #2).
Figure 4. Operative photograph showing blister-like area within the
pseudocyst cavity (white arrow) (Case #2).

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JOP. Journal of the Pancreas - http://www.joplink.net - Vol. 12 No. 5 - September 2011. [ISSN 1590-8577]
471
coined by Sandblom in 1970 [10]. In his case reports,
he described three cases of hemosuccus pancreaticus;
in two cases, the source was a ruptured aneurysm of the
common hepatic artery and, in one case, an aneurysm
of the splenic artery. In 80% of cases, hemosuccus
pancreaticus complicates an underlying pancreatic
disease; 20% of the cases correspond to a vascular
anomaly [8, 11]. Several mechanisms could be
involved: 1) rupture of a pseudoaneurysm or an
aneurysm of the peripancreatic artery into the
pancreatic duct and 2) bleeding of the intact or
aneurysm-containing artery to the pseudocyst
communicating with the duct. This kind of
complication is more common in chronic pancreatitis.
Rupture of a pseudoaneurysm/aneurysm or an intact
artery into a pseudocyst occurs from cyst-induced
pressure necrosis or autodigestion of the vessel wall by
pancreatic enzymes (elastase and trypsin). During an
episode of acute pancreatitis, hemosuccus pancreaticus
can occur after necrosis of the arterial wall, or by
weakening and rupture due to thrombosis of the vasa-
vasorum (associated with infected necrosis). Other
causes of hemosuccus pancreaticus are: trauma [3],
pancreatic tumors [5], bleeding from arteriovenous
malformations [6], pancreas divisum [12] and ectopic
pancreas [13]. Finally, hemosuccus pancreaticus can
occur as a complication of ERCP and EUS-guided
FNA of the pancreatic cyst [7].
The typical manifestations are abdominal pain and
symptoms of bleeding into the gastrointestinal tract.
Pain is localized to the epigastrium or radiates towards
the back. The cause is a transient increase in intraductal
pressure by a blood clot. Approximately 48 hours later,
the pain is relieved due to the egress of the blood into
the gastrointestinal tract producing melena,
hematemesis or occasionally hematochezia. Bleeding is
usually intermittent in nature. Its magnitude varies
from occult blood loss to massive life-threatening
hemorrhage. Other clinical signs may be nausea,
vomiting, icterus, and a palpable and pulsating
epigastric mass. Both of our patients presented with
increased abdominal pain and features of an upper
gastrointestinal hemorrhage. A palpable non-pulsatile
lump was found in one case (blood-filled pseudocyst).
Due to the intermittent nature of the bleeding,
diagnosis is difficult and often delayed. The approach
to this problem is same as to other causes of upper
gastrointestinal bleeding. The first step is assessment of
the severity of the blood loss, resuscitation and
appropriate monitoring. A detailed history and
examination should be obtained with attention to risk
factors. The next step is the identification and
localization of the source of the bleeding followed by
definitive therapy.
Upper gastrointestinal endoscopy can visualize active
bleeding via the papilla in 30% of patients [11], thus
raising the suspicion of hemosuccus pancreaticus.
Diagnosis is confirmed by CT scan or by visceral
angiography. Contrast-enhanced CT is an excellent
modality for demonstrating pancreatic pathologies, and
it also demonstrates the features of acute or chronic
pancreatitis, pseudocysts and pseudoaneurysms. On
pre-contrast CT, a characteristic finding of clotted
blood in the pancreatic duct, known as a sentinel clot,
is seldom seen. Visceral angiography is the most
sensitive diagnostic technique for a visceral artery
aneurysm or pseudoaneurysm. Its sensitivity
approaches 96% [3]. In our cases, the CT scan
correctly diagnosed the source of bleeding in one case
and, in the other case, it showed blood within the
pseudocyst, indirect evidence of blood loss from the
peripancreatic vessels. On the other hand, angiography
delineated the source of bleeding correctly but
angioembolization failed due to technical factors.
There are two therapeutic options for this entity:
surgery and angioembolization. Angioembolization is
safe and effective for immediate hemostasis, with a
success rate of approximately 80 to 100%. Recurrent
bleeding may occur in about 17-37% ofd patients [14]
following embolization which can be managed by
surgery or by repeat embolization. Although
embolization is the first line of treatment, surgical
therapy is the procedure of choice in hemodynamically
unstable patients when angiography fails to localize the
source of bleeding, when angioembolization fails (as in
Case #2) or when there is a pancreatitis-related
indication (i.e., drainage of a pseudocyst) (as in Case
#1). The procedures described for controlling bleeding
include intracystic ligation of the bleeding vessel,
external ligation of the feeding vessels, a distal
pancreatectomy or occasionally a pancreatico-
duodenectomy. A hemostatic procedure is often
accompanied by a cystogastrostomy or a cysto-
jejunostomy, as in one of our cases. Overall mortality
of surgical intervention ranges from 20 to 25%. Re-
bleeding rates are significantly lower (0-5%) than
embolization rates [15, 16]. There was no mortality or
recurrence of bleeding in our cases. We believe that
surgery is safe and plays an important role, particularly
where expertise for interventional radiology is lacking,
as in our case.
CONCLUSION
The diagnosis of hemosuccus pancreaticus requires a
high level of expertise. It should be considered in
patients presenting with upper gastrointestinal bleeding
and a history of acute or chronic pancreatitis or a
pseudocyst. Embolization and surgery are both equally
effective and complementary. The choice of therapy
depends on the clinical condition of the patient as well
as local availability and expertise of the practitioner.
Conflict of interest The authors have no potential
conflict of interest
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