Hemosuccus pancreaticus: A case of upper gastrointestinal bleeding arising from a pancreatic pseudoaneurysm

@#Pancreatic pseudoaneurysms are possible complications of chronic pancreatitis. These may present as hemosuccus pancreaticus, a rare cause of upper gastrointestinal tract bleeding where a pseudoaneurysm erodes into an adjacent pseudocyst or pancreatic duct, manifesting as bleeding through the pancreatic duct into the duodenal papilla. We report a case of a 32-year-old male with a history of chronic pancreatitis presenting as intermittent upper gastrointestinal tract bleeding secondary to hemosuccus pancreaticus from a pancreatic pseudoaneurysm. The patient underwent multiple sessions of endovascular embolization, which successfully controlled the bleeding despite some failed attempts; thus, a potentially morbid last-resort surgery was avoided.

Hemosuccus pancreaticus: rara asociación entre pancreatitis aguda, alcoholismo y sesiones vasculares en la circulación esplácnica / Hemosuccus Pancreaticus: an unusual association of acute pancreatitis, alcoholism and vascular abnormalities of the splanchnic circulation

La pancreatitis aguda o crónica puede resultar en lesiones del conducto pancreático, además, la corrosión por el jugo pancreático puede provocar la ruptura de la pared vascular periférica, lo que conduce a hemosuccus pancreático (HP) definido como el sangrado del conducto pancreático a través de la ampolla de Vater. El sangrado suele ser intermitente, repetitivo y, a menudo, no lo suficientemente grave, como para causar inestabilidad hemodinámica. La mayoría de los pacientes tiene antecedentes de enfermedades pancreáticas originales y cuando esto no se cumple, debe incluirse en el diagnóstico diferencial para alcohólicos crónicos con hemorragia digestiva alta intermitente. Presentamos una forma clínica atípica en un paciente masculino de 55 años de edad, con antecedentes de HTA, alcoholismo y aneurisma de la aorta abdominal, quien consultó por dolor tipo cólico en abdomen superior, náuseas y vómitos; luego se asoció disminución del estado de conciencia, alternando con episodios de agitación psicomotriz y primo convulsión generalizada. Una vez ingresado, sucedieron varios episodios de melena. La tomografía abdominal mostró aumento de tamaño y densidad (unidades hounsfield de 58-61) en cabeza y cuerpo del páncreas, por lo que se realizó una angiografía abdominal con protocolo de páncreas y se evidenció doble lesión aneurismática de la arteria esplénica y la arteria gástrica. Falleció en el postoperatorio(AU)

Acute or chronic pancreatitis can result in lesions of the pancreatic duct; in addition, corrosion by the pancreatic juice can cause the rupture of the peripheral vascular wall, which leads to pancreatic hemosuccus defined as bleeding from the pancreatic duct through the Vater ampulla. Bleeding is often intermittent, repetitive, and often not severe enough to cause hemodynamic instability. Most of the cases have a history of strictly pancreatic original diseases, when this is not the case, the PH should be included in the differential diagnosis for chronic alcoholics with intermittent upper gastrointestinal bleeding, We report here an atypical presentation in a 55-year-old male patient with a history of hypertension, alcoholism and an abdominal aortic aneurysm. He consulted for colicky abdominal pain in the upper abdomen, nausea and vomiting; subsequently he presented decreased consciousness, alternating with episodes of psychomotor agitation and generalized seizures. Once hospitalized he had several bouts of melena. The abdominal tomography showed an increase in the size and density (hounsfield units of 58-61) of the head and body of the pancreas. An abdominal angiography with a pancreas protocol was performed, which evidenced a double aneurismal lesion of the splenic and gastric arteries. The patient died after surgery(AU)

Apresentação atípica de um tumor neuroendócrino pancreático não funcional - relato de caso / Atypical presentation of a nonfunctional neuroendocrine pancreatic tumor - case report

Objetivo: relatar um caso de tumor neuroendócrino não funcionante do pâncreas, demonstrando a dificuldade diagnóstica devido a sua apresentação atípica no caso em questão. Método: as informações foram obtidas por meio da revisão de prontuário, assim como registro fotográfico dos métodos diagnósticos, nos quais a paciente foi submetida, e revisão bibliográfica. Considerações finais: o caso relatado e o levantamento de publicações possibilitaram a demonstração de uma apresentação incomum de um tumor pancreático. Embora rara, é fundamental ao profissional médico considerar a possibilidade de sangramento gastrointestinal alto oriundo do pâncreas, como no caso em questão.

Objective: to report a case of nonfunctioning neuroendocrine pancreatic tumor, demonstrating the diagnostic difficulties due to its atypical presentation in this case. Method: the data were obtained through medical chart review, as well as photographic record of diagnostic methods to which the patient underwent and literature review. Final considerations: the case report and the research of publications allowed the demonstration of an unusual presentation of a pancreatic tumor. Although rare, the medical professional is critical to remember the possibility of upper gastrointestinal bleeding originating from the pancreas, as in the case in question.

Hemosuccus Pancreaticus due to Intraductal Pseudoaneurysm / 대한췌담도학회지

Pseudoaneurysm is one of life-threatening complications of chronic or acute pancreatitis. It can lead to massive bleeding into the abdominal cavity, the retroperitoneum, or the gastrointestinal tract. Hemosuccus pancreaticus, meaning hemorrhage through the pancreatic duct into the duodenum is an important diagnostic clue suggesting the presence of pancreatic pseudoaneurysm. A 74-year-old man presented with hematochezia and active bleeding from the ampulla of Vater was noted on upper endoscopy. Abdominal computed tomography scan demonstrated a nodular enhancing lesion within the pancreatic duct. Celiac trunk angiography also showed a nodular enhancing lesion suggesting pseudoaneurysm in the pancreas. However, due to the difficulty of identifying the feeder artery of pseudoaneurysm by selective angiography, embolization was not feasible. Therefore, distal pancreatectomy was performed and ruptured pseudoaneurysm within the pancreatic duct could be confirmed. Herein, we report a case of hemosuccus pancreaticus due to ruptured intraductal pseudoaneurysm that was successfully treated by surgical management.

A Case of Hemosuccus Pancreaticus Associated with Pseudoaneurysm of Splenic Artery / 대한췌담도학회지

Splenic artery pseudoaneurysm (SAP) is a rare condition, occurring from many causes like pancreatitis, peptic ulcer, surgery, abdominal trauma and iatrogenic origins. SAP poses a great challenge to clinicians because it can lead to a variety of symptoms from abdominal pain, nausea, vomiting to massive bleeding into gastrointestinal tracts as well as abdominal cavity. A 43-year-old female who had previously been managed for alcoholic chronic pancreatitis and thrombotic thrombocytopenic purpura was admitted with hematochezia and dizziness. Patient went into shock from bleeding, however, there was no bleeding focus on initial CT scan and gastroduodenoscopy. Shock occurred repeatedly due to the severe blood loss from gastrointestinal tracts. On the 4th day in hospital, duodenal bleeding was suspected on gastrointestinal bleeding scan and bleeding from ampulla of Vater was found on follow-up gastroduodenoscopy. SAP which causes hemosuccus pancreaticus was diagnosed on angiography and it was treated successfully by embolization.

A Case of Hemosuccus Pancreaticus Mistaken for Hemobilia / 대한소화기내시경학회지

Hemosuccus pancreaticus is a rare cause of chronic and intermittent chronic gastrointestinal hemorrhage, and this condition cannot be easily detected by endoscopy. We report here on a 51-year-old woman with obstructive jaundice and a history of acute pancreatitis and chronic alcoholism. Abdominal computed tomography showed a dilated distal common bile duct. We performed endoscopic retrograde cholangiopancreatography to decompress the bile duct and we found a blood clot on the orifice of the ampulla of Vater. Hemobilia with massive bleeding was seen during the examination. Angiography for controlling the hemorrhage showed the pseudoaneurysm of the pancreaticoduodenal artery. Angiographic embolization was successful for controlling the arterial hemorrhage. The patient remained symptom-free and he was discharged without complications.

A Case of Pancreatic Endocrine and Exocrine Tumor with MEN Type I / 대한소화기내시경학회지

An acinar cell carcinoma of the exocrine pancreas is a rare tumor with reported a incidence of 1% to 2% of pancreatic carcinomas. Cases of acinar cell carcinomas with amphicrine features have been reported in recent decades. However, there are no reports of two simultaneous pancreatic masses: an endocrine tumor and, an exocrine tumor. We encountered a 59-year-old female patient presenting with abdominal pain and melena. The acinar cell carcinoma was a 1x1 cm-sized round solid mass in the head of the pancreas. The islet tumor was a 2.5x1.5 cm-sized round mass in the body of the pancreas. The endocrine tumor was nonfunctioning. Melena resulted from the hemosuccus pancreaticus due to a ductal invasion of the acinar cell carcinoma. The patient had a parathyroid adenoma with hyperparathyroidism. Therefore, both the islet tumor and parathyroid adenoma with hyperparathyroidism were strongly suggestive of a MEN I.

A case of hemosuccus pancreaticus in arteriovenous malformation / 대한내과학회지

Hemosuccus pancreaticus describes the syndrome of gastrointestinal bleeding into the pancreatic duct, manifested by blood loss through the ampulla of Vater. Pancreatic arteriovenous malformation (AVM), while extremely rare, are frequently complicated by gastrointestinal bleeding. Endoscopy is essential to rule out other causes of upper gastrointestinal bleeding. In rare cases, active bleeding is seen from the duodenal ampulla. Selective celiac angiography is the only diagnostic test. Angiography is always necessary to facilitate tactics of treatment, even if diagnosis has been established by non-invasive imaging modalities. To obtain complete regression, total extirpation of the affected organ, or at least the involved portion, should be performed before this disease leads to the lethal complications of gastrointestinal bleeding and portal hypertension. Transcatheter arterial embolization is the only alternative treatment for the control of hemorrhage. We experienced a patient with upper gastrointestinal bleeding in which the diagnosis of hemosuccus pancreaticus secondary to a AVM in chronic pancreatitis was diagnosed preoperatively. We report our experience with a review of literatures.

A Case of Hemosuccus Pancreaticus Showing Active Bleeding from the Ampulla of Vater / 대한소화기내시경학회지

Hemorrhage through the pancreatic duct into the duodenum, so called 'hemosuccus pancreaticus', is a rare cause of gastrointestinal bleeding with diagnostic difficulties. We report a 44-year-old man with recurrent upper gastrointestinal bleeding due to rupture of pseudoaneurysm into the pancreatic duct. Initial upper gastrointestinal endoscopy failed to identity the site of the hemorrhage. Active bleeding from the ampulla of Vater in duodenum was found on repeat endoscopy. Abdominal computed tomography disclosed pseudoaneurysm arising from the splenic artery caused by chronic pancreatitis. Splenic angiogram showed large psudoaneurysmal sac with wide neck, arising from distal splenic artery. Angiographic embolization was successful in controlling the arterial hemorrhage. The patient remained symptom-free 5 months after the embolization. Hemosuccus pancreaticus, although rare, remains important in the differential diagnosis of upper gastrointestinal bleeding of obscure orgin.

Two Difficultly Diagnosed Cases with Pseudoaneurysm in Chronic Pancreatitis Pseudoaneurysms Identified Inadvertently during Percutaneous Drainage and Hemosuccus Pancreaticus / 대한소화기내시경학회지

Pseudoaneurysm is a rare life-threatening complication of chronic pancreatitis. It can be diagnosed by various imaging modalities including computerized tomography (CT), ultrasound, and angiography. Early diagnosis and radiologic or surgical treatment can promise better outcomes. However, pseudoaneurysm is not easily diagnosed. It can be misdiagnosed as a pseudocyst with secondary infection. Rarely, the correct diagnosis is made by an inadvertent trial with percutaneous drainage. The endoscopically identified hemosuccus pancreaticus is also a rare finding. Recently, we experienced two cases of pseudoaneurysm in patients with chronic pancreatitis. They did not have any evidence of bleeding in the initial endoscopy or evidence of pseudoaneurysms in the initial ultrasound and CT scan. In one case, the pseudoaneurysm was identified during a percutaneous drainage procedure, performed to diagnose and manage a cystic lesion which appeared to be an infected cyst. In the other case, the pseudoaneurysm was suspected after the hemosuccus pancreaticus was found during endoscopy performed due to recurrent hematemesis. Both cases were successfully treated with arterial embolization of the pseudoaneurysms.

Hemosuccus Pancreaticus (Hemoductal Pancreatitis, Gastrointestinal Hemorrhage Due to Rupture of a Splenic Artery Aneurysm into the Pancreatic Duct)

Hemorrhage through the pancreatic duct into the duodenum is rare presentation of upper gastrointestinal bleeding. This condition is most commonly associated with inflammatory disorders of the pancrease with the bleeding originating from an area of hemorrhagic pancreatitis, abscess, or pseudocyst. A pseudoaneurysm of the splenic artery be can form as a result of erosion and autodigestion by the inflammatory process of this major blood vessel. More frequently, splenic artery aneurysms rupture into the greater or lesser peritoneal sacs, stomach, retroperitoneum, colon, or splenic vein. We experienced a patient with a prolonged history of upper gastrointestinal bleeding in which the diagnosis of hemosuccus pancreaticus secondary to a ruptured splenic artery aneurysm was diagnosed preoperatively. We report our experience with a review of the related literature.