ABSTRACT
INTRODUCTION: Hemosuccus Pancreaticus (HP) is a rare etiology of gastrointestinal bleeding, that usually occurs secondary to rupture of an aneurysm in the setting of chronic pancreatitis. The nature of the intermittent bleeding seen in HP, makes it difficult to diagnose. Once diagnosed a definitive surgical versus interventional radiological embolization is pursued. CASE DESCRIPTION/METHODS: A 41-year-old male was referred to the clinic for hematemesis in the setting of alcohol abuse, frequent alcohol related pancreatitis and radiographic evidence of liver fibrosis without cirrhosis. He also had acid reflux and was on omeprazole for this. He denied any on going hematemesis, melena, diarrhea, dysphagia or NSAID use. He had never had any endoscopies in the past. The patient had been smoking half a pack of cigarettes daily. An elective outpatient EGD could not be scheduled and was delayed as per CDC COVID-19 guidelines. A month later when he presented to the rheumatology clinic, routine labs indicated a drop in hematocrit to 22.7 (hemoglobin 6.5 g/dL). When called he denied any stigmata of gastrointestinal blood loss, fatigue or abdominal pain. An EGD revealed normal esophagus and stomach with blood in the bulb and second portion of the duodenum with no obvious lesions to explain the blood. A side-viewing endoscope demonstrated active bleeding from the minor papilla. No bleeding was observed from the major papilla. The patient had an urgent CTA was done which showed a large 3.7 cms. pseudoaneurysm of the gastro-duodenal artery with hematoma in the pancreatic head. A visceral angiogram with coil and gelfoam embolization of the large pseudoaneurysm of the gastroduodenal artery was performed with good proximal and distal control of the pseudoaneurysm. The patient did not have any further drop in his hematocrit. DISCUSSION: Our patient did not have melena, which is the key symptom. However, with the background knowledge of chronic pancreatitis with endoscopic evidence of active bleeding from the minor papilla lead us to look for a pancreatic aneurysm, with subsequent IR embolization of the culprit gastroduodenal aneurysm.