Hemosuccus pancreaticus, also known as pseudohematobilia or Wirsungorrhage is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a. Methods: We reviewed our experience with management of 17 patients admitted to surgery or gastroenterology units for hemosuccus pancreaticus between. Hemosuccus pancreaticus (HP) is a rare and potentially life threatening clinical entity and is described as bleeding from the ampulla of Vater.
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Hemosuccus pancreaticus: A mini-review
Kolkata, West Bengal, India. 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. 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 [ 12 ].
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 [ 48 ], 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. A 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. 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 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. 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 month follow-up. CECT abdomen showing a large pseudoaneurysm of the splenic artery black arrow Case 1. A 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.
A lump was palpable in the epigastric region which was non-pulsatile. 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 hemosjccus 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 gemosuccus 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 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.
CECT abdomen axial showing a large pseudocyst with extravasation hwmosuccus contrast within it black arrow Case 2. CECT abdomen coronal showing a large pseudocyst with extravasation of contrast within it black arrow Case 2.
Operative photograph showing blister-like area within the pseudocyst hemsuccus white arrow Case 2. Lower and Farrell first described bleeding through the pancreatic duct due to hemoskccus rupture of a splenic artery in [ 9 ], but the term hemosuccus pancreaticus was coined by Sandblom in [ 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.
Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding
Several mechanisms could be involved: This kind of complication is more common in chronic pancreatitis. 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 vasavasorum associated with infected necrosis. Other causes of hemosuccus pancreaticus are: 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.
Hemosuccus Pancreaticus: A Mysterious Cause of Gastrointestinal Bleeding
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 pancrearicus definitive therapy. Diagnosis is confirmed by CT scan or by visceral angiography.
Contrast-enhanced CT is an excellent modality for demonstrating pancreaticks 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 pancreatticus artery aneurysm or pseudoaneurysm.
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: 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.
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 pancreaticoduodenectomy.
A hemostatic procedure is often accompanied by a cystogastrostomy or a cystojejunostomy, as in one of our cases. There was no mortality or recurrence of bleeding in our cases. We believe that surgery is safe and plays an pancgeaticus role, particularly where expertise for interventional radiology is lacking, as in our case. 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. All Published work is licensed under a Creative Commons Attribution 4.
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