Hemosuccus Pancreaticus: 15-Year Experience from a Tertiary Care GI Bleed Centre

Abstract

Background. Hemosuccus pancreaticus (HP) is a very rare and obscure cause of upper gastrointestinal bleeding. Due to its rarity, the diagnostic and therapeutic strategy for the management of this potentially life threatening problem remains undefined. The objective of our study is to highlight the challenges in the diagnosis and management of HP and to formulate a protocol to effectively and safely manage this condition. Methods. We retrospectively reviewed the records of all patients who presented with HP over the last 15 years at our institution between January 1997 and December 2011. Results. There were a total of 51 patients with a mean age of 32 years. Nineteen patients had chronic alcoholic pancreatitis; twenty-six, five, and one patient had tropical pancreatitis, acute pancreatitis, and idiopathic pancreatitis, respectively. Six patients were managed conservatively. Selective arterial embolization was attempted in 40 of 45 (89%) patients and was successful in 29 of the 40 (72.5%). 16 of 51 (31.4%) patients required surgery. Overall mortality was 7.8%. Length of followup ranged from 6 months to 15 years. Conclusions. Upper gastrointestinal bleeding in a patient with a history of chronic pancreatitis could be caused by HP. All hemodynamically stable patients with HP should undergo prompt initial angiographic evaluation, and if possible, embolization. Hemodynamically unstable patients and those following unsuccessful embolization should undergo emergency haemostatic surgery. Centralization of GI bleed services along with a multidisciplinary team approach and a well-defined management protocol is essential to reduce the mortality and morbidity of this condition.

Rare presentation of a massive intermittent upper gastrointestinal bleed

“…Other signs may include residual blood clots located near the ampulla, which may be difficult to visualize with no signs of peptic ulcer disease, varices or gastritis [7]. If no clear bleeding source, CT scan of the abdomen is the first line imaging modality of choice to identify pancreatic pathology followed-by angiography, which is considered the gold standard for detecting PAs and first line treatment [5,10].…”

“…Surgery depends on the location of the bleeding but most common procedures include bipolar arterial ligation, direct intra-pseudocystic ligation with pseudocyst drainage [9]. Pancreatic resection maybe necessary to control the pancreatic disease and the arterial bleeding with such operations as pancreaticoduodenectomy or splenopancreatectomy preferred in the setting of chronic pancreatitis [5].…”

“…Endoscopy rarely reveals active hemorrhaging and often CT scan or angiography is needed to locate the source of the hemorrhage. If the source is located, interventional radiology should be consulted and proceed with embolization [5].…”

“…Aneurysms and pseudoaneurysms are commonly formed in the setting of both acute and chronic pancreatitis [2]. However, these are not the only causes of hemosuccus pancreaticus (Table 1) [2][3][4][5][6][7].…”

Haemosuccus Pancreaticus in Chronic Pancreatitis — Diagnosis and Treatment

“…However, ischemia also can develop in the tissue supplied by the artery if the collateral circulation is not sufficient, and other complications of aneurysm infection and splenic infarction may arise. Sources bleeding from a pseudoaneurysm were reported to arise from the splenic artery in most cases but also the gastroduodenal artery, from the branch of the superior pancreaticoduodenal artery, from the branch of the inferior pancreaticoduodenal artery, from the superior mesenteric artery or vein, and from an unnamed intracystic artery [30]. Some authors documented that recurrent bleeding rates were about 30% [12].…”