Intraoperative packing of a pancreatic pseudocyst complicated with bleeding pseudoaneurysm

Abstract

Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually due to rupture of a visceral artery aneurysm in chronic pancreatitis. Other causes of HP are rare. We present a case of HP which occurred in a patient with chronic calcifying pancreatitis and a pancreatic pseudocyst documented by ultrasonography and computed tomography. With detectable fresh blood in the descending duodenum, an aneurysm in the pancreatic head was revealed by superior mesenteric angiography as the suspected origin of intermittent bleeding from the pancreatic duct. Because an artery feeding the pseudocyst could not be identified, angiographic embolization was not possible. Surgical resection or ligation was difficult by laparotomy; therefore, intraoperative packing of the pseudocyst with absorbable gelatin sponges was achieved via a cannula through a directly punctured site in the pseudocyst wall. The patient has been followed for 4.25 years with no further episodes of HP. It is possible that the packing of a pancreatic pseudocyst with gelatin sponges is a method that can be used in similar cases, where control of hemostasis is the primary concern. The packing of a pancreatic pseudocyst with gelatin sponges is a technique that can be performed not only via laparotomy but also via laparoscopy or concomitant angiography and ultrasonography.

Haemosuccus pancreaticus and seven episodes of recurrent unlocalised upper gastrointestinal bleeding

“…In addition to the variability of which diagnostic modality provided the final diagnosis, there is also quite a bit of variance with respect to presenting symptoms/signs, as well as physical examination findings. In addition to obvious signs of upper GI bleeding (haematemesis, haematochezia and hypodynamic instability), the presenting findings often correlated well with the location of the pseudocyst and the chronic cause of pancreatitis 9–31. Additionally, we noticed a pattern of historical and radiological findings that were represented among a minority of case studies (as well as our patient), including a history of vascular malformations and pseudoaneurysm/ectasias.…”

“…Similarly, a negative upper GI or EGD is not specific enough to rule out haemosuccus pancreaticus. Interestingly, some case studies report that upper endoscopies initially noted bleeding and/or clots in the duodenum—however, as with our patient, these findings were dismissed as scope injury or non-specific findings 15 17 27. Thus, high suspicion must be maintained in the appropriate clinical context to diagnose haemosuccus pancreaticus, especially in patients with recurrent unlocalised bleeds.…”

“…This broad definition, thus, includes any bleeding source in the pancreas, pancreatic duct or pancreas-adjacent structures (eg, splenic artery) that can bleed into the pancreatic duct 7 8. While it is difficult to reliably estimate the prevalence, the current case series suggests haemosuccus pancreaticus make up <1% of upper GI bleeds 9–31…”

“…To help situate our patient’s presentation within the broader population of those presenting with haemosuccus pancreaticus and understand how to better improve existing evaluation algorithms for upper GI bleeds, we performed a comprehensive literature review of all case studies indexed in PubMed that contained the terms ‘pseudocyst’ and ‘haemosuccus pancreaticus’ (online supplemental table 1; n=24 studies9–31 and 36 patients). Two of the original 26 case studies were excluded because the bleeding was unrelated to pancreatic pseudocysts.…”

Hemosuccus Pancreaticus as a Rare Complication of Bariatric Surgery

“…As of 2006, our review of the literature uncovered descriptions of approximately 100 cases of hemosuccus pancreaticus ( 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 ). Patients may present with anemia, hyperamylasemia, epigastric or left upper quadrant pain, which improves after a pressure-releasing upper or lower GI bleed, and hyperamylasemia ( 4 , 5 ).…”