Pancreatic duct haemorrhage

Abstract

Town 7925, South Africa Pancreatitis complicated by pseudocyst or abscess formation is an unusual cause of massive gastrointestinal haemorrhage' -3. Such haemorrhage usually results from inflammatory or enzymatic erosion of vessels of adjacent viscera, with the formation of an expanding false aneurysm and subsequent rupture into the stomach or duodenum. Rarely the false aneurysm may rupture into the pancreatic duct with blood entering the duodenum via this route.In 1969 Sandblom4 described three cases of bleeding from the pancreatic ductal system and termed the condition 'haemosuccus pancreaticus'. Fraisnet et aL5 called the condition 'Wirsungorrhagia'. and Longmire6 proferred the term 'haemoductal pancreatitis'. Pancreatitis, however, is not a prerequisite for bleeding via this r~u t e~.~, and pancreatic duct haemorrhage (PDH) effectively describes this condition without aetiological limitations or the use of eponyms.Only 36 cases of bleeding via this route have been reported in the English literature' -2 6 . This paper documents an additional case and reviews the literature, with particular reference to diagnosis and management. Case reportA 49-year-old male chronic alcoholic was admitted to Groote Schuur Hospital with a diagnosis of pancreatic ascites. Abdominal paracentesis confirmed the presence of clear straw coloured fluid with an amylase content of 7500 Phadebas units. Two weeks previously he had undergone negative investigations for an episode of melaena which required a 7 unit blood transfusion. Clinical examination revealed an ill pyrexial patient with epigastric tenderness, ascites, and occult blood positive stools. Abdominal X-ray revealed pancreatic calcification. Ultrasound excluded a pseudocyst,and endoscopic retrograde pancreatography was aborted as serosanguinous fluid was seen issuing from the papilla.The patient was started on total parenteral nutrition, but his course was punctuated by a low grade pyrexia and left upper quadrant pain. In addition a falling haemoglobin required two separate blood transfusions. In the third week a tender epigastric mass developed, which was shown on ultrasound to be a 5cm pseudocyst, and the patient became jaundiced. Investigation also showed him to have an ESR of 105 mm/h (Westergren), a haemoglobin of 9.7g/dl, and a serum amylase of 3850 Phadebas units/l (N: 7C-300). Seven weeks after his initial presentation the patient complained of sudden severe epigastric pain. A fleeting bruit was detected over the epigastric mass and rectal examination disclosed fresh melaena. Emergency gastroscopy was negative, and an arteriogram demonstrated a large false aneurysm of the distal splenic artery ( Figure I). In anticipation of difficult surgery a balloon catheter was positioned, via the femoral artery, with its tip in the proximal splenic artery, so that inflation would occlude the splenic artery and allow easy control of the bleeding (Figure2). The patient was taken directly to surgery with the catheter in situ but with the balloon deflated.At operation the anatomy was...

Haemorrhagic Shock as a Result of Bleeding to Pancreatic Pseudocysts - The Problem of Emergency Service

“…The blood flowing through the lumen of PPC and the main pancreatic duct can also go through to the duodenum or cumulate direct-ly in the peritoneal cavity (23,24) or retroperitoneal space, if the cyst is rupted. It is called "haemosuccus pancreaticus" or "Wirsugorrhagio" (20,25,26).…”

Late outcome after acute pancreatitis: Functional impairment and gastrointestinal tract complications

“…Blood may flow along the pancreatic duct to the duodenum when the aneurysm is in the pseudocyst and the latter communicates with Wirsung's duct. This type of hemorrhage is termed haemosuccus pancreaticus [31]. This entity is diagnosed if blood is observed to issue from the papilla during endoscopy, but it is infrequent, as endoscopy is generally carried out only when hemorrhage has temporarily subsided.…”

Review of general surgery 1985

“…Aldridge and his colleagues (1985) record no fewer than eight cases ofischaemia of the transverse colon in 15 patients with acute necrotizing pancreatitis. Another unusual complication is reported by Brown et al (1985) massive haemorrhage along the pancreatic duct. Haemorrhage complicating pancreatitis usually results from inflammatory or enzymatic erosion of vessels of adjacent viscera with an expanding false aneurysm which then ruptures into the stomach or duodenum.…”