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. 1. Introduction Hemosuccus pancreaticus (HP) is a rare and potentially life threatening clinical entity and is described as bleeding from the ampulla of Vater via the pancreatic duct. It is the least frequent cause of upper gastrointestinal bleeding (1/1500) and is most often caused by chronic pancreatitis, pancreatic pseudocysts, or pancreatic tumors [1–3]. HP is often difficult to diagnose, partly because of its rarity and due to its anatomical location and also because the bleeding is often intermittent and cannot be easily diagnosed by esophagogastroduodenoscopy (OGDscopy) in the intermittent phase [1, 4]. The diagnosis is not always easy to establish and often a long period elapses between the onset of the first symptoms and the precise location of the source of bleeding [2, 4]. The objective of our study was to highlight the challenges involved in the diagnosis and management of HP and
References
[1]
A. M. Callinan, J. S. Samra, and R. C. Smith, “Haemosuccus pancreaticus,” Australian and New Zealand Journal of Surgery, vol. 74, pp. 395–397, 2004.
[2]
P. H. Sandblom, “Gastrointestinal haemorrhage through pancreatic duct,” Annals of Surgery, vol. 171, pp. 61–66, 1970.
[3]
W. E. Lower and J. T. Farrell, “Aneurysm of the splenic artery: report of a case and review of literature,” Archives of Surgery, no. 23, pp. 182–190, 1931.
[4]
S. Etienne, P. Pessaux, J. J. Tuech et al., “Hemosuccus pancreaticus: a rare cause of gastrointestinal bleeding. A series of 9 cases,” Gastroenterologie Clinique et Biologique, vol. 29, no. 3, pp. 237–242, 2005.
[5]
J. L. Peroux, J. P. Arput, M. C. Saint-Paul, R. Dumas, P. Hastier, and F. X. Caroli, “Wirsungorragie compliquant une pancréatite chronique associée á une tumeur neuroendocrine du pancréas,” Gastroentérologie Clinique et Biologique, vol. 18, pp. 1142–1145, 1994.
[6]
R. Frayssinet, J. Sahel, and H. Sarles, “Les wirsungorragies,” Gastroentérologie Clinique et Biologique, vol. 2, pp. 993–1000, 1978.
[7]
M. Suter, F. Doenz, G. Chapuis, M. Gillet, and P. Sandblom, “Haemorrhage into the pancreatic duct (hemosuccus pancreaticus): recognition and management,” European Journal of Surgery, vol. 161, no. 12, pp. 887–892, 1995.
[8]
T. Sugiki, T. Hatori, T. Imaizumi et al., “Two cases of hemosuccus pancreaticus in which hemostasis was achieved by transcatheter arterial embolization,” Journal of Hepato-Biliary-Pancreatic Surgery, vol. 10, no. 6, pp. 450–454, 2003.
[9]
V. Vimalraj, D. G. Kannan, R. Sukumar et al., “Haemosuccus pancreaticus: diagnostic and therapeutic challenges,” HPB, vol. 11, no. 4, pp. 345–350, 2009.
[10]
J. P. Arnaud, R. Bergamaschi, V. Serra-Maudet, and C. Casa, “Pancreatoduodenectomy for hemosuccus pancreaticus in silent chronic pancreatitis,” Archives of Surgery, vol. 129, no. 3, pp. 333–334, 1994.
[11]
B. Risti, B. Marincek, R. Jost, M. Decurtins, and R. Ammann, “Hemosuccus pancreaticus as a source of obscure upper gastrointestinal bleeding: three cases and literature review,” American Journal of Gastroenterology, vol. 90, no. 10, pp. 1878–1880, 1995.
[12]
A. El Hamel, R. Parc, G. Adda, P. Y. Bouteloup, C. Huguet, and M. Malafosse, “Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis,” British Journal of Surgery, vol. 78, no. 9, pp. 1059–1063, 1991.
[13]
B. E. Stabile, S. E. Wilson, and H. T. Debas, “Reduced mortality from bleeding pseudocysts and pseudoaneurysms caused by pancreatitis,” Archives of Surgery, vol. 118, no. 1, pp. 45–51, 1983.
[14]
C. A. Benz, P. Jakob, R. Jakobs, and J. F. Riemann, “Hemosuccus paucreaticus—a rare cause of gastrointestinal bleeding: diagnosis and interventional radiological therapy,” Endoscopy, vol. 32, no. 5, pp. 428–431, 2000.
[15]
M. De Perrot, T. Berney, L. Bühler, X. Delgadillo, G. Mentha, and P. Morel, “Management of bleeding pseudoaneurysms in patients with pancreatitis,” British Journal of Surgery, vol. 86, no. 1, pp. 29–32, 1999.
[16]
J. Koizumi, S. Inoue, H. Yonekawa, and T. Kunieda, “Hemosuccus pancreaticus: diagnosis with CT and MRI and treatment with transcatheter embolization,” Abdominal Imaging, vol. 27, no. 1, pp. 77–81, 2002.
[17]
H. Bergert, I. Hinterseher, S. Kersting, J. Leonhardt, A. Bloomenthal, and H. D. Saeger, “Management and outcome of hemorrhage due to arterial pseudoaneurysms in pancreatitis,” Surgery, vol. 137, no. 3, pp. 323–328, 2005.
[18]
J. L. Bohl, L. A. Dossett, and A. M. Grau, “Gastroduodenal artery pseudoaneurysm associated with hemosuccus pancreaticus and obstructive jaundice,” Journal of Gastrointestinal Surgery, vol. 11, no. 12, pp. 1752–1754, 2007.
[19]
L. P. Gambiez, O. J. Ernst, O. A. Merlier, H. L. Porte, J. P. M. Chambon, and P. A. Quandalle, “Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis,” Archives of Surgery, vol. 132, no. 9, pp. 1016–1021, 1997.
[20]
H. Akpinar, O. Dicle, E. Ellidokuz, A. Okan, Y. G？ktay, and E. Tankurt, “Hemosuccus pancreaticus treated by transvascular selective arterial embolization,” Endoscopy, vol. 31, no. 2, pp. 213–214, 1999.
[21]
E. Lermite, N. Regenet, J. J. Tuech et al., “Diagnosis and treatment of hemosuccus pancreaticus: development of endovascular management,” Pancreas, vol. 34, no. 2, pp. 229–232, 2007.
[22]
J. S. Bender, D. L. Bouwman, M. A. Levison, and D. W. Weaver, “Pseudocysts and pseudoaneurysms: surgical strategy,” Pancreas, vol. 10, no. 2, pp. 143–147, 1995.
[23]
D. I. Heath, A. W. Reid, and W. R. Murray, “Bleeding pseudocysts and pseudoaneurysms in chronic pancreatitis,” British Journal of Surgery, vol. 79, no. 3, article 281, 1992.
[24]
F. Boudghene, C. L'Hermine, and J. M. Bigot, “Arterial complications of pancreatitis: diagnosis and therapeutic aspects in 104 cases,” Journal of Vascular and Interventional Radiology, vol. 4, pp. 551–558, 1993.
[25]
G. Singh, D. R. N. Lobo, A. Jindal, R. K. Marwaha, and S. K. Khanna, “Splenic arterial hemorrhage in pancreatitis: report of three cases,” Surgery Today, vol. 24, no. 8, pp. 752–755, 1994.
[26]
A. C. Waltman, P. R. Luers, C. A. Athanasoulis, and A. L. Warshaw, “Massive arterial hemorrhage in patients with pancreatitis. Complementary roles of surgery and transcatheter occlusive techniques,” Archives of Surgery, vol. 121, no. 4, pp. 439–443, 1986.
[27]
M. Udd, A. K. Lepp？niemi, S. Bidel, P. Keto, W. D. Roth, and R. K. Haapiainen, “Treatment of bleeding pseudoaneurysms in patients with chronic pancreatitis,” World Journal of Surgery, vol. 31, no. 3, pp. 504–510, 2007.
