P2148 - Hemosuccus Pancreaticus: A Gastrointestinal Bleeding Mystery With Literature Review

Award: Presidential Poster Award

Award: Presidential Poster Award

Nader Mekheal, MD¹, Sherif Roman, MD², Mina Fransawy Alkomos, MD³, Derrick Jeon, MD⁴, Erinie Mekheal, MD², Alisa Farokhian, MD, BS⁵, Hardikkumar Shah, MD², Abdalla Mohamed, MD³, Shaker Barham, MD⁶, Shoaib Azam, MD², Sami Adib, MD³, Yana Cavanagh, MD³, Walid Baddoura, MD⁶, Matthew Grossman, MD^6
1St. Joseph University Medical Center, Wayne, NJ; ²St. Joseph Medical Center, Paterson, NJ; ³St. Joseph's Hospital and Medical Center, Paterson, NJ; ⁴St. Joseph University Medical Center, Paterson, NJ; ⁵St. Joseph's Regional Medical Center, Paterson, NJ; ⁶St. Joseph's University Medical Center, Paterson, NJ

Introduction: Hemosuccus pancreaticus (HP) is defined as bleeding from the ampulla of Vater through the pancreatic duct. It is a rare complication associated with acute or chronic pancreatitis. Diagnosis of HP is challenging, and computed tomography (CT) angiography remains the gold standard for diagnosis. We present a case of recurrent pancreatitis complicated with HP.

Case Description/Methods: A 62-year-old male with a medical history of recurrent pancreatitis and alcohol dependence presented with a sharp and diffuse abdominal pain associated with nausea, vomiting, and one episode of melanotic stool. Labs were significant for elevated liver enzymes, total and direct bilirubin, lactic acid, and lipase. CT abdomen with contrast demonstrated acute pancreatitis with pseudocyst formation anterior to the tail of the pancreas measuring 4.5 x 3.5 cm. Patient was admitted for management of acute pancreatitis.

On day 4, he reported multiple red bloody bowel movements and worsening abdominal pain. He also became hypotensive and tachycardic. The rectal exam was positive for maroon color blood per rectum. CT angiography of the abdomen revealed bleeding from the 2nd portion of the duodenum. Esophagogastroduodenoscopy revealed blood coming out of the ampulla of Vater consistent with HP (Figure 1). Interventional radiology was consulted; however, no active bleeding was found. The patient was transferred to the intensive care unit for close monitoring and his symptoms improved. His hemoglobin remained stable after receiving two units of packed red blood cells, and he never required surgery.

Discussion: HP is a rare cause of upper gastrointestinal bleeding with source can be the pancreas itself or arteries adjacent to it. During acute or chronic pancreatitis, pancreatic juices can cause corrosion to the peripheral vascular wall and cause arterial aneurysm or pseudoaneurysm. Common arteries reported are splenic, hepatic, gastroduodenal, or pancreaticoduodenal artery, with splenic artery most commonly involved. As in our patient, HP can also result from pancreatic pseudocyst due to their communication with the pancreatic duct, which can be intermittent due to clot formation in the main duct.

Arterial embolization is the first-line treatment for HP, as shown in table 1. Surgical options are associated with higher mortality and re-bleeding rate; thus should be reserved for patients with active bleeding and hemodynamically unstable. In our case, initial angiography did not show active bleeding, and no intervention was required.




Disclosures:


Nader Mekheal, MD¹, Sherif Roman, MD², Mina Fransawy Alkomos, MD³, Derrick Jeon, MD⁴, Erinie Mekheal, MD², Alisa Farokhian, MD, BS⁵, Hardikkumar Shah, MD², Abdalla Mohamed, MD³, Shaker Barham, MD⁶, Shoaib Azam, MD², Sami Adib, MD³, Yana Cavanagh, MD³, Walid Baddoura, MD⁶, Matthew Grossman, MD⁶. P2148 - Hemosuccus Pancreaticus: A Gastrointestinal Bleeding Mystery With Literature Review, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.