Services Institute of Medical Sciences Lahore, Punjab, Pakistan
Muhammad Hassan Naeem Goraya, MBBS1, Nadeem Hussain, MD2, Hafiz M. Kashif Saleem, MD2, Muhammad Umair Khan, MBBS1, Faisal Inayat, MBBS2, Zahid I. Tarar, MD3, Junaid Rasul Awan, MBBS4, Zahra Akhtar, MBBS5, Gul Nawaz, MD6, Muhammad Adnan Zaman, MD7 1Services Institute of Medical Sciences, Lahore, Punjab, Pakistan; 2Allama Iqbal Medical College, Lahore, Punjab, Pakistan; 3University of Missouri School of Medicine, Columbia, MO; 4University Hospital Limerick, Limerick, Limerick, Ireland; 5University of Texas Medical Branch, Galveston, Galveston, TX; 6Marshfield Clinic, Marshfield, WI; 7Wexham Park Hospital, Slough, England, United Kingdom
Introduction: Hemosuccus pancreaticus (HP) is a rare, treacherous, and life-threatening cause of upper GI bleeding. It frequently presents a diagnostic and therapeutic challenge. HP from a peripancreatic or visceral artery pseudoaneurysm is increasingly reported. To our knowledge, this is the first systematic review on HP from gastroduodenal artery (GDA) pseudoaneurysm.
Methods: A systematic search of MEDLINE, Embase, Scopus, and Cochrane was conducted for studies published between inception and June 20, 2021. The search terms included ‘’hemosuccus pancreaticus’’, ‘’wirsungorrhage’’, ‘’hemoductal pancreatitis,’’ ‘’pancreatic duct bleeding,’’ ‘’upper gastrointestinal hemorrhage,’’ “pseudoaneurysm,” and “gastroduodenal artery”. Two authors independently reviewed the titles and abstracts of the search results. We also reviewed reference lists and abstracts from major gastroenterology conferences. Two authors retrieved and reviewed full-text versions for eligibility. After exclusion, a total of 35 articles were included in our final quantitative analysis.
Results: HP from GDA pseudoaneurysm has been reported in a total of 37 cases, dating from 1984 to 2021. The male-to-female ratio was 6.4:1. The age of patients ranged from 17 to 94 years (mean ± SD: 50.62 ± 15.86 years). A total of 26/37 patients had a history of pancreatitis. The size of the GDA pseudoaneurysm ranged from 15 to 80 mm. Clinical presentations included hematochezia (46%), melena (41%), abdominal pain (38%), and hematemesis (27%). Mean admission hemoglobin was 6.01 mg/dL. In extensive diagnostic workup, repeat EGD detected bleeding in 19/37 patients. Angiography was used in 23/37 patients, with 100% diagnostic yield. When applied, diagnostic yields of CT, MRI, and EUS were 79%, 89%, and 94%, respectively. Angioembolization was successful in 25/30 (83%), whereas surgery was performed in 5 patients. The overall rebleeding and mortality rates were 14.7% and 8.1%, respectively.
Discussion: This systematic review presents data on this rare association, which prompts clinicians to remain oriented about this stealth killer. HP should be among differentials of obscure GI bleeding. While conventional EGD may miss this elusive lesion, side-viewing endoscopy may help in detection. Selective angiography is the criterion standard of HP diagnosis. Conventional angiography with coil embolization remains a preferred treatment strategy (Figure 1). Early diagnosis can help to limit morbidity and mortality.
Figure: Figure 1: Hemosuccus pancreaticus following gastroduodenal artery pseudoaneurysm. A: Coronal post-contrast computed tomography abdomen showing large pseudoaneurysm, measuring up to 3 cm, in the area of the gastroduodenal artery. B: Superselective angiography of the gastroepiploic artery, confirming location distal to the origin in the gastroduodenal artery. C: Post-embolization angiography demonstrating complete occlusion of the gastroduodenal artery, with no further filling of the pseudoaneurysm. D: Coronal computed tomography angiography 29 mo status post-embolization ruling out a radiological evidence of a recurrent pseudoaneurysm.
Muhammad Hassan Naeem Goraya indicated no relevant financial relationships.
Nadeem Hussain indicated no relevant financial relationships.
Hafiz M. Kashif Saleem indicated no relevant financial relationships.
Muhammad Umair Khan indicated no relevant financial relationships.
Faisal Inayat indicated no relevant financial relationships.
Zahid I. Tarar indicated no relevant financial relationships.
Junaid Rasul Awan indicated no relevant financial relationships.
Zahra Akhtar indicated no relevant financial relationships.
Gul Nawaz indicated no relevant financial relationships.
Muhammad Adnan Zaman indicated no relevant financial relationships.
Muhammad Hassan Naeem Goraya, MBBS1, Nadeem Hussain, MD2, Hafiz M. Kashif Saleem, MD2, Muhammad Umair Khan, MBBS1, Faisal Inayat, MBBS2, Zahid I. Tarar, MD3, Junaid Rasul Awan, MBBS4, Zahra Akhtar, MBBS5, Gul Nawaz, MD6, Muhammad Adnan Zaman, MD7. P2121 - Hemosuccus Pancreaticus From Gastroduodenal Artery Pseudoaneurysm: A Systematic Review of the Diagnostic and Therapeutic Conundrums, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.