University of Missouri School of Medicine Columbia, MO, United States
Zahid I. Tarar, MD1, Faisal Inayat, MBBS2, Junaid Rasul Awan, MBBS3, Nadeem Hussain, MD2, Muhammad Hassan Naeem Goraya, MBBS4, Gul Nawaz, MD5, Muhammad Umair Khan, MBBS4, Zahra Akhtar, MBBS6, Arslan Afzal, MD7, Adnan Malik, MD8, Muhammad Adnan Zaman, MD9 1University of Missouri School of Medicine, Columbia, MO; 2Allama Iqbal Medical College, Lahore, Punjab, Pakistan; 3University Hospital Limerick, Limerick, Limerick, Ireland; 4Services Institute of Medical Sciences, Lahore, Punjab, Pakistan; 5Marshfield Clinic, Marshfield, WI; 6University of Texas Medical Branch, Galveston, Galveston, TX; 7Woodhull Medical Center, Brooklyn, NY; 8Loyola University Medical Center, Maywood, IL; 9Wexham Park Hospital, Slough, England, United Kingdom
Introduction: Hemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding (UGIB) that can be torrential and life-threatening. It frequently presents a diagnostic and therapeutic conundrum. We hereby delineate a diagnostically challenging case of HP from gastroduodenal artery (GDA) pseudoaneurysm where the patient had to undergo extensive evaluations for low hemoglobin at outside hospitals.
Case Description/Methods: A 45-year-old African-American male was referred for the evaluation of low hemoglobin following hematochezia and abdominal pain. His medical history included chronic hepatitis, hypertension, alcohol abuse, and occasional smoking. Hemoglobin level at the outside hospital was 3.2 g/dL. He was administered 4 packed RBC units and was transferred to our hospital. At presentation, he was hemodynamically stable. Physical examination revealed severe tenderness in the upper abdomen. On admission, his hemoglobin was 7.7 g/dL, hematocrit 24.5%, and MCV 81.4%. EGD showed gastritis in the antrum but no active bleeding (Panel A). CT abdomen revealed chronic pancreatitis and a large pseudoaneurysm in the pancreatic head (Panel B). Selective celiac angiography confirmed the pseudoaneurysm originating from the GDA (Panel C). Coil embolization was performed, resulting in no further filling of the pseudoaneurysm (Panels D and E). Post-embolization CT angiography ruled out a recurrent pseudoaneurysm (Panel F). His hemoglobin levels remained stable thereafter. He was discharged home on day 5 of admission. No symptoms or signs of UGIB recurrence were noted in 6 months of follow-up.
Discussion: HP is defined as bleeding from the ampulla of Vater through the pancreatic duct. It accounts for 1 in 1500 cases of UGIB. Common associations include chronic pancreatitis, pancreatic tumors, or pseudoaneurysm usually from the splenic artery. HP from GDA pseudoaneurysm remains exceedingly rare, with less than 25 cases reported in the English literature to date. It is difficult to diagnose by endoscopy due to its peculiar location, intermittent hemorrhage, and overall rarity. Visceral angiography is the gold standard for the diagnosis and treatment of aneurysmal causes. Due to the life-threatening potential of HP, clinicians should remain cognizant of this elusive etiology of UGIB. Early diagnosis can help to limit prolonged suffering, repeat hospitalizations, and multiple blood transfusions.
Figure: Figure: Diagnostic and therapeutic interventions performed on this patient. A: Upper endoscopy showing mild patchy gastric mucosal erythema and small erosions in the antrum, with no evidence of fresh or recent bleeding. B: Axial contrast-enhanced computed tomography abdomen demonstrating large pseudoaneurysm in the pancreatic head, with calcifications throughout the pancreatic parenchyma, consistent with chronic pancreatitis. C: Selective celiac angiography revealing a large pseudoaneurysm, arising from the junction of the gastroduodenal artery and gastroepiploic artery. D: Post-embolization angiography demonstrating complete occlusion of the gastroduodenal artery, with no further filling of the pseudoaneurysm. E: Final selective angiogram of the superior mesenteric artery showing no retrograde filling of the pseudoaneurysm through the inferior pancreaticoduodenal artery. F: Axial computed tomography angiography 29 mo status post-embolization demonstrating coil embolization changes of the gastroduodenal artery.
Zahid Tarar indicated no relevant financial relationships.
Faisal Inayat indicated no relevant financial relationships.
Junaid Rasul Awan indicated no relevant financial relationships.
Nadeem Hussain indicated no relevant financial relationships.
Muhammad Hassan Naeem Goraya indicated no relevant financial relationships.
Gul Nawaz indicated no relevant financial relationships.
Muhammad Umair Khan indicated no relevant financial relationships.
Zahra Akhtar indicated no relevant financial relationships.
Arslan Afzal indicated no relevant financial relationships.
Adnan Malik indicated no relevant financial relationships.
Muhammad Adnan Zaman indicated no relevant financial relationships.
Zahid I. Tarar, MD1, Faisal Inayat, MBBS2, Junaid Rasul Awan, MBBS3, Nadeem Hussain, MD2, Muhammad Hassan Naeem Goraya, MBBS4, Gul Nawaz, MD5, Muhammad Umair Khan, MBBS4, Zahra Akhtar, MBBS6, Arslan Afzal, MD7, Adnan Malik, MD8, Muhammad Adnan Zaman, MD9. P2573 - Hemosuccus Pancreaticus Secondary to Gastroduodenal Artery Pseudoaneurysm: A Cautionary Tale of the Magician in Gastrointestinal Bleeds, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.