E0337 - A Complicated Course of Pancreatic Pseudoaneurysm Presenting as Hemosuccus Pancreaticus

Anish Paudel, MD¹, Nirav Shah, MD², Parth Desai, DO², Oluwaseun Shogbesan, MD³, Jesus Salas Noain, MD⁴, Suravi Khanal, MBBS⁵, Biraj Shrestha, MD², Uchit Thapa, MBBS⁶, Kristina Bhattarai, MBBS^7
1Reading Hospital Tower Health, West Reading, PA; ²Tower Health - Reading Hospital, Reading, PA; ³Reading Tower Health, Reading, PA; ⁴Reading Hospital Tower Health, Reading, PA; ⁵Manipal College of Medical Sciences, Pokhara, Gandaki, Nepal; ⁶Bassett Medical Center, Cooperstown, NY; ⁷Manipal College of Medical Sciences, Kathmandu, Bagmati, Nepal

Introduction: Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding, usually from a pancreatic pseudoaneurysm. It can be life-threatening due to a challenging diagnosis given the intermittent nature and unusual site of bleed.

Case Description/Methods: 67-year-old man with a history of heavy alcohol use was admitted for worsening abdominal pain and distention. Contrast-enhanced CT scan of his abdomen revealed cirrhosis, ascites, and two cystic lesions in the pancreatic head measuring 15mm and 5mm, respectively. EGD was performed for variceal screening that revealed a duodenal sweep visible vessel without active bleeding. It was treated with epinephrine injection and bipolar electrocoagulation. Extrinsic mass effect was felt along the distal stomach and proximal duodenum during the procedure. The patient complained of worsening generalized abdominal pain the next day, and a repeat scan revealed a large mass concerning pancreatic head mass hematoma (4.6×3.7 cm) with acute bleeding. His hemoglobin was low but stable at 11.4 (N=14.0-17.5) g/dl. The patient underwent Interventional Radiology (IR) guided embolization within the gastroduodenal artery across the origin of the superior pancreaticoduodenal arcade. The inferior pancreaticoduodenal artery was also embolized (figure 1). Subsequent Multiphase CT scans of the abdomen revealed persistent active extravasation but appeared less prominent than in the prior study. No further interventions were pursued as the residual lumen was expected to thrombose on its own. The patient was discharged to rehab but promptly returned to the emergency department following two episodes of coffee ground emesis. His Hb dropped to 7.0 g/dl. CT scan again showed enlarging hematoma (4.9×4.3 cm) with active extravasation. The patient underwent IR guided puncture of the pseudoaneurysm from a posterior approach, and the site was injected with 0.9cc of onyx followed by 150 units of thrombin. Shortly following the procedure, the patient sustained asystole and passed away.

Discussion: Hemosuccus pancreaticus is most frequently caused by the rupture of a pseudoaneurysm of the peripancreatic arteries associated with chronic pancreatitis. The bleed is intermittent and thereby can be missed during endoscopies. Bleeding from branches of the hepatic artery is rare in contrast to the splenic artery. Clinicians should have a high degree of suspicion for Hemosuccus pancreaticus in patients with a history of chronic pancreatitis presenting with intermittent melena.



Disclosures:


Anish Paudel, MD¹, Nirav Shah, MD², Parth Desai, DO², Oluwaseun Shogbesan, MD³, Jesus Salas Noain, MD⁴, Suravi Khanal, MBBS⁵, Biraj Shrestha, MD², Uchit Thapa, MBBS⁶, Kristina Bhattarai, MBBS⁷. E0337 - A Complicated Course of Pancreatic Pseudoaneurysm Presenting as Hemosuccus Pancreaticus, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.