Introduction: While most cases of acute pancreatitis resolve without issue, roughly 20% are considered moderately severe and associated with local complications (e.g. pseudocysts, necrotic collections), organ failure, or systemic complications such as exacerbation of comorbidities. We present an interesting case of acute pancreatitis complicated by necrosis, portal vein thrombosis, and hemosuccus pancreaticus.
Case Description/Methods: A 55 year old man with chronic alcohol use presented to the emergency room with epigastric pain radiating to the back, vomiting, and decreased colostomy output for one day. CT abdomen revealed pancreatic fat stranding, peripancreatic head fluid collection, and a portal vein thrombus. Heparin drip was initiated. On hospital day 4, while awaiting MRI abdomen to further evaluate the fluid collection, the patient developed maroon stools and frank clots in the colostomy bag, eventually requiring transfusion of 2 units of RBCs. The MRI clarified the fluid collection as a 3.1 cm necrotic fluid collection filled with debris, fluid, and hemorrhage. An emergent EGD revealed a blood clot protruding from the ampulla (Figure 1). Imaging and endoscopic findings supported the diagnosis of hemosuccus pancreaticus. On visceral angiography, interventional radiology reported an eroded gastroduodenal artery which was embolized with coils. The patient required no further intervention to address the GI bleeding.
Discussion: Hemosuccus pancreaticus is the least common cause of upper GI bleed, estimated at 1/1500 cases, which translates to difficult or delayed diagnosis, and high mortality rates (overall estimated at 9.6%; 90% if untreated), owing to its risk of exsanguination. It is defined as arterial bleeding into the pancreatic duct. Diagnostic work-up with imaging such as CT angiography or MRCP should be pursued in patients with pancreatitis, pancreatic pseudocysts or tumors, who present with gastrointestinal bleeding. Endoscopy may reveal bleeding or clots at the ampulla, and should be done to rule out other causes. Treatment often involves visceral angiography, though may require pancreaticoduodenectomy in severe cases.
