A Cautionary Tale: Hemosuccus Pancreaticus In A Patient With A History Of Chronic Pancreatitis

INTRODUCTION: Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding from the pancreatic duct and is usually secondary to chronic pancreatitis, pancreatic pseudocysts, or tumors. We present a diagnostically challenging case of upper gastrointestinal bleeding (UGIB) from the pancreatic duct in a relatively young patient with a history of recurrent pancreatic injuries and alcohol use. CASE DESCRIPTION/METHODS: A 35-year-old man with recurrent acute and chronic alcohol-induced pancreatitis presented with acute melena and general fatigue. In the emergency department, complete blood count showed a hemoglobin of 6.4 compared to 13 earlier in the year. He received one unit of packed red blood cells, intravenous (IV) fluids, and IV pantoprazole. During his hospital course, he experienced an episode of hematemesis, and he continued to have melena. Subsequently, esophagogastroduodenoscopy (EGD) was performed and revealed blood in the second portion of the duodenum but no other remarkable sources of bleeding. The patient's hemoglobin continued to trend downwards. Tagged red blood cell scan showed blood accumulation in the proximal small bowel of the right hemiabdomen. A repeat EGD was performed, showing blood in the ampulla of Vater. Contrast-enhanced computed tomography angiography and magnetic resonance cholangiopancreatography revealed a likely thrombosed pseudoaneurysm in the gastroduodenal artery with mass effect on the pancreatic neck, severely narrowing the splenoportal vein confluence. Imaging also confirmed evidence of chronic pancreatitis as well as hepatic steatosis. An arteriogram with successful coil embolization of the gastroduodenal artery was performed. The patient’s clinical status improved, and he was discharged home in stable condition. DISCUSSION: Our case represents how hemosuccus pancreaticus can be difficult to diagnose in an acutely anemic patient with risk factors for typical etiologies of UGIB. The delay in diagnosis and treatment can be attributed to repeated endoscopies unable to visualize the source of bleeding as well as the intermittent bleeding itself that can often resolve without intervention.Figure 1.: Esophagogastroduodenoscopy reveals bleeding in the second portion of the duodenum.Figure 2.: Magnetic resonance cholangiopancreatography demonstrates a hematoma in the pancreatic neck, markedly narrowing the pancreatic duct and splenoportal confluence.Figure 3.: Post embolization angiogram at the level of the common hepatic artery shows successful coil embolization of the gastroduodenal artery.