Benjamin Fiore, MD1, Thomas E. Mellor, DO1, Nanae Takatori, MD2; 1Naval Medical Center, San Diego, CA; 2Sharp Rees Stealy Medical Group, San Diego, CA
Introduction: Hemosuccus Pancreaticus (HP), typically defined as bleeding from the major papilla, is an exceedingly rare cause of gastrointestinal bleeding. Even rarer, is the subset due to bleeding from the minor papilla via the duct of Santorini, with data limited to few case reports. We present a case of HP with bleeding from the minor papilla secondary to rupture of a gastroduodenal artery (GDA) branch pseudoaneurysm into a pancreatic pseudocyst from a previous episode of gallstone pancreatitis.
Methods: A 63-year-old female with history of end stage renal disease on hemodialysis, coronary artery disease status post recent drug eluting stent on dual antiplatelet therapy, and remote history of gallstone pancreatitis with known pseudocysts presented with 1 day of nonspecific abdominal pain and 4 episodes of small volume black stool. Exam revealed normal vital signs, benign abdomen, and black stool in the rectal vault. Labs notable for hemoglobin 7.6g/dL (baseline 8.5), and elevated lipase to 282 unit/L [13-60]. Endoscopy with side viewing scope revealed bile from the major papilla and frank bleeding from the minor papilla. CT angiogram demonstrated a lobulated pancreatic head, with multiple cysts and 1cm enhancing nodule concerning for a pseudoaneurysm or islet cell tumor. IR angiography identified the blood supply of the nodule as a branch of the GDA with visible blush treated successfully with coil embolization. MRI of the abdomen showed fullness of the pancreatic head without a discrete mass or evidence of pancreas divisum. Endoscopic ultrasound was recommended, but patient declined. Overall, her presentation was consistent with ruptured pseudoaneurysm into a pseudocyst causing HP from the minor papilla. Discussion: HP occurs from an abnormal communication between the pancreatic duct and a vascular structure. Pancreatitis (acute or chronic) is the most common cause of HP; others include arterial aneurysm, pancreatic tumors, iatrogenic, trauma, and pseudoaneurysm of the GDA seen in 20-25% of cases. Endoscopic visualization of bleeding from the papilla is diagnostic but occurs in only 30% of cases. CT is utilized to identify etiology and infrequently reveals a sentinel clot in the pancreatic duct. IR is the gold standard for therapy with immediate success rates of 79-100% and surgery reserved for hemodynamic instability. Effective therapy is crucial; left untreated, the mortality rate is as high as 90%.
Side-viewing gastroduodenoscopy of the minor duodenal papilla with frank blood (left) and major duodenal papilla with bile (right).
CT angiography of the abdomen and pelvis with IV contrast demonstrating arterial enhancing pancreatic head nodule (arrow).
IR angiography of gastroduodenal artery branch pre (left) and post (right) successful coil embolization.
Disclosures: Benjamin Fiore indicated no relevant financial relationships. Thomas Mellor indicated no relevant financial relationships. Nanae Takatori indicated no relevant financial relationships.