S3636 Inferior Pancreaticoduodenal Artery Pseudoaneurysm Rupture Presenting as Hemosuccus Pancreaticus

Introduction: Hemosuccus Pancreaticus (HP) is a rare condition, defined as bleeding from the ampulla of vater via the pancreatic duct from a bleeding source in the pancreas and surrounding vasculature. We describe a rare case of inferior pancreaticoduodenal artery pseudoaneurysm secondary to celiac artery stenosis eroding into the common bile duct and bleeding through the ampulla of vater and santorini presenting as HP. Case Description/Methods: A 39-year-old man with a history of multiple episodes of acute alcoholic pancreatitis presented with epigastric abdominal pain, tenderness, nausea, and non-bloody emesis. His previous episode of acute pancreatitis was complicated by a hemorrhagic pancreatic pseudocyst and a common bile duct (CBD) stricture, necessitating stent placement and embolization of a pancreatic arcade artery pseudoaneurysm. Laboratory tests revealed leukocytosis (26.8), elevated liver enzymes, and lipase (2515). Abdominal ultrasound showed CBD dilation (13 mm). Enhanced computed tomography of the abdomen revealed a 3.5 cm mass at the pancreatic head with surrounding inflammatory changes and embolization coils around the pancreas. Acute pancreatitis and acute cholangitis were suspected, prompting an emergent endoscopic retrograde cholangiopancreatography (ERCP), which demonstrated fresh red blood in the stomach, duodenum, and large blood clots obstructing the end of the biliary stent and the minor papilla in the duodenum. The biliary stent was retrieved, and a biliary sweep was performed, complicated by active bleeding from the CBD, resulting in hemodynamic instability. Interventional radiology conducted an angiogram that revealed active bleeding from a pseudoaneurysm of the inferior pancreaticoduodenal artery, which was successfully embolized. The patient stabilized and was discharged after 3 days with outpatient GI follow-up. Discussion: Hemosuccus pancreaticus is a rare disorder presenting with intermittent gastrointestinal bleeding, hematemesis, abdominal pain, and decreasing hemoglobin. Diagnosis typically involves esophagogastroduodenoscopy, contrast-enhanced computed tomography, and selective arteriography, though esophagogastroduodenoscopy shows active bleeding from the papilla in only 30% of cases. In this instance, the patient exhibited non-bloody emesis and diffuse abdominal pain while being hemodynamically stable. Imaging indicated common bile duct occlusion with sludge. During esophagogastroduodenoscopy and ERCP, blood clots in the papillae were removed, leading to profuse bleeding and hemodynamic instability requiring urgent IR embolization. Management of a pancreaticoduodenal pseudoaneurysm ideally involves elective embolization or surgery.