S3606 Beyond the Scope: A Rare Splenic Artery-Pancreatic Duct Fistula Diagnosed After Exhaustive Evaluation [Hemosuccus Pancreaticus]

Introduction: Hemosuccus pancreaticus (HP) is a rare and challenging cause of gastrointestinal (GI) bleeding due to hemorrhage into the pancreatic duct, most often from a ruptured pseudoaneurysm. We present an exceptionally rare subtype: a direct fistula between the splenic artery and pancreatic duct, without pseudoaneurysm or pseudocyst formation—described in fewer than 5% of HP cases. Case Description/Methods: A 60-year-old man who had alcohol-related chronic pancreatitis, previous gastric ulcer repair, type 2 diabetes and previous deep vein thrombosis without anticoagulation presented with recurrent hematochezia, fatigue, and a hemoglobin level of 4.7 g/dL. He had an extensive but nondiagnostic evaluation over 2 years that included 4 esophagogastroduodenoscopies, 2 colonoscopies, a capsule endoscopy, a Meckel scan, 2 computed tomography angiographies (CTA) and 2 nuclear RBC-tagged bleeding scans. The patient received 23 units of packed red blood cells during the latest admission but the bleeding source was not identified. During an active bleeding episode, the third CTA revealed a fistulous connection that directly linked the splenic artery to the pancreatic duct. The patient received endovascular coil embolization of the splenic artery which resulted in no additional bleeding and his hemoglobin levels stabilized at 1-month follow-up. Discussion: On average, patients with HP undergo 2–6 endoscopic procedures and multiple imaging studies before diagnosis, particularly when bleeding is intermittent. This case emphasizes the need for heightened clinical suspicion in patients with alcohol-related chronic pancreatitis and recurrent, transfusion-dependent lower gastrointestinal bleeding. active bleeding and definitive endovascular coil embolization are crucial to achieving hemostasis and avoiding surgical morbidity.